Sometimes I really get annoyed and pissed off with some of the junior doctors and the frontliners. If they are not into treating patients and care for patients, then they should just quit and find another job. Over the last few weeks I have come across few cases that was mismanaged even after being referred by a consultant (obviously from a private sector). Some how, some of these frontliners are arrogant and feel that they should not take any ideas/opinion from private specialist. I will give you these examples:
1) A 60-year-old man who has Mitral stenosis, AF , Diabetes and Gout came to see me for frequent attack of Gout. He is being planned for valve replacement surgery soon. His diabetic is being followed up by a Klinik Kesihatan(KK) and under insulin therapy. I noticed that his diabetes is not well controlled despite being planned for surgery soon within the next 2 months. This is a well-educated english speaking patient. His FBS was 15 and HBA1C was > 10%. Thus I advised him to adjust his insulin dose by himself by educating the patient to monitor his blood sugar at home regularly. I also managed his gout accordingly. 2 weeks later, he came back to see me and what he told me really irritated me. It seems that the MO in the KK refuse to see him since he had seek advise from a private consultant. He claim that the patient must only listen to him!! I wonder why is the blood sugar not well controlled then? Then I realised another stupidity that this MO is doing! When I looked at the little green book that all diabetics carry, I noted that his so-called “FBS” was always between 4-6.0 mmol/L while his own home GM monitoring was above 10 mmol/L all the time.
So I asked the patient ” Do you go fasting when they take the blood? ”
Answer: ” Yes and I also take my insulin before I go to see them???? WTH!! no wonder his blood sugar is low when he goes to KK. Sometimes, he even gets hypoglycaemia symptoms while waiting to take blood.
Is this arrogance or stupidity?
2) A 38 weeks pregnant mother was noted to have IUGR by a KK MO. She was referred to the specialist clinic of a GH. Patient’s referral letter was seen by a MO at the clinic and given appointment in 2 week’s time!! WTH, by then she will be 40 weeks pregnant. Even me, who had not done O&G for 15 years, knows that IUGR need to be delivered by 38 weeks! The patient was shocked and came to my hospital for opinion.
3) A 30 weeks pregnant mother was diagnosed by a private consultant to have Placenta Praevia Type 2 with previous scar, possible placenta accreta was considered. She was referred to a GH after spoken to the MO on call. Now she is 36 weeks pregnant and no proper plan has been made for her. In fact, she has not even seen or followed up by any specialist up to today. Only once it was written ” discussed with DR so ….so” . Such a high risk patient being followed up by MO with no proper delivery plan??? what the hell is happening?
4) A 20-year-old boy who became paraplegic after a MVA was admitted to our hospital for UTI sepsis (Pseudomonas MRO organism). He was on halovest. He was started on Sulperazon and the fever settled on 2nd day. He had appointment at GH the next day for removal of halovest. Our Ortho consultant wrote a letter to the GH doctor to admit this patient and con’t the antibiotic for atleast another 4 days. When the patient saw the doctor at GH, the letter was read but just thrown to the side. The halovest was removed, T unasyn was prescribed and the patient was not admitted. 3 days later, fever spiked again and readmitted at my hospital. Despite a letter from a private consultant, the opinion was ignored! Now, the patient has to spend more money!
Some how I feel that the newer generation of doctors and even specialist are becoming more uncaring and only interested in finishing their work and going back home. This, along with arrogance is screwing up the system. However, they don’t seem to realise their stupidity and the fact that patients are getting smarter. Sooner or later, lawyer’s letters going to reach their doorstep and the government is not going to cover you!
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Why private hospital need to refer patients to government hospital?Is it because lack of specialty?Money concern?Dont want to take challenging cases?which one is that…
Whatever said, in terms of full support facilities, government hospitals are atill the best. For eg: blood bank support, ICU support etc. In the interest of the patient, private consultants will decide whether the patient can be safely managed in their respective hospitals depending on what facilities that they have. Secondly, the cost of managing complicated cases in private hospital is just too high for any patient to be able to afford. A day in ICU will cost RM3-4K!!
I would like to correct the above statement: government hospitals are still the best because they are cheaper (free at times when you have a Guarantee Letter or you have been referred to Social Welfare). This results in government ICUs being full almost all the time, resulting in patients being ventilated in the ward, sub-optimal conversion of an “acute cubicle” in the ward catering for patients who are actually in need ICU care. Sometimes we commit ourselves too much in the ideals of patient management forgetting the reality of our own setting.
It is a misconception that government hospitals are that bad. Going public does have it’s perks, such as knowing there is a lower risk of profiteering from patients.
Then again, govt hosp wards are not air conditioned, and staff attitudes can be… well… difficult to deal with sometimes.
I have had family members who had better experiences in govt hospitals than private hospitals (im from perak).
People sometimes dont understand that if they come to an emergency department with say, a “twisted ankle” (?fracture), they are going to be a low priority patient from the start and it can be hours before they are seen. It does not mean the hospital is bad – that’s just how things are – urgent (or potentially life threatening) cases get seen first.
You may be seen quicker in a private hospital, but as mentioned, it does cost quite a bit. Had my appendix out not too long ago at a private center in the klang valley. Cost a pretty penny but at least it got done fast (read: short waiting list).
If you know someone in the government hospital, things will get done faster! This is happening more and more commonly nowadays.
Mint Berry, why did you decide to have your appendix fixed in a private center? Did you have acute appendicitis or was it a planned operation? Correct me if I’m wrong but if it was acute there should be no waiting time, even in a public hospital. You should top the list as your appendix could well – blow up!
Actually, patients with uncomplicated appendix do have to wait for OT time in government hospital. I have seen patient’s who perforated their appendix while waiting for OT time but not the fault of the doctors but just too many more complicated cases in OT.
Oops i should hv elaborated. It wasnt an acute abdomen or anything. No peritonism. Rovsing’s negative. Not febrile. But it was this really nagging, annoying, paroxysmal RIF pain. Ok maybe I wasnt a stereotypical case… I may not have dx myself up as a medical student.
My family has no contacts in the government system.
Probably long working hours for medical officers and specialists are not good after all. If fatigued, these doctors will do more harm than the houseman.
i thought now the shift system is implemented in malaysia?
anyway i doubt it is long working hours
I don’t think this got anything to do with working hours. KK MOs work office hours and most specialist takes turns to do their call and clinic work.
I hope I will not be as such….scary to learn that this behavior exist.
this is how serious the GMC UK treats incompetent doctors with “recongnized degrees”
Click to access Ivanov(1).pdf
now imagine if we have to do that?? over 80% of the workforce will be affected.
and another case
Click to access Rajinder_Kumar_-_17_Feb_2011.pdf
not being clinically competent =professional misconduct
mana bole ikut GMC. kalo ikut betul2 sat lagi anak pengarah kena buang, anak HOD kena buang, anak dato mana tah kena buang.semua xda kerja.
esok keluar paper, MMC tidak adil la, MMC bias la.tengok la nk buat common MQE pun flip-flop.
kalo betul2 chronic MO kan district pun kena buang, tapi kalo chronic MO pun kena buang sapa nak jaga district…MA? MA ok la xyah kena MMC pun. specialist pun kalo ikut standard pun ble kena buang. nak buang semua payah la.
dulu kalo jadi doktor…rakyat hormat..bagus dia ni jadi doktor, amanah pandai sebab susah nk jadi doktor. sekarang kalo jadi doktor rakyat cakap ” eleh mak bapak dia hantar blaja..ada duit” jadi la doktor. mcm air-asia cakap now everyone can fly
msia ni kena overhaul semua sekali tengok kalo orang amanah je nk ubah nk improve kena shot down. so orang amanah pun either 1) join jadi corrupt or 2) leave the system 3) buat hal sendiri. tengok la judiciary, police service..education..sekarang health service, senang cerita semua civil service la rosak.
kita bukan nk kata msia teruk, orang takde makan lapar dok tepi jalan ke apa. memang la ada lagi teruk. tapi kalo compare ngn africa sampai bila nk maju. ni dah 50 tahun jd tah apa menda tah, silap langkah jadi macam filipina or brazil. sekarang dh mcm filipina dah…professional semua tinggalkan negara sendiri.
dulu zaman tun razak, tengku semua bagus. civil service bagus. dapat kat siapatuh…dr M..habis jahanam..semua nak materia achivement nk cepat. sekarang negara jahanam salahkan barat la ..salahkan yahudi..salahkan orang bukan melayu la salahkan semua orang. diri sendiri salah tak nak mengaku. biasalah ..Dr M mudah lupa.
tatau la camne nasib Malaysia ni, tunggu bankrap baru orang sedar kot. baru ada “awakening”
“Now everyone can fly” …. so true so true. 🙂
I know people with not even one A in SPM doing medicine in Romania.
kalo nak kecek baso pun xleh eja btul2 mmg sudah xde harapan lagi…
Medical officers and specialists need to use their clinical judgments when they receive referrals from private specialists. I have some bad experience in the past.
For example:
1) a young patient was admitted to private hospital for simple pneumonia and was started on 5 antibiotics!! Ceftriaxone (to cover gram positive), Azithromycin (to cover atypical pneumonia), Metronidazole (reason is to cover anaerob), Ciprofloxacin (to cover??) and Amikacin ( reason is to cover gram negative and for synergistic effect)
2)hypertensive patients who seek treatment at private hospital for giddiness almost surely got the CT brain to rule out stroke even though without neurological deficits regardless the risk of radiation. So do little children who have some knock on their heads, CT brain are always performed to exclude bleeding. It is really unethical.
3)Not uncommonly (at least 3 times), I had received referral from private hospital of dying patients, who couldn’t even able to survive for more than 1 hour after arrival in GH (The specialist involved actually knew the patient was dying but insisted to send the patient over). Also, don’t forget the horrible handwriting of many private specialists.
I just want to point out that there are bad apples everywhere. There are good and bad doctors either in GH or private hospital.
5 antibiotics ? wow, I think the doctor needs reassessment! I will talk about unethical practices(in private sector) later under a different topic. I don’t think it is the specialist who sent the cases, most of the time it will be the MO who wrote on behalf of the specialist but I must admit that it does happen.
It was the specialist who sent the case. I was medical officer on call and received a phone call from resident MO of a private hospital. I told that MO the patient was going to die soon, why don’t just keep at the private hospital? Just 5 min later, I received a phone call from an arrogant specialist who insisted the patient to be sent to GH. The patient died upon arrival at the ward…
Simple la GTY, they don’t want the patient to die in the private hospital, looks bad.
Recently I got one case came to me 2 days ago. It was a 2 month old pregnant lady came for 2nd opinion. She told me the doctor from other GP said her baby was death and must do D&C. After I repeated the scan, magnified and showed the mother baby’s heart was beating perfectly. It means the doctor just want to earn the D&C $ only. This is really really BAD :(.
I presume that this is a GP? A lot of GPs out there are not even trained in doing ultrasound and yet they follow-up antenatal cases. MMC must come up with a way to credential GPs who are qualified to do Ultrasound.
For the first case above, the patient was given an IM Injection when he is on Warfarin!! By the time he came to see me , he already had bruises ! I had no choice but to tell this educated patient that he should not take any IM injection! And the GP knows that the patient is on Warfarin.
#1 OMG. I dont think i’ve ever seen such a combination… ever. This is hazardous as it causes bugs to develop resistance. if this was a young guy with some chronic lung disease (CF!) and long lived multi resistant bugs in his lungs then the story may be different though. I am not very familiar with antibiotics, but if im not mistaken (from anecdotes), the trend is to give one “big gun” antibiotic (teicoplanin, meropenem, tazocin) and another relatively broad spectrum one… after all cultures have been taken (including a NPA).
#2 and #3: Well there we go…. profiteering.
Actually it is not profiteering. A specialist in a private hospital do not get a single cent for ordering CT scan etc. The real reason is : cover backside medicine” or CBM
lol CBM… I thought that most places would have some sort of guidelines regarding who actually needs to be irradiated. Like the Nexus or canadian C-spine clearing guidelines.
Ceftriaxone is still a relatively good antibiotic in countries that use it selectively and cautiously. It’s really easy to write up 1g Ceftriaxone stat on a patient’s orders… but quite often it’s not the most suitable antibiotic to give. During orientation at ED (melbourne), we were specifically told: “Please check the antibiotics guidelines before starting a pt on abx. Avoid using 1g Ceftriaxone stat doses unless stipulated by the guidelines”.
Correct me if im wrong: generic Ceftriaxone is widely available and not too expensive. I think i’ve heard it discussed in a forum re drug resistance… but im not sure if it’s ceftriaxone or one of its cousins.
am I the only one that will comment on “ceftriaxone to cover gram positive”?.
Ceftriaxone covers Gram neg. =.=
Unless Gram positive bacteria in Malaysia behaves differently
Ceftriaxone actually has gram negative coverage too. I was shocked when I saw this regime, therefore I gave the specialist a call. Then he gave me the explanation above.
Thanks for Sharing doc. Keep up the interesting post
Dr Paga, saw your reply on how IM injections are contraindicated in a patient on warfarin and got interested… so patients on warfarin can’t have injections of any sort? If IM is contraindicated, I guess IV would be as well. How then should we administer medication if we want the effect to be quick? Wouldn’t a bruise be a small issue as compared to the general illness at hand? Thanks in advance, I really like your articles too.
In patients on warfarin, you can give IV injections as it is visible and can be compressed to prevent bleeding. For IM, pt may develop internal bleeding which is not visible and can lead to huge haematoma! It is not just a small bruise!
Pardon my frank opinion, but reading your post from the beginning to the end, I sense prejudice and bias emitting from the writing.
If the currently naive and idealistic public reads your post, I assure you that a significant majority will feel and may even adopt your perspective towards GPs, Tertiary MOs, District MOs, Young Specialists, or Government Specialists.
It is purely not my intention to highlight in detail about private malpractice in the name of “defensive medicine”, but allow me to enlighten our audience on the realities of Government Healthcare facilities.
1. Overcrowded
KKs in urban areas receives 1000+ patients per day, sometimes manned by 8-10 MOs with/without an in-house FMS who may also cover 5-6 other KKs. This results in a ratio of 1 MO seeing 100 patients per day from 8-5 (12.5 patients per hour with 4.8 minutes spent per patient). This is still happening in KK Seremban, KK Port Dickson, and other KKs in major urban centers last I heard. Rural KKs may receive less or more patients per day depending on the population, but these are a few known KKs, their number of MOs and patients according to my last contact with them: Negeri Sembilan – KK Linggi (1 MO, 80-100 patients per day), KK Pasir Panjang (2 MOs, 150-200 patients inclusive of them covering the nearby KD to see Obstetrics cases), KK Bukit Pelandok (2 MOs, 90-110 patients). Selangor – KK Kuala Selangor (2MOs, 110-150 patients), OPD Tanjong Karang (3MOs, 220-300 patients), KK Sekinchan (2MOs, 110-120 patients). Sabah and Sarawak? (go ahead and ask any of our colleagues there, imagine yourself seeing such numbers of patients)
Government District Hospitals (The Major Issue)
Emergency Department admission rate varies accodring to places but as far as 2 anonymous district hospitals I have worked in receives 2000-3000 patients per month, noninclusive of their attached OPD/ Visiting Specialists Clinic. They have 6-9 MOs per whole hospital, with 1-2 MOs being oncall everyday. They cover everything from simple otrhopedics surgery (Ray amputation, I&D, Knee Aspiration), to Normal obstetrics delivery and O&G care (PIH, GDM) to general paediatrics and neonatology (NNJ, Presumed Sepsis), to medical and surgical patients. They perform basic procedures (pleural/peritoneal diagnostic/ therapeautic taps, Emergnecy RSI intubation, Central lines, etc. Because of the always-full status of nearby tertiary hospitals, some district hospitals are forced to take care ill patients (with inotrope/s, with chest tubes, and at times intubated patients) in a very sub-optimal support (no ICU, poor blood bank support, poor lab support). Thus a few district hospitals start to send their MOs for training for ICU/ anaesthetic attachment and have 1-2 ventilator/small “ICU/CCU” of their own (i.e Banting, Port DIckson) They may also have perhaps 1-2 in-house physicians who at time do daily/EOD passive calls. District Hospitals MOs also do post mortems for all MVA patients and a few conspicuous death (nothing fancy like the blown-up Mongolian girl).
Government Tertiary Hospitals
This is a bit difficult to elaborate since they vary by types of hospitals and departments. New and computerized hospitals (Putrajaya, Sungai Buloh, Serdang, Ampang,etc) have limited beds (they will not/ rarely receive patients outside their full computerized capacity i.e if each ward has 26-30 beds they will not admit more than that i.e no such thing as extension beds). This results in to a status of full/near-full almost all the time, especially their CCU, ICU, HDW. In difficult times they have to allow perhaps 5-6 patients receiving ICU care (intubation, frequent observation, etc.) sub-optimally in general wards. The old school paper and pens hospitals (Seremban, Klang, GHKL (not sure whether if they have converted)) will receive patients so long as they are patients to receive. This results in a ward of 30 beds being filled up to 60-80 patients. At one moment of time (maybe quite some time ago) there was this horror story of a patient being found dead in the ward for more than 4 hours during morning rounds. People blame it on the 2 MOs covering that ward with 4 other wards, with the 2 SN covering the ward, but I blame the government.
2. Under-staffed
Housemen aside, there are relatively fewer MOs/ Physicians/ other specialists (if any) in Government Hospitals. Last time I went to a KPJ hospital, there were 3-4 MOs per Zones in the Emergency Department. If you go to Seremban, there will be only 1-2 MOs per Zones (yes, with HOs), 1 MO per whole Emergency Unit in Tanjong Karang, Sabak Bernam 24-7, 1-2 MOs in Port Dickson (no HOs in these hospitals) per shift. The number of SNs and technical staffs are also more in private (for the lucrative salary, benefits, work environments, fewer patients).
3. Lack of Technical support
Go to Tanjong Karang, Sabak Bernam, Port Dickson, Jempol Hospital and try to trace back a renal profile taken 2 weeks ago. This will be the process: 1. Ask the PPK to do so 2. The PPK will go to the record office and trace the old notes from a million files (if not lost) 3. The old notes are then brought to the MO, who will then flip over notes kept since the beginning of time, and then he may get the result. Not all hospitals (especially not the old ones) have even a descent PC support) The same goes for searching old notes. Plus the public will at times have this attitude of not bringing any discharge notes/ OPD book with them and telling us “kat hospital ni kan ada rekod?”. I hope I can somehow reach out to the public now and deliver this message: your old notes are important so that we can know previous results, previous medications and future plans.
4. “Do if needed” approach
In a government hospital, we will send you for an imaging, and will only send relevant investigations when required. This is to cut cost and to make sure that the limited resources are not exhausted. Medications are limited and are usually basic (Metformin instead of Metformin MR, PCM instead of Tramadol-PCM combination, etc.) We will not jump to an MRI unless indicated, we will not do a CT Thorax for a PTB or an USS Abdomen for an appendicitis/ gastritis. I am sure the public will appreciate that these are sometimes done in private hospitals, as I have sometimes received their referrals (without prejudice of their intentions or undermining their management), but I am not the best person to explain why this is happening. A safe explanation is the stance of “defensive medicine”, which I hope can be explained later.
With all being said, this is only the tip of the iceberg.
Most of the time, these are the main contributors of sub-optimal care, instead of plain arrogance and stupidity.
But I hope in the future Dr. Paga will have better choice of words/adjectives to describe his peers and juniors, and a better approach to address the issues as stated earlier. I think it is better to contact those involved and advise them, or even report this through MMC/ lodge a proper report, or contact their superiors (FMS/ Specialists/ HOD) for them to be corrected rather than to discredit them in the eye of a public, at times being swayed to popular beliefs through oratory talks and ostentatious alternative, ignoring the sore truth.
On the other hand, I will be lying through my teeth if I say that private centers are handling the same amount of patients and are facing the same myriad of problems. (Yes, I do locums and also have a clinic in a private hospital despite serving in a government hospital).
The public must also understand that the glut involves only the House Officers for now, while the MOs, Specialists and Consultants are still in short numbers.
The so-called new generations as Dr Paga has generalised…
(“Some how I feel that the newer generation of doctors and even specialist are becoming more uncaring and only interested in finishing their work and going back home. This, along with arrogance is screwing up the system. However, they don’t seem to realise their stupidity and the fact that patients are getting smarter. Sooner or later, lawyer’s letters going to reach their doorstep and the government is not going to cover you!”)
…as a WHOLE, in my personal opinion, did nothing to deserve this proclamation of being arrogant, stupid and uncaring. There are bad apples everywhere in private and government service of course, and being young will always render you inexperienced, but there will always be a better way of correcting the problems besides conveying blogs with elements of sedition and slander to the eye of the judgmental public.
I would also like to seize this opportunity to remind myself and muslim doctors everywhere:
” Sesiapa yang menghina seseorang kerana dosa yang pernah dilakukannya, maka dia tidak akan mati sebelum melakukan dosa tersebut” -Hadith Riwayat Tirmizi
I apologize, especially to Dr. Paga, a Senior Consultant in his own right, and to anyone who takes offense in what I have written.
Thank you.
“When death comes, the good we have done will mean nothing. We are judged in life by the evil we destroy”
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“The public must also understand that the glut involves only the House Officers for now, while the MOs, Specialists and Consultants are still in short numbers. ”
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I’d click “like” if there were a button for this. Deserves to be bolded and highlighted and emphasized.
Nice perspective on the issue discussed. Didnt know the situation was so overcrowded..
The glut will soon involve MOs, logically. As increase number of HO = incoming wave of increase number of MO.
Thanks for your lenghty comment. I am not sure how much of my blog postings that you have read. I started this blog since January 2010 and ALL that you have said has been written in my blog. It will take the whole day for you to read the blog entries.Please visit my education page and look under “Malaysian Healthcare system for the dummies Part 1-4”. I have written what you have written above. I have worked in district hospital seeing almost 150patients a day. I have also worked in one of the busiest general hospital in Malaysia. I have mentioned about ovrecrowded hospitals, KKs and General hospitals etc etc.
As for the staffing point of view, things are changing! Some KKs which only had less than 4 MOs before are now having close to 10 MOs. The biggest OPD in JB use to have less than 10 MOs(including contract) before but now they seem to have 17 MOs and MAs are not seeing anymore cases. I was informed that Malacca GH has close to 50 MOs each in surgical and medical department. The only department with shortage was O&G and 10 post HO doctors were sent to O&G department in October! so , soon the glut will affect MOs as well. I was told by reliable sources that the MO post for NS, Malacca and Selangor is deemed full. Many who completed HO is these states are being sent down to Johor. The number of post for SN in government hospitals are also full with many who applied for a job got rejected. However, why we do not see any improvement in the service provided? the answer is “lack of supervision and attitude plus poor quality”. I know many HODs and specialists sitting and running a clinic in a private hospital during office hours!! shouldn’t they be supervising these doctors? I always believe that you should only be commited working at one place.
There is no proper supervision from senior doctors and HODs. I know of a lot of HODs who do not give a damn of what is happening in their department. You mentioned that we should complain to the respective HODs about these issues. For the 2 O&G cases above, this is not the first time this is happening in this referred hospital. My O&G consultant had numerous times personally called and complained to the HOD but no action was taken. The same issue keep cropping up untill my consultant gave up. The HODs answer is always the same “this is a problematic MO and I had spoken to him many times etc etc” but NO action is taken. And forget about MMC, please try complaining to them and see what happens!The whole issue is that NO action can be taken to these civil servants as the process is just too long…………
So, after some time you get fed-up and start writing issues like this. I still think public should be educated to ask questions. There is nothing wrong of writing about these issues in a blog. In western countries, issues like this appears in newspaper! If you go back and read the cases that I mentioned abouve, it has nothing to do with the issues that you brought up. The first case is pure arrogance of refusing to see a patient just because he seek advise from a private sector. The second and third is just pure uncaringness as any good doctor would have done a proper assessment no matter how busy they are as these were referred cases.The 4rd case is again arrogance despite a letter from a consultant saying that the patient is having MRO UTI sepsis.So, we are talking about 2 different issues.
As a matter of fact I have been reading your entries regarding the “healthcare system” for quite some time. In contrary to the majority of your audience I usually find the given facts somehow inaccurate and biased, rendering the urge to write my own perspective to buffer yours.
Firstly regarding the earlier issue, If you feel other options has been exhausted and a public display of offences committed is required, then I would again like to advise you to be more selective, precise and accurate and evade generalization of an issue. After displaying the 4 cases, your summary of “newer generation” sinking the healthcare ship down an abysmal whirlpool sounds extrapolated and generalizing all members of the newer generation. It is good that the public are starting to be more knowledgeable and starting to sue us to keep the whole in check, but unnecessary generalization of the whole being incompetent will only bring prejudice in the public.
Truth be told, I am not a part of this new generation, but I do feel that they are salvageable, if not improved. I do have family members in the system and I have seen their performances respectively, not that bad at all throughout the years. Junior MOs nowadays are trained in 6 separate disciplines during housemanship (despite how many they are per system), and at times I feel they are more competent than some of my colleagues ever were. A senior ortho-surgeon once did rounds in an anonymous hospital and asked for a patient to be referred to medical for “glycemic and BP control”… does this sound familiar?
…and a junior MO who just finished district said that there is no need because he can manage this patient’s DM and HPT despite being a newly appointed orthopedic MO. The surgeon lashed out saying they are not medical and medical management is medico-legally managed solely by medical. I bet MOs nation-wide can vouch for me on this one. Is such incidence not often? if it is, are they not done in front of HOs?
Who are teaching newer generations this crap and others?
At one moment of time, a few if not many district MOs (now a part of the older generations) rely on MAs on intubation, and mismanagement is turned on a blind eye because there is nobody else but the few MOs. Go ahead and ask the senior MAs and SNs. I asked a SN from Tanjong Karang, the newer generation of MOs, as MOs, are starting to utilise the OT in district to do small surgeries, some being very reliable and independent compared to the older ones. The older ones being they who were there in the 70s or 80s. Now they have specialized and turned old and start to condemn their juniors for the same thing that they have done.
Senior and famed doctors, as house officers at one moment of time did only 1-2 postings (maybe 3 at max) during housemanship. Go ahead and ask Dato’ P Kandasamy, Dato’ SIva (both from Seremban) senior consultants and lecturers, how many posting did they do as housemen?
We must acknowledge that the number of patients going to the government sector is increasing (hey, Malaysians are nowhere from getting richer except a selected few, and the rate of bankruptcy among the young is increasing). The increase in the number of MOs is irrelevant if it is not in exponential to the increase in the number of patients coming to the hospital. We must also acknowledge that the development of healthcare system has much improved compared to 30 years back, and patients are now choosing to come to the hospital compared to seeing Bomohs, Singsehs, Bidans, etc.
The issue is overcrowding of HOs, where only those who are truly willing to learn will survive, earning a credible reputation. The issue is not the whole newer generation going the bad, leaving the older generation (who in majority are resting in piece, near-pension, or earning big-bucks in private centers) to be revered as better doctors. There may be an increase in the number of incompetent doctors, but I feel that incompetence can never carry you far. The system itself has a multi-tiered strainer. The incompetents, if they fail to improve, will fail their masters, will never pass their MRCPs, will eventually be sued and have their career ended, will sell illicit drugs and have their career ended, will become politicians, or will end up in public health or become medical representatives, will become administrators, or will become a chronic GP with no customers, or will at least be known by the local population as the old-good-for-nothing doctor.
I have a theory…I call it the Senior Syndrome, and it is a constant reminder to myself and other senior-ly peers so that we will not embarrass ourselves with false self-proclamation. Here it goes:
“When we become a senior in a field, we tend to see the juniors as lesser beings compared to when we were in their position (as the junior) and we tend to remember all the excellent bombastic things we do, and “forget” all the humiliating mistakes we have done.”
e.g. There is this one Orthopedic Surgeon, a friend of mine, he brags during rounds that when he was a houseman, he took care of 60 patients alone, and was praised by his MOs and Specialists, and can do almost everything the MO can do. Yes, I will agree with him on all his given facts because they only happened after 4 months in the posting (extended of course) but I wonder why can’t he recall the day he cried when he failed to set an IV access in a patient during tagging, get scolded for 2 consecutive months, fractured a bone during CMR and nearly quit to become a medical representative? Must be the cerebral atrophy I guess…
Dear Dr. Paga, we are not discussing 2 different issues, but we are giving light to 2 different perspectives regarding the same issue. I must confess that my approach is to forever guide and teach, and aid my juniors, so that they can be better than me. I know they make mistakes, and at times some of their attitude is terrible, but I may have made the same mistakes myself when I was their age, and I may have displayed the same choler.
Teach our younger successors, their failure to perform will always mirror our failure to train them, or our mistakes in training them(regardless of how screwed up the government is)
P/S: I will check your facts about Malacca GH MOs hitting the number 50 though.
Well, I may have generalised the issue but that is the reality if you ask most of the HODs and supervisors. As I said earlier, lack of supervision is the main problem as you have rightfully said. Unfortunately, in the civil service, there is no way this bad apples can be removed! That is the problem. Forget about them not passing MRCP etc as no matter what happens they will still be in the system.
Actually even in those days we do use OT in district hospitals but it just depends on which hospital and how far is it from the nearest hospital.
Even though the number of patients visiting government hospitals are increasing , same can be said for private hospitals which is mushrooming everywhere. Why is that so? Simply because many patients are just using the government hospitals for chronic illness management. For acute problems they go to private hospitals. You don’t need to be rich as a simple medical card can treat any acute illness in private hospitals. AND patients still do go to sinsehs and bomohs but they end up in the hospital finally!
As you rightfully said, we should train them but there are not many trainers out there anymore in gov sector. Some are not trainable anyway!
Somehow I feel I know you. You must be from IMU or Seremban GH! BTW Dato Kanda and Dato Siva were my HODs when I did my housemanship in Ipoh! People like them are no more in civil service.
yes, some of the information said in there are so much true esp regarding the workload at a private KK. I came from KK seremban, despite increasing numbers of MO in the KK, the more you get MOs, the more jobs we have to do. eventhough we have atleast 8-9 MOs in OPD, but at times, it only left us to 5-6 rooms only because the others had to go for courses, relief at other KK which are short of MOs (from leave/ courses), so in the end, back to square one. some MOs have to handle program sekolah, occupational health, outbreak contact tracing, we are always on the move. despite having 8-9 rooms each day, we still see about 70-100 pts of range per doctor. sometimes, MOs at other nearby KK cut short, asked pt to come to our KK just to get a referal letter to klinik pakar eventhough dr particular MO at KK are just the same level as us and they can write the referal themselves directing to the designated department. because of this “no respect for own colleague” attitude, we are burdened with patients all around seremban/ nilai/ mantin/ PD/ lukut etc..all coming to us. patients now a days are very demanding too. its not easy to cope with the situation
i guess we all are not perfect, whether we’re working in the government or private. i had a pt ones when i was a HO in HKJ in OnG dept. she’s an Indonesian and she had a antenatal follow up at a private obs. hospital. on the day she was meant for her delivery, after ARM, she was noted to have TMSL, so the private doctor decided to do LSCS but because she cant afford the payment, she asked to be referred to my hospital. the worst part was that, she’s in delivery pain, already ARM with TMSL, but came to our PAC (patients’ assessment centre) alone by taxi. it could be because she couldnt even afford to pay for the ambulance payment. but itsn it so inhuman to let a pregnant lady who was in severe pain to ride a taxi on her own??? so its all about money…i had another case, prem in labour, also referred from a private practise, came in a taxi and actually delivered the baby. but the lucky part was that, atleast the doctor there informed us abt the incoming case. so we were all prepared. i was at the front door waiting and actually got up in the taxi and delivered the premmy in the taxi. but the former case, the doctor dont even informed us about the case and we were shock when she arrived at the front desk.
in KK, i have seen quite a number of cases where the GP ( this is more applicable to GPs rather than private hospital’s doctors)…diagnosed patient with diabetes and hypertension but no proper follow up, pt would come monthly just to get their medications, no proper blood investigation follow up, sometimes pt was not well educated about their diseases and illness subsequently defaulted treatment because they thought finish medicine, illness also gone. by the time they come to us, their BP shooting up, sugar super high….
i guess this is not just about incapable doctors, but the workload/ burden that we have to go thru. facing all kind of attitudes of patients coming in to KK like kedai kopi…(i’m serious)… in my KK on a busy day, we only have atleast 5 minutes per patient….everyday we hope and pray there would not be any negligence from us.
To me, with the increasing number of MOs in KK, situation should get better but poor management is the problem. The HOD’s are not doing their job leaving the KK poorly handled. There are also a lot of problematic MOs in KKs nowadays, taking EL as they like, going missing, coming late to work etc etc. That’s the reason you see patients from rural areas being sent to you for referral. If you check properly, you will know the reason. That’s why I keep saying that no matter what the quantity is, quality is deteriorating and there is nothing you can do about it as the bad apples cannot be removed. My wife is in KK and I know exactly what is happening. I had written about this before under Malaysian Healthcare system series.NO matter what you complain about an underperforming MO in your KK, nothing will be done.
I will come to ethical issues of private hospitals later in my series.
Forget about GPs. As you said, I have seen diabetic patients who has been seeing Gps for years but sugar poorly controlled and not a single blood test has been done over the years. Then you will notice patient will be telling you that sugar control is getting better!! woolah, his creat will be 500! diabetic cured!
Indeed there is a serious problem about our healthcare system. Honestly the quality of housemen and junior medical officers are really worrying. Today there is a houseman in our hospital who can’t even name the heart valves! I always told my housemen that I personally won’t seek treatment in the government hospital if I am a layman. Fortunately I know who to look for in government or private hospital when I am sick.
What is so important about naming valves?Can u name the ligaments of the ankle?Dont be so proud with so little knowledge and experience..Teach them,not scolding,underestime or belittle these juniors doctors…if they dont want to work,take appropriate action..
What else cal all of you guys do beside complaining here?come on do something that could fasten changes..Beside just discussing or complaining here,bring articles in this blog to the MINISTRY,MMC,MASS MEDIA and other which are related.
No point of just discussing here because nothing wont change…Nowadays,doctors need to do something really significant
FYI, knowing heart valves is basic science which even a Form 5 or Form 6 students should be able to answer. It is different then talking about ankle ligaments ! What the commentor is trying to say is that the quality of “so-called” medical graduates nowadays are questionable. If you do not even know the valves in the heart, how did you graduate in the first place? AND the seniors are not here to teach you basic science which suppose to be thought in medical school. Might as well you don’t go to medical school if you want the consultants to teach basic science.
BTW, you think MMC, MInistry , mass media is not aware of this? Please read DR David Quek’s article in my previous blog entry!
Yes, we actually trying very hard to teach to them everyday. However it is very difficult to teach if the housemen don’t have basic medical knowledge of anatomy and physiology. How to explain the pathophysiology of mitral & tricuspic regurgitation/ stenosis if the housemen can’t even name them? If we have to start from anatomy, the ward round will take forever to finish and the housemen will start grumbling.
There’s a difference between not being able to correctly identify where murmurs originate and not being able to name each of the cranial fossas. The former is real practical knowledge while the latter is almost never used in day to day medicine. I’d say being able to name wrist bones lie somewhere in between (I still cant… so fail lol).
Do you mean carpal bones? Ha ha, I still remember the mneumonic “She Looks Too Pretty, Try To Catch Her”, however can’t remember the name already.
Sally Left The Party To Take Cathy Home 🙂
as a medical student, i know that if u don’t know the heart valves, u will not be able to diagnose a patient that presents to u with a heart murmur etc, not all medical knowledge are equal such as the ligaments of the ankle & the heart valves.. if only u knew what u were talking about.
I was wondering, is there a maximum amount of times a houseman is allowed to be extended? If there wasn’t, I think those who can’t name something simple like heart valves or normal BP shouldn’t even be allowed to go near a patient. They should instead be forced everyday to sit in the corner reading on the lacking topics, until their answers can satisfy my questions. I mean, if I were the consultant I would do this. Solves a whole lot of problems – no danger to patients, no overflow of housemen (the good ones stay and learn with me, the useless shall rot at the corner). After all, I don’t pay their paychecks and I can’t fire them, so why not just let them rot in the corner as a HO until I’m satisfied with their performance?
They will continue to rot as they will still get paid at the end of the month whether they work or not!
That’s fine with me. How a man gets his rice really isn’t my business, since I’m not the one paying him. Oh yeah, and he can work to. By ferrying patients, sending blood, urine and stool samples, mopping the floor, buying lunch, washing my car… isn’t it great??! Why are the consultants moping around anyway. Just answer my reasonable questions and they shall be allowed to see patients!
There is only so much time a person can spend in a department as a HO before he cracks and quits.
Sorry to say, but you are being naive. Most HOD don’t want to extend the incompetent HOs to avoid all the paper work that they need to do. They just want the HO to get out of the department.That’s the reason the DG can proudly say that 95% of HO complete housemanship in 2 years! So, your theory of incompetent HO being extended, cracking and quiting DO NOT work in reality.
Don’t forget that corrupt businessmen are running the country. With the coming liberalization of healthcare, do you honestly think that ethics and professionalism is going to survive? I fear we may be approaching a dark age in malaysian healthcare (if we are not already in one), and may require a revolution of sorts to set it straight after a decade or two of underperformance.
Who’s going to be our Harry Potter?
btw Painkilling Machine sounds like an anesthetist, but somehow I feel he is Harwant Singh
I believe our profession will survive, provided we, the actual players, do not forget how we survived in the first place. This government’s effort in corrupting the healthcare system is nothing new to us, they have tried it before and forever they will try to do it again. Unfortunately we as doctors have no strong political power.
But every one of us have this obligation to make sure it will survive. I hope we can somehow turn our current misery to our advantage, and the only way I see it is for both the old and the young to play their parts.
The old, despite well, being old and maybe fewer in numbers, must always teach, encourage and try to shape the young, regardless of how horrible this process may be. You do not have to be a lecturer to teach a houseman. Our MOs, specialists and superiors were also not paid to teach us, and they were not lecturers, but they did teach us well. With each step of seniority we gain, we must show wisdom and inspire our juniors to excel. Even if we have to teach them to read again, we must. We have no choice, for we will someday be among our patients and die, and we cannot for now choose our successors; we can only train them. The day we give up teaching will be the day we end the future of our profession.
The young, despite being so many and less miserable than your elders were, must respect your elders. I care not for from where you graduate, but I take serious care about your performance. You must always challenge yourselves and prove to your predecessors that you are better than them or at least will try to be. However, I hope that you will not behave so rudely as your colleagues has exhibited throughout Dr Paga’s blogs. Remember youngsters, whatever benefits you have gained today, did not come from your writing to the papers, your parents calling the Hospital to scold the specialists, or your intelligence per se. Part of the benefits (calls are actually fruits of what your predecessors have fought for many years, through hardship, through petitions (we did not have cellular phones at the time), through strives you don’t even know existed. This blood and sweat of the old bears these fruits for the young, and for that I do think a meager of respect is necessary, for courtesy sake.
Survival is not about bringing to display the gap in comparative achievements, but about the continuation of the passing down of knowledge for continuation of improvement.
Of course there will forever be problems, but as doctors, by God’s will our effort will heal them.
I am just a nobody, no big shot, just a doctor.
Well said! Really well said!
To the so called “Pain Killing Machine”,could you suggest where are the best hospital to do housemanship?
Based on your opinion,is there any suggestion on how to fix this country healthcare system
Next,information that you gave through your comment were very encouraging,not demolarising,reasonable,not sarcastic,professional and very assertive.
Keep up giving the truth and not influenced by anything
Both Dr Paga and the anaesthetist(? pain killing machine) are giving their opinion on the situation.
Glass half full or half empty?
It’s the same ol’ story of the optimist’s rose colored glasses vs the pessimist’s prophecy of doom.
Neither is the more truthful.
It doesn’t matter if it’s half full or half empty …. as long as there’s whiskey in it
Just let me be a doctor.
You are not pay my salary.
The Government pay ok?
The degree I get from “X Uni” is recognized by MMC.
Why complain so much?
If got more doctor,the rakyat benefit.
See more case and less stress for doctors.
All the thing you say about heart valves,murmurs,not know antibiotics,cant read ECG all can slowly study.
If you really care the patient-dont complain.more doctor is better- ok, in private become competitive and price become the cheaper-the rakyat benefit ok?
Firstly, to be a good doctor you need a good command of ENGLISH. No one is stopping you from becoming a doctor. Nowadays, you don’t need brain or good command of English, just money is enough. But who cares how many patients you are going to kill in the name of “slowly study”! Reading ECG, knowing heart valves , knowing antibiotics are the reason why you go to medical school!! If not, why don’t you become a houseman after SPM.
Of course more doctors is better but more incompetent doctors is a disaster! No rakyat is going to benefit OK! BTW, soon doctors will become jobless, so what are you going to do?
wow…..the last reply really made my day and made us all reinforce the fact that there are some dubious doctors out there…man, apart from academic and aptitude, u need attitude….and please brush up your English……after 5-6 years of mugging all that English textbooks (and still mugging), i am pretty sure your proficiency in English would have improved…..but ,coming to think about it, maybe you didn’t do any studying in the first place……
and Vinod, Dr P is actually doing you a favour …..he is preparing you for your rather bleak future….
Most of the comments here like to condemn other people rather than giving constructive idea!!!What kind of doctors are this country having here and outside there??
In fairness, there are a lot of constructive comments out there. Read thru the comments in the other postings. Most of us know what needs to be done in order to improve the situation, but the people that control things don’t want to change.
Is it possible that you are oversimplifying the circumstances of the above patients when they met those so called government doctors who are waiting to get sued?
Your comments seem a bit harsh……
Nope. It is the reality. I have tons of examples. Do you know that government hospitals are getting sued almost on a monthly basis? Just recently a government hospital was asked to pay 2.8 million by court. Do you know how many cases are being settled out of court? That’s why once the new medical act is enforced, all doctors have to buy their own medical indemnity insurance