Case 1:
2 weeks ago, a 60+ year old man came to see me. He came with 4 days history of inability to open his mouth completely, unable to protrude his tongue, stiff neck muscles and upper back. He denied taking any medication such as Maxolon. He has a chronic venous ulcer of the RT ankle area over the last 1 year.
I examined him and found a locked jaw, inability to protrude his tongue with stiff muscle of the neck. His venous ulcer was dirty and full of slough. As a benefit of doubt, I gave him stat dose of IM Kemadrine but after waiting for more than an hour, no response was seen which excluded oculogyric crisis. A diagnosis of TETANUS was made. Since I did not have Tetanus Immunoglobulin in my hospital and the patient unable to afford admission, I referred him to the general hospital. I wrote the word “TETANUS” huge enough in the referral letter that any “monkey” can see it . I thought everything would have been taken care.
Today, I heard the horror story of what happened to this patient. He was seen by a doctor at the GH who did not even bother to read and take note of my letter, not sure whether he/she even examine the patient, did a TMJ Xray and referred for an appointment to see a dental surgeon!!! The patient then decided to go to another nearby private hospital despite his financial constraints, to get admitted and be rightfully treated as Tetanus.
Case 2:
A 3 months year old baby was brought to a district hospital for recurrent jerky movement of the limbs and up rolling of eyeball to left. He was seen by a doctor and discharged claiming that FBC was normal as thus nothing to worry about!! The baby was brought to our hospital the next day with almost persistent on and off jerky movements and my pediatrician said that it was a clear-cut seizure. A diagnosis of meningitis was made but unfortunately, it is probably too late. The seizure was resistant to anti-seizure medications and had to be intubated and sent to general hospital for ventilation. Most likely the baby might have developed hypoxic encephalopathy and may develop CP in the future.
Case 3:
A 86-year-old man was admitted to a GH for fever, cough and lethargy. He was diagnosed to have Left basal Pneumonia and treated with antibiotics. He was discharged after 2 days and given appointment 2 months !! We all know that a simple pneumonia can cause death in an elderly man. He was brought to see me today with worsening condition.
Has our standard of healthcare gone this low? Is this going to go into a vicious cycle of mediocrity? The first case is a blatant disrespect to the physician who referred the case. I presume the decision was made by an MO who probably would not have seen a single case of Tetanus in his/her life! Probably, he/she do not even know what is tetanus!! If you don’t know, please ask a senior or call and ask a specialist. Worst come to worst, just admit the patient based on the diagnosis given by the private physician. I find this as a serious attitude problem which is affecting some of the current generation of doctors. No respect to other doctors or colleagues, especially if the referral comes from a private doctor. I have seen many cases like this but I am just giving an example.
I don’t know what to say about the second case! How can a recurrent jerky movement of a 3month year old baby can be normal!! This was exactly what Dr Wong YO was saying in his letter yesterday. Doctors nowadays depend on investigations then taking proper history and examining the patients. Just because FBC was normal, the patient was sent back home!! Do you know that FBC can be normal in sepsis? Whenever a medical student tells me that the WBC is normal and thus infection is excluded, I will tell him/her to fly kite!
The 3rd case just proves that there is lack of empathy to elderly patients. A pneumonia can kill an elderly patient. This is a well-known fact. It is one of the commonest cause of death in the elderly. How can you discharge the patient and give an appointment after 2 months!! Even if your bed is full and need to discharge this patient, you should have arranged an appointment to see him within the next 4-5 days or even earlier.
I have a feeling that the situation is only going to get worst with the glut of doctors that are emerging and lack of good trainers. What Dr Wong YO said will come true that doctors nowadays do not have the passion, empathy and genuine interest in treating patients. I feel for the patients.
Pagalavan's Avatar 
Too bad! Too many junior inexperience doctors in public hospitals working without adequate supervision by the seniors. Most senior consultants have washed their hands for various reason, left the system and let them rot by itself. All of us are partly to be blamed but the biggest culprit is the MMC and MOH for not doing enough to retain the experienced consultants.
Yes the MOH is to blame. But we cannot keep blaming lack of supervision when many of these junior doctors never even bother to refer to more experienced doctors. These spoilt brats simply DO NOT CARE for anyone except themselves. They (and their doting parents) must take some responsibility for their own behaviour too.
In my hospital, I have seen private physicians making the effort to call the specialist in charge of the ward informing them about the cases they are about to admit to their wards. And in their referral letters, they do state that they have spoken to dr xxx. The patients do get admitted from the A/E without much hindrance.
Perhaps, this is a good practice that we can emulate.
Yes. I do that as well but even then I have seen some junior doctors behaving like they are the super consultants. They can even discharge the patient home despite you have written that ST so so……. It has happened before.
The only time it does not happen is when I transfer the patient from ward to ward using my ambulance.
this is the result of “cheap affordable MD degrees with no entry requirements” at degree mills of
the countries we are all aware of.
So many good doctors, very very promosing and talented people, have left the service for two reasons.
1. Poor remuneration for initial investment into studies
2. Discrimination for postgraduate studies
You may argue that doctors should not be affected by money, but lets be frank. A lot of the good ones are not local grads, and due to nation building (discriminatory) policies, they had to pay 250-400k out of pocket to become doctors.Salary issues aside, they are chucked to some crazy small town to serve while their ‘luckier’ counterparts, who despite being given full scholarships etc, are sent to urban places under top consultants as M.O’s.
ok fine.
As an M.O, the game plan is work hard, play little, study for Part 1 of something-something, and pray you can become a surgeon. Those ‘luckier’ counterparts or those with cables will be chilling around not doing anything. What happens? Clearcut postgraduate studies discrimination. You can call me whiny… you all know what happens. “My junior who I taught how to do a procedure, and still needs my help, gets into Masters before me” is very very commonly heard.
So, what happens? Good doctors leave the service, becoming GP’s. There they flourish. They excel. They own practices and start to make a decent living. Sure some are unethical, but most of them enjoy the autonomy and freedom of being principal practitioners.
Whats really happening is that MOH Human Capital is flowing out of “public specialist” domain to “private generalist” domain.
So what you have are a huge bunch of good GPs, profit minded of course, serving the people who can afford their services. Aesthetics, diagnostic tests, labs, whatever la.. you know its happening.
ok now i feel better after ranting.
Which is why, now, we have this great 1Care plan. Integrate the “private generalist” with the “public specialist”.
Get all those who worked hard to plug the holes of the weak and incompetent.
Way to go Geniuses.
Before you know it, someone plays the ‘rascist’ card. And we are back to square one.
There is one simple simple way to solve this problem.
The DG of MOH and the President of MMC should never be the same person. Too much conflict of interest. In the UK, they are not just different people, they are always at logger heads.
Then we have a chance to liberate some healthy competition and quality. Just saying.
I disagree with 1care…great for what?..rm60 for dr consultation..pharmacy benefit most..
I wonder what would happen if Dr Paga was the President of the MMC
1. Derecognition of most private university’s degree, especially the hopeless ones
2. Strict enforcement of entry criteria to medical schools in order for qualifications to be recognised
3. Total review of recognition of qualifications from foreign universities
4. Stringent testing of doctors during housemanship to ensure only the ones who meet standards are passed
Would be even better if Dr Paga becomes DG, Minister of Health, Minister of Higher Education.
In view of the coming election:
Dr Paga X
Calon BN
Calon PR
Or as an independent candidate… like a boss 😉
I agree with you..this is how we should be..
Dr. Pagalavan what do you think of this article
http://thestar.com.my/news/story.asp?file=%2F2012%2F3%2F26%2Fnation%2F20120326215658&sec=nation
especially on the post graduation part
already they are taking students with poor qualification and from 6 month post-spm foundation with crappy spm results . with per intake 230 + students and they have two intakes per year . Now they are planning to build a hospital and Postgrad Training center for all their students to specialize . Will things get worst ?
It’s politics. Politicians are trying to make money from our innocent society. Most private medical colleges in Malaysia do not even have enough staffs to teach medical students!! I wonder who is going to teach the postgraduate students? As usual politicians talk non sence as though you can do postgrad immediately after MBBS!
will that be a burmese hospital? just being sarcastic.
by the way, do you think it will become a teaching hospital for the MMMC student like HUKM and UMMC? Is that means student no longer posting in Muar Hosp? (personally i think Muar will have better exposure than the new hosp)
about attitude problem, i can see a-lot right now, i can say those who study not by parents’ pressure is less than the fingers you have.
problem is surely the entry requirement.
Yes, most likely MMMC will make this as one of their teaching hospitals. However, they will still use the gov hospitals as Manipal Hospital will be a private hospital.
Now with latest SPM results out claiming to be the best in the last 5 years, am aniticipating the situation to get worse having practically most of them striving for a scholarship in medicine…Lord, I have no idea when will this end….!!!!
It will end when doctors become jobless. Only then parents will begin to realise that after spending so much, no job to earn a living.
Nice article docs….keep it up. Enjoying reading your article
Experience its myself, wrong diagnosed & spending RM here & there.
Weird parts is GH docs send me for Neck X-ray after complaining of chest pain
With pain killer i’m discharge without any follow up
Finally meet you & diagnosed with Panic Attack
Thanks to you & Dr Siva….i’m getting my life back.
Thanks Chris. A good history from a patient can always make a difference.
im not going to blame anyone on this matter. yes, i do agree those situation should not be happening. it is against the oath we carry daily as a medical practitioner. we sometimes get carried away with our ‘status’. we oversee things.. human factors i suppose. we want and we need solutions.
We must think why one may act with such terrible decision making.
These kind of matter should have a formal report to the ‘upper guys’. Not for merely punishment or anything.. but for prevention of future mishap. We need to start taking things seriously. The unsafe acts (errors made and violations) are indeed influenced by numerous factor; Precondition of the unsafe acts.. (physiological,mental health, crew resources, etc.).. Poor / unsafe supervision.. organizational influences.. any major loop holes in each sections contribute to Dr’s mismanagement and neglects.. We have to voice it out on proper channel. Doctors need to start to love what they do and do what they love. Back to basic. Last but not least.. 30th March 2012 is a Doctor’s Day (in US at least).. HAPPY DOCTOR’S DAY. 🙂
From my past experience of formal complains, the file will be classified as NFA (No further action). Sometime the staff will be transferred out to KK so that they can kill more patients!! I am writing a formal complain for the tetanus patient.
Poor baby… and I just did did bloods (a traumatic experience for me :p ) on an infant that was smiling, distractable, feeding well, having lots of wet nappies, and afebrile. All because the mother was concerned he was feeding “a bit less” and a slightly erythematous area around the umbilicus that was about to fall off.
The cases highlighted by Dr Paga are clear cut negligence.
Whining about the standard of education and lack of support does not absolve the individual doctor who made the mistake…. at least from a legal standpoint. Hope the patients dont lawyer up.
hi doctor Paga.
i have just finished my SPM in 2011 and had been following your blog since February 2011. I understand the current issue of malaysian health care system Since i am a chinese and so i am thinking of going to taiwan for my med education. This is because Taiwan and china are having a project that encouraged all chinese that are living oversea to come back to “our country of origin” for tertiary education at a very attractive tution fees(around RM25K per year). So i am just wondering are u familiar with taiwan training system after graduation and how does it postgraduate training system works?
Are you sure you can get RM25k per year for a medical degree? Please be careful. Double or even triple check with the relevant authority in Malaysia or even Taiwan to make sure your degree is recognized and enable you to work here in Malaysia or Taiwan. Medical school usually don;t come cheap and in Malaysia there are many con man, please be very careful.
i know i sounds like a trap but this thing does really exist. If you understand Mandarin u can google search“侨生”. going to taiwan is real but the fees does not being said on the net. The fees are heard from a student of my father (my father is a teacher) which are still in med school now. And i also heard this project from a classmate of my aunt, where she is now still in Taiwan and now already a pediatrician.
Yes. Malaysians have been going to Taiwan for many years for medical education. Only 8 universities are recognised in Malaysia, all after 1996 http://mmc.gov.my/v1/docs/Jadual%20Kedua%2011-12-09.pdf. However, Taiwan follows US system where after internship, you will go directly to specialisation. After 3 years you can call yourself a secialist. This postgraduate training system is not recognised in Malaysia by NSR. However, since the specialist accreditation is not legaly enforced in Malaysia, many are coming back and claiming they are specialist. Personally, I find many incompetent specialist “trained” from Taiwan. I know 1 who claim he is an anaesthetist but did not know how to intubate!! Another who claim he is an ENT surgeon but did FESS surgery for 4 hours when it usually only takes less then 45 min!
Those examples mentioned by Dr.Page could be the exception rather than the rule. Just like how in Malaysia we have people (many of them) who slipped through the cracks. It happens in many other countries too, not excluding the US, Canada and Australia. I am not convinced that all products of taiwanese residency (postgraduate training) program are incompetent. Probably depends on many factors including the medical school, postgraduate training program and the student’s own ability.
I find that the line ‘ a project that encouraged all chinese that are living oversea to come back to “our country of origin” for tertiary education’ sounds like a perfect con man phrase. I would be very careful if I were you. SOunds like a trap.
taiwan’s government has good subsidies towards tertiary educations. All taiwanese go to uni. without paying anything, and overseas chinese get the benefit of tuition fee discount. However, to get the benefit u must take qualification from the independent chinese school’s exam, which study chemistry and bio in chinese. students holding A-level and STPM etc is not allowed to enter their chinese MD, I’ve no idea regarding the parallel running english degree. u have to ask Dr.Paga’s opinion.
Personally i think their specialist is abit weird?? My relative holding several sub-specialty at once??? not sure how their system work, but definitely not like malaysia.
As I said, the speciality training is weird as you said. After intern, spend 3 years in internal med and you can call yourself internal med specialist. Then spend another 3 years in emergency department and you can call yourself Emergency physician. As far as I know, there are no proper exams or degree. You just need to register with the Taiwan Society of ………. and you are know as a specialist in …… etc
Dear Dr.Paga
I emailed my friend who is currently in a specialist postgraduate training program in Taiwan and this is her brief answer on the training and qualifying exam for specialist in Taiwan
Reply:
—“There are quite a few overseas Chinese doctors (e.g. from Myanmar) who take the harder/difficult jobs like internists or ED positions to earn good money without first passing the national board exam. (it is legal as long as they work under the supervision of attendings). This occurs atregional hospitals where they are underserviced but not in major high-volume centers.
The specialist system is very well-established. It is only natural for any resident to pass the specialist qualifying exam and obtain a specialist’s qualification —> every doctor I know(so far) goes through this process with no exceptions”—
From my friend’s reply. I am unsure if those people who went back to Malaysia from Taiwan without passing a specialist qualifying exam is supposed to declare themselves specialist (even if the had been a “specialist” in those under serviced area in Taiwan”). It sounds illegal and that those probably should be investigated.
yup, I agree. That’s the reason why I said that proper regulations should be in place before we give license to practise for doctors returning from overseas. Previously they suppose to do compulsory service and thus they will undergo gazettement process in MOH. Now, with this new rule , no one supervises or monitors them. NSR is not compulsory yet and thus some private hospitals are using these “untrained” guys to make money.
Remember I told you about ENT surgeon doing FESS for 4 hours!! Today, he appeared in the newspaper http://www.bharian.com.my/bharian/articles/Kapastertinggaldalamhidung/Article/
To be honest I find many young doctors today interested in material acquisition rather than work on becoming a skillful doctor. I have many young doctors friends who do locum like crazy without having enough sleep and then go to work in hospitals only to be like a half dead person and diagnose a patient. Please look at the doctor who is serving you, if he/she looks worse than you are be extra cautious. I am not making this up….it’s all nothing but the truth.!!!
Yes and the shift system is making more of this kind of doctors.
Precisely, I don’t understand the young generation doctors these days. They think having a DR. in front of their names means they need to own themselves a fancy car, nicely renovated home to show off their status to the society. I never thought it will coem to this extend, many of them whom I had considered to be good frineds have become very pompous and status conscious people.
Dear Dr Paga and all,
I have realized that there had been misconceptions regarding the medical education in Taiwan as expressed above. Please allow me to clear your doubts and, unfortunately, any misunderstanding you might have on this matter.
For your information, I was the national top scorer (national top 4) for STPM 2011 and had represented Malaysia in the International Chemistry Olympiad 2011 in Ankara, Turkey. I am now doing MD medicine course in Taiwan because, apparently, they have much transparent and unbiased admission process compared with the local “universities” we are all too familiar with. Merits and suitability in pursuing a medicine degree are qualities they seek and embrace, in contrast to blind ignorance of the declining quality of medical education our Malaysian officials are accustomed to.
What are the specialties of medical education in Taiwan? Well, for starters, it is strictly controlled and regulated by a certain Board for Medical Education of Taiwan, known as the Taiwan Medical Accreditation Council (TMAC), which uses standards to accredit medical schools that are comparable to the standards used to accredit medical schools in the United States. (Source: http://www2.ed.gov/about/bdscomm/list/ncfmea.html) The standards of accreditation are deemed equivalent to that of General Medical Council of the UK and even Australian Medical Council of Australia.
But that is not even close to what Taiwan’s medical education has to offer. A 7-year programme comprises the first two years in studies of medical humanities, philosophy, importance of the societal role of physicians, core humanistic values, medical history and ethics and the like. In the midst of medical education, we are constantly being asked, what makes a good doctor? The most self-fulfilling part of this is to always seek the answer to that question through practical actions. For instance, there are a myriad of volunteer activities from which we medical students can choose from, such as medical tour to rural areas, medical volunteering team to underdeveloped countries such as Swaziland and even serving the public in matters of public health education. From these learning opportunities, we have but obtained a chance to experience for ourselves the true meaning of being a doctor, to serve and to always be humble to the ones in need of help.
I shall continue to summarize Taiwan’s medical education but I shall seize the opportunity here in making corrections on the misconceptions mentioned above. We have stringent standards in working such that our medical education standards are on-par with other similar developed nations. For instance, we ensure that Taiwan-trained doctors are of homogeneous and superior standards through a compulsory national board exam which every doctor-to-be has to sit for after his internship. This is required even before we graduate from medical school. Would it not be absurd that we conduct our specialist training as loosely and as sub-standardized as what you have respectfully mentioned, that we are but “self-declared” specialists? We do in fact have tough standards in conducting our specialist training. For instance, the residency posts required for specialist training are competed for by most of the top-graduating class of Taiwan’s medical schools. This is so because there are limited posts for residency as TMAC has to ensure the quality of specialist training. The criteria required to complete the specialist training include many provisions such as paper publishing, clinical training performances and continuous clinical skills assessment. These are some of the papers I have found regarding Taiwan’s medical residency programmes:
http://www.ncbi.nlm.nih.gov/pubmed/16777633
Click to access 110301.pdf
By the way, many doctors from Taiwan had been able to complete their residency programmes in Taiwan or the United States, and proceed to expanding their medicine career in places where new sciences and knowledge blossom. Some exhibited the true spirit of being a doctor by providing professional services in the most destitute of areas, such as the Kingdom of Swaziland. Only a very small minority chose to return to places where partiality and ignorance had plagued and retarded the development of such an important field to humanity and the society.
If there is any need of further information, please feel free to let me know and I will try my best to answer any retaining doubts or questions which you might have.
Thank you.
Thanks for the info. TMAC is for medical school accreditation and undergraduate degree accreditation. But the issue here is mainly about their specialist training. I know they follow the US based residency system but the issue is how do we check whether these people who come back are properly trained specialist? Furthermore, many of them are very subspecialise specialist but the healthcare in Malaysia is totally different. They may be good in what they do but not necessarily good in general issues. For example: a gastroenterologist may be good in his field but in Malaysia you need to be a general physician as well and that’s where the problem arises. I know in Taiwan general problems are sorted out by their emergency physicians before referring to the respective specialist but not in Malaysia.
Generally Taiwan trained specialist do not give a good impression here. I know an O&G specialist who can’t do TAHBSO? She even needed supervision to do LSCS. I know a Gastroenterologist who could not manage a Cardiac failure! Just give frusemide and send the patient back. An anaesthetist who do not know how to intubate? This are real stories but they claim they are specialist in Taiwan, have worked more than 10 years and registered with the respective societies. However, I have seen a few emergency physicians who were good theoretically. Some of them may be good theoretically but not from clinical point of view.
I suspect some of these ‘specialists’ may not really be specialists. Maybe just people who are the equivalent of MOs or not completed their specialist training and somehow con the govt in Malaysia into thinking they are specialists.
Just like how we have multiple MRCP holders practicing as specialists in Malaysia without having gone thru the required clinical experience.
They don’t need to con as there is no regulations in place! MMC only gives you a license to practise as a doctor but not as a specialist. The onus is on the hospital who recruits them to credential these people.
I think those examples are not just happening within the Taiwanese trained specialist (and these people could have been the incompetent ones within the system when they can’t do what they are supposed to do!)
The examples give in regards to incompetency can happen to any specialist graduated from any countries where the incompetent one slipped through the cracks (i have been hearing many horror stories about Malaysian own graduates as well).
The examples where the specialists in other countries are not trained to cater to the health care system in Malaysia is a real issue and it’s really up to the Malaysian MOH to find a way to assess their suitability in working in Malaysia. And i certainly don’t think we can generalized it to everyone trained in US residency based program. In Canada and the US, in the smaller centres, there are many specialized internist who still have to play the role of general internist.
Yup, that was the reason the old system of 3 years compulsory service was better and a proper supervision could be done. Unfortunately now, we do not know how competent these people are when they just go to private unsupervised. In most countries, you cannot straight go and practise alone by claiming you are a specialist! The regulation is weak and we are not ready for this!
http://pagalavan.com
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Dear Dr Paga,
Thank you for your reply. I understand that the issue causation lies with the Malaysian authorities in their failure to regulate the qualities of doctors, or specialists in that sense, so as to ensure a competent healthcare environment locally.
However, just to clarify some remaining doubts on the issue of Taiwanese trained specialist, I have enclosed here the rules and regulations, the criteria, and even the paper-based board examination questions (one part of the continuous assessment in the residency training programme, as I could not find past years of the clinical skills test) of the neurology residency training programme.
I apologize because I could not manage to find the English version of these rules and regulations regarding the neurology residency programme, but I could briefly point out and translate some important contents:
http://www.neuro.org.tw/park/park_paper.asp
There will be a board examination every year for residents who have completed their specialist training. The examination comprises both theoretical and clinical skills phases. As you can make out from the schedule attached at the bottom (they are usually very transparent with regards to implementation of policies ), the resident in training will have to sit for a final exam for every year of training and is assessed by consultants monthly. The results will be announced openly through a name-list made public. For neurologists who want to renew their license, the renewal outcome is based thoroughly on credits of which one will accumulate throughout their practicing years with various academic or clinical achievements. For instance, whether one publishes at SCI journals with high impact factor, participation in international medical conferences etc.
Past-year questions can be found here:
http://www.neuro.org.tw/park/park_school.asp
The lesson we can learn from Taiwan is that they always revise and try to improve on their policies as with what they have been doing lately with their renowned National Health Insurance. May this quality be known and practiced by Malaysian authorities so as to lift this country from stagnation in development.
Im a 4th year medical student in a local uni, i would like to state my disappointment with the government hospital and clinic..
my late grandfather who was 66 years old, had painless hematuria last year in september, unfortunately the doctor in Klinik kesihatan had treated him only as pyelonephirtis, but in december he had sudden onset of complicated left inguinal hernia, then after the inguinal repair he had been having loss of appetite and loss of weight. besides he also have constipation..
in february this year, he had severe abdominal pain, after brought to the hospital, they finally found that he had abdominal mass on the left lumbar region suggestive of renal mass..
he was finally diagnosed with left renal mass carcinoma, in march, fews weeks after that he passed away..
my main concern here is why didnt they do ultrasound at the first place, as painless hematuria in an old man in enough to suspect cancer..
secondly while waiting for biopsy result in february and march, he had constipation and loss of appetite, he was very cachexic, sadly the MO refused to admit him to the ward regardless of his poor condition..
i really hate the part when they finally diagnosed him as RCC, they simply ask us to be strong to accept the fact that he was not going to stay for long.. it was such a disgusting experience..
This is what I have been saying all this while in my blog. The frontlie junior doctors do not have any empathy towards patients. With the glut of doctors currently, the situation will only get worst! However, RCC has a poor prognosis. The outcome would have been the same but I do agree that a good doctor would have referred this patient to a urologist when he presented with painless haematuria or atleast followed up closely
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