I found this article in the Borneo Post interesting http://www.theborneopost.com/2012/05/17/50-of-housemen-in-sabah-cant-cope-need-retraining/. For once, a top civil servant in a state has openly said that the current generation of housemen are unable to handle stress and the workload of a doctor. It is indeed the truth. Many of these housemen have some serious attitude problems where they think that they know everything and don’t need to ask or learn from anyone. Trust me, patients are getting smarter and more patients are going around doing further investigations on their own and seeking 2nd opinion etc.
Just 2 days ago I had a patient who came for a check up. He was just discharged from a district hospital after a MVA with cerebral concussion. He is known to have complicated diabetes on insulin therapy and was told to have renal impairment by the klinik kesihatan quite some time ago (2010) where he is still under follow-up. He was admitted for 8 days , not sure why but was put on drip and some blood investigations were done. Towards the end of admission he complained of shortness of breath but nothing was done by the doctor. He was discharged with the following medications:
What do you notice ?
The moment the patient walked into my clinic , I knew what is the diagnosis. He was slightly tachypnoeic with sallow appearance, classical of a renal failure patient. His Creat was 640 mmol/L.
So, do you see what I am trying to say? I use to say that doctors can save lives and kill patients with just a stroke of a pen!. This patient was given Ponstan (NSAIDS) which is contraindicated in renal impairment as it can worsen renal function and lead to acute renal failure! I am very sure the same medication was given right from the day of admission! I am also very sure a renal profile blood test would have been done. So, is this doctor who have completed housemanship successfully not aware of this, something that I knew even when I was a medical student?
Did you notice Ventholin tablet being prescribed? It has been ages since I prescribed Ventholin(Salbutamol) tablets to any patients. The fact that this tablet was prescribed to this patient shows that the patient did have shortness of breath before discharge!! Nothing was mentioned to this patient about his renal condition. His daughter brought him to see me as the shortness of breath was worsening. CXR showed fluid overload.
I referred him to GH for dialysis. I just hope he survives as he is just 50+ years old. I brought up this case as I feel very sad to see that basic medicine is not being practised. Did the doctor ever bother why this patient is having shortness of breath? Does he even care for this patient?
It is sad indeed………………..
50% of housemen in Sabah can’t cope, need retraining
by Mariah Doksil. Posted on May 17, 2012, Thursday
KOTA KINABALU: About 50 per cent of some 500 housemen in Sabah have to undergo retraining after being found to be unable to cope with work-related stress, while some of them were suffering from depression, according Sabah Health Director Dr Mohd Yusof Ibrahim.
He said the new generation of housemen or medicine graduates undergoing supervised practical experience is not the same as the housemen many years back.
“My personal opinion, the new generation does not having the ability to cope with stress and their field of training, especially those who graduated from overseas, are unable to face the same situation in our country,” he said.
“Under the new system, housemen are only required to work for an average of 60 hours in a five-day week with two days off, which is even better compared to our times when we didn’t have days off,” he told the press after launching the Queen Elizabeth Hospital 1 (QEH1) 8th State Clinical Conference on Sports Medicine.
Yusof said that apart from failing to cope with stress, those trained outside Malaysia experienced culture shock when facing the situations in the country.
Some claimed they are overworked, but most doctors were trained like that in order to be good doctors, he said.
Yusof said that apart from the hospital authorities, parents should explain to their children that working as a doctor is tough as it involves saving lives.
He stressed that the two-year training they received is not enough for the new generation housemen because it is very common to see many of them having to repeat their training before their posting to district hospitals.
“If they fail during the second training, we will send them to another hospital. I am sure all specialists and senior doctors are willing to help them because it is important to have
Pagalavan's Avatar 
If the doctor involved is under my jurisdiction, I would appreciate anyone who picks up a negligent act or mistake to contact me so that I can sort him/her out and prevent a similar incident from happening.
Yes you are right but the last time I did that, I was told to shut up and mind my own business. The problem with the current generation is that they do not want to be told/thought. Worst still when the person who is giving advise is from the private sector!
When I wrote a letter to pengarah regarding my earlier Tetanus case , I received a 3 sentence reply which was a waste of time !
Dr Pagalavan , i think it;s a bit unfair to compare your trained eye to that of a houseman however i agree that the doctor who saw your patient was simply taking shortcuts.. In regards to houseofficers in Sabah , i am glad Dr Mohd Yusof has voiced what all of us have been feeling that the shift system simply does not allow enough training to be instituted and merely creates doctors who think highly of themselves for merely finishing horsemanship … Just wait till these chaps reach the Masters level…. it will be another adventure altogether.
This is not a housemen. It is an MO in district hospital with no specialist. Furthermore, I am sure even a medical student can pick this up!
Dr.Paga, i am just curious in why you are pointing fingers just toward the houseman. Does the MO or the attending hold no responsibility to check or discuss the management plan for all their patients?
This is an MO. What I am saying is that the training they are getting is becoming useless.
This district hospital got no HO or specialist!
Well, that is true but doing discharge medication is part of the houseman responsibility if I’m not mistaken. My consultant used to say to me, being admitted to hospital is a good opportunity to check and balance our patients’ medications. Especially those patients who had like hundreds pill to swallow in a day.
This is a district hospital with NO housemen or specialist
I’m rather not blaming the shift system for the inadequate training of the young doctors. It is how they approach the system is more important. From my experience when I was working within the shift systems in Australia, the system did not really improved my working hours. All it did was improved the time roster on the paper only. I admired the attitudes of my work acquaintances in the way that we will try our best to sort out our own patients; instead of pass over to the next doctors. We will do that even though we have to stay 3-4 hours extra. We tried to maintain that culture within our hospital, and most of us happy to do that because we want to learn and accept the expectations in regard to our professions. I think the problems lies in the fact these young housemen probably not that keen of being a doctor or have different expectation when they applied for medical courses. I really wish that the government can organized something like work experience placement for the SPM takers. Lets the students knew what they getting into before wasting years of their life for something they not happy to commit to.
merely : there was a time when JPA scholars were placed in hospitals before they started their courses. haven’t seen them around for awhile though. IMO quite useless, because one will never feel the stress of a doctor by just hanging around during office hours 5 days a week. Also, Malaysians will not give up a ‘prized’ govt scholarship no matter what, esp the parents.
regarding the story u share, patient with renal impairment and discharge with tons of inappropriate medication, why the pharmacist dont say anything? or perhaps the pharmacist too scared to intervene the doctor’s decision? i thought doctor and pharmacist work together, of course the doctor had the veto, but pharmacist should say something in polite ways.. or did i too naive?
Dyana : even in state hospitals, there are many wards without an in-house pharmacist. As this is a district hospital, the pharmacist is most likely in the dispensary/store. They wouldn’t know the current clinical condition of the patient. Also, the new house pharmacists nowadays can be as bad as the HOs. Just this week I had one who refused to dispense diclofenac gel to a CKD patient, because ‘it is bad for your kidneys’. *facepalm*
Why many wards without an in-house pharmacist? Isn’t there was a complaint in the news (not sure in Star or NST) that there is a surplus of pharmacists and many of them cannot get a job?
When you talk about government service , we talk about the number of post. It is NOT unlimited. So, the number of post filled has already reach almost 90%. Same will happen to doctors soon.
There is no such thing as in-house pharmacist if what you mean is pharmacist following doctors or doing rounds in wards!
Just this week I had one who refused to dispense diclofenac gel to a CKD patient, because ‘it is bad for your kidneys’. *facepalm*
y u facepalm?
Absorption of diclofenac (or any NSAID) through the skin is very limited and has minimal systemic effects. Therefore application of NSAID creams / ointments is proper, definitely NOT BAD for your kidneys. The least the pharmacist could do was call me up and ask, rather than provide ‘ajaran sesat’ to an unsuspecting patient.
I am not sure where you work BUT in Malaysia, pharmacist don’t do rounds with doctors. In some big hospitals, they do but usually will be the junior intern pharmacies.
THis is a district hospital with no specialist. There will be only 1-2 pharmacists in the hospital, usually doing dispensing work only! They don’t see patients!
Asked on Behalf of Jobless Pharmacists: too many pharmacists as per MoH’s posts for pharmacists, which hasn’t increased in proportion to the workload.
same thing for specialists/MOs. my dept’s specialist posts have not increased for more than 10 years.
**clarification: in-house pharmacist in my previous comment applies to in-ward pharmacist who should know the clinical condition of the patient. most hospitals do not have such pharmacists.
Sorry Dr Paga ,, Point noted… It’s definitely negligence on the part of the MO then… It’s funny how these chaps get away with such gross mistakes actually
The system will make them to get away! Try complaining , no action will be taken. The same salary paid every month for ‘killing’ patients!
Well, I am not sure how doctors are trained today
When the patient walks in, his manner will hint the doctor what is wrong
when you take a history, the doctor already diff diagnosis in his mind
when you examine a patient, the doctor confirms the diagnosis
when you investigate with a scan – uss/CT/MRI you are deciding what treatment mode are going to give……
today…. labs will investigate,
then seeing the results, the stupid doctor tries to find an answer to the result..the classical example being low hb and when you examine the patient she is either pregnant or a huge fibroid that is missed…..
CT/MRI is used and misused to look for a lesion….how can one use a diagnostic method as a screening tool
Dr Paga, look a BP Diagnostic centre….
they have a half cooked Medical officer who gathers all results, gives vaccines
then they carry out osteoporotic study with a heel scan. uss and Xrays are done by a technician, send to by email for the Radiologist to interpret. Small insignificant cysts causes anxiety to the patient…so they are using diagnostic tools as screening tools…..shooting without an aim and at the same time causing anxiety to the client or patient as bystander who can be shot at any time and be aware…As you have said….situation will worsen…boleh Malaysia boleh………………
yang
It all started in the name od medical tourism!! Money money money…………
Dear yang,
I couldn’t agree with you more. The American style of doing every investigation under the sun on every patient, and then looking for abnormal results is a substandard way of practicing medicine. Money, time and resources are wasted (one reason why the US has poor health outcomes despite spending twice as much as any other country on healthcare) and patients are exposed to harm due to the number of false positives that over-investigations inevitably result in.
This is happening even in Singapore, where the PUBLIC hospitals are offering health screening packages – the PAP Corp wants the public healthcare sector (i.e. their health clusters) to make money. Their motivation is money rather than lack of confidence in their clinical judgement (which I think is the problem in Malaysia)
Doctor, I may not be a doctor but I feel that the doctor mentioned in your article is incompetent, i.e. not properly trained!
Perhaps, because of this he don’t even know what he was doing!!!
Nowadays, I understand that those from unrecognised medical universities have to take a qualifying exam and they can go on taking it after every failure until they pass!!!
Unlike previously where they are out of luck after three tries!!!
The whole health care system in the public sector is a shamble; no thanks to the Health Ministry!!!
Of course, senior government officials don’t have to subject themselves to such incompetent service.
Most probably, they will go overseas for treatment!!!
Not only the HO. The Health Minister, High Educational Minister and MMC also need retraining. They have created the mess and now want the specialists to cover their ass? Dr Yusof request will not stop the problem because the root of the problem is not solved. Dr Paga already mentoined the problem but told to shut up instead they want the specialists to cover their mistakes. The problem is too large to be tackled. Since we can’t control the medical schools, high education minstry, health ministry, the napolean, MMC and others. The last resort is to create awareness among the parents and medical candidates. You successfully taught one incompetent HO but after that the ministry won’t thank you and send you another 10 more to thank you.
I am opposed to the idea of working 70 hour weeks.
Life’s about balance. Yes being a doctor is supposed to be stressful but to what point?
With the increase in the number of doctors, working hours could become more sane: say, 8-10 hours a day, five days a week.
Give them 2-4 hours of protected teaching time a week.
moderate working hours also means less stress… which is bad because it inhibits learning and is fundamentally bad for health on so many levels (effects of cortisol).
Subculture within a hospital is also to blame. Once upon a time, I myself almost signed off some ketorolac for a guy who walked in to abdominal pain. Turned out he had a eGFR in the 20s and creatinine in the hundreds. Why? Because the over enthusiastic nursing staff had drawn up the stuff and were like “hey the pt in bed 10 is in pain. i’ve drawn up some ketorolac and could you please sign this off?”. I was as green as doctors come and looking after a few patients in ED simultaneously…Hadnt got down to seeing the patient yet (he just got transferred into a cubicle). Thank god I checked.
Junior doctors need to learn to to be pushed into doing things like signing off orders or blindly filling up discharge medications: something I myself have done in the past in high-turnover scenarios like the ED short stay unit – copy/pasting patient’s inpatient drug charts onto prescription forms. Quite often you dont really even know the patient that well because they are under different treating teams – you only know the current plan by the patient’s treating team and you assume the drugs on the inpatient form is correct. There is all the possibility that the doctor in question knew about ARF and whatnot but after being overworked he was just following orders from someone to “fill up the discharge meds form” blindly. This attitude has to change.
eek… learn NOT to be pushed into doing things. [Correction]
From the details from the notebook, I can only understand that the patient was admitted for CC for 8 days(If there is any worsening, shouldn’t the patient be referred to bigger hospitals for further ix, CT brain etc, if not done yet). I’ll keep it in mind that maybe I should admit my patients for CC for that many days the next time as well. Just to keep the wards full… Lol!
Hi Dr.Paga, I’m curious why only certain hospital have in-house pharmacist. I’m final year medical students who did my elective posting at Queen Elizabeth hospital not long ago. Throughout my 3 weeks posting there, while joining the ward round every morning,there was pharmacist (2 of them actually,one senior another was a junior) following ward round.They follow ward round every morning, and I noticed sometimes the specialist will even discuss with the senior pharmacist regarding management of the patient.(mainly on the medication, side effects..) So, it seems that in this hospital the in-house pahrmacist do involve in the care of the patients..
This happens only in big state hospitals. Smaller hospitals does not have this kind of services. Furthermore, it also depends on the management of the hospital and the number of pharmacist in each hospitals.
[audio src="http://bfm.my/assets/files/TheBiggerPicture/2012-05-15_DavidLim_LeavingTheCountry.mp3" /]
Haha, this guy was my student at Monash, the first batch. The difference between Australia and Malaysia is the standard of the houseofficers recruited. Australia has a good quality control whereas in Malaysia, everything BOleh. The problem now is that there are too many housemen with inferior quality and the consultants can’t do anything about it. So, who will not get angry. I can tell you that half of the current housemen will not be fit to work by Australian standards.
Congrats to this chinese guy. I believe many medical grads wish to work overseas. Easy for a person who have secured a job in Australia to be that vocal and critical about Msia HO training system. Sooner or later those who remain in this country is not by choice but due to circumstances….
Dr Paga is the exception…perhaps.
The grass is ALWAYS greener in other side…Despite that I wanna go to Australia too if given a chance!!!!
Dear Dr. Pagalavan,
First of all, i would like to thank you on behalf of everyone for all the information that you provided.
I am currently a 1st year student in Volgograd State Medical Uni ( I didn`t chose here, i was given a scholarship). I`ve read some of your posts regarding Russian Med. Graduates and indeed, most part of it are true. But I`m not like others, i am a determined person who wants to be a cardiothoracic surgeon and hope to achieve my dreams one day. I have read from your blogs regarding how incompetent some Russian graduates are, and honestly i’m dissapointed too with the systems here. In fact i knew about all these before coming here, but unlike others, my family can`t afford to send me to Med. School if i were to reject the offer. Hence i am here, in Russia.
Well, sorry sir for the long introduction. I need your advises. i`d searched almost everywhere and asked almost everyone with Med. background abt it. But I think Sir, you are the most suitable person that can answer my question.
1)
Sir, I was told that Russian Grad`s cert aren`t really recognized in Malaysia ( Although we can still practice in Malaysia ), and specialization will often be rejected. Is that true?
2) Sir, is it possible for me to take USMLE? I can self-study USMLE at the same time, attend my normal lectures/classes here. Is it recommended? Will it make any difference? I know USMLE is not easy, but if i start early, with enough determination and discipline i believe i can make it through the 3 steps.
3) Sir, is it recommended that i take the USMLE Step 1 in year 2014, which by the time i already finished my 3rd year. I`ve actually skimmed through the USMLE Step 1 and cross reference with my syllabus, it is actually almost similar. Not completely similar but generally the ideas and subjects are almost similar.
4) Last but not least, what advice do you have for us Russian graduates here? Some of us, that i know of, we know that we are incompetent as compared to those who graduates from USM, UKM or Ireland, etc etc. But we make every lectures/ every class/ every knowledge counts so that we can one day me as professional as everyone and able to serve the nation. What advice do you have for us Sir?
I`m a really motivated person, sir. Despite what you posted, it never change my attitude and i never once feel like giving up, because i know what i am doing, i know where i am headed too, and what my passions are. I might be naive sometimes but i never give up.
I really hope you can answer my questions. I would like to say thank you in advance, your words and advises will serve as a catalyst for me to reach my dream.
A big thank you Sir.
It would be better if you could personally write to me sir,
email: opdaryljw@gmail.com
Just out of curiosity, if you’re a scholarship holder, why should you even bother with the USMLE? Are you not required to serve your bond in Malaysia?
Dear Train,
Yes, sir. You are right, i am obligated to work in Malaysia for a minimum of 10 years, but i love Malaysia more than what they are paying me in overseas, hence i will continue to serve in Malaysia as well in the future.
The are few reasons why i am planning on taking the USMLE.
i) To be “more” qualified in order to be on the list for specialization .
ii) To learn more and know more than just what they are teaching here.
iii) Last but not least, to actually boost up my confidence and to prove that, I am as competent as other doctors out there..
Glad you asked.
Thanks ^^
1) As long as it is recognised by MMC, should not be a problem. Whether your application to Master’s is accepted or not is up to the respective universities.
2) Yes, of course you can sit for USMLE but for what purpose? You are bonede and thus you need to return home. Passing USMLE also do not guarantee you a post in US. It is very competetive.
3) Up to you.
4) The most important training to become a doctor is practical training. No matter how many lectures you attend or how many books you memorise, you will not become a good doctor without seeing patients in the ward, taking history, doing physical examination and making a diagnosis.
I am happy you have real passion and interest in medicine. As long as you are willing to learn and work hard for the rest of your life, you will become a good doctor.
Thank you sir, for you time and advises.
I will really work hard to strive to be what i want to be..
Thx^^
dear beloved people,
having worked both in a state and district hospital, i would agree that the the junior doctors are really lacking good quality training.
but one cannot cast blame on either the seniors or the system or too many housemen, its like blaming the sun for skin cancer….
what the system also lacks is experienced seniors/specialists, the bulk of whom are distributed in state hospitals…
we probably have got more “un-specialized” doctors such as chronic m.os in our health system than we have specialists….and the production of more housemen has resulted in a bigger ratio of “un-…specialized” doctors serving our people…
and it would be a strain for the ministry of health and university to open up more seats for specialization course for our m.os…
if there is a way to make use of our current situation of too many junior doctors, to train them not only to complete housemen, but also to open up more avenues/career pathways for postgraduate training ( as the number of seats for local masters are limited ), it would help produce more trained doctors to take up the burden of our disproportionately higher housemen ratio..
Yup, this is what I have been saying. We do not have enough trainers!
Hello! I just wanted to share a brief experience of mine (or rather, my father’s), if anyone is interested.
My father was really ill, so my mother went with him to see a doctor (I wasn’t available to go with them). He came back from the clinic with packets and packets of unlabelled medication. I could hardly believe it – how am I supposed to tell what is what just by looking at the shape/size/smell/colours of the pills? All that was written on each package was the requisite dosage – an instance of the killer doctors that are released into private sectors these days, like Dr. Pagal’s case above.
Anyway, my poor father took the medicine and he got inherently worse the next day, so I went with him to a government hospital’s ED. There was a very nice young houseman there who took notes on my father’s condition. He was really enthusiastic about his job too – he’d only been working for a couple of months. An MO walked in and straight away started yelling at him for standing there! My father (who knew very well about the HO-bullying trend thanks to yours truly) despite being really sick, immediately defended him by telling the MO firmly that the houseman was merely asking about his condition, i.e., doing his job. The MO gave the houseman a suspicious look and went away – an instance of random houseman bullying.
After everything was done, the MO gave us his prescription, and again went away (goodness knows where to). However, the MO had forgotten to sign it! So the pharmacy refused to give us our medication. We told the pharmacist that this was an emergency patient and he really needed the medication. We’d been there the whole day and my poor father was really worn out by then. The pharmacists, despite our prompting, refused to go and obtain the signature from the MO because they were “scared” of the MO apparently. So we had to wait for hours and hours. The pharmacists even suggested we go home and come back tomorrow for the medication. – an instance of pharmacists refusing even to ask the MO if she had authorised the prescription. Thus, I think as in the case Dr. Pagal has raised here, pharmacists would rarely (like the “ajaran sesat” case above) dare to intervene with a doctor’s decision. Or is it an instance of an MO extending bullying to the pharmacists?
Hours and hours later, the HO passed by and saw us and he asked us why we were still there. We told him the situation and he kindly signed the prescription for us. After all, the MO did give us the prescription – she just forgot to sign it. Might I add that if it were the other way round, the MO would probably skin the HO alive for forgetting to sign and then doing a disappearing act for hours!
wow, sounds like she passed the a55hole’ism #101 course with flying colours, with a next level antisocial aura surrounding her – striking fear in those who dare ask her anything.
Under the private healthcare & facilities act, all medications given by clinics MUST be labelled!! If you are sure it is not labelled, please make a complain to the state UKAPS unit.
What you have just mentioned above about the MOs attitude does happen and I will put the blame on the HOD and the system. Most HODs in government service now are not bothered what the junior MOs are doing.
@ Mint Berry Crunch: Ahaha, that is such an awesome description!
@ Dr. Pagal: Yes, it is totally unlabelled and I was really indignant about it too. However, the doctor seems to rather old (verge-of-retiring-old) and he doesn’t seem to get many customers at all… so I thought I should let him be instead of breaking his “rice bowl”. Maybe I should just give him a well-meant reminder so he doesn’t do it to other patients in future!
Suggest drawnsands to name the hospital so that the MO concerned or MOs there (could be more than one with such attitude?) may happen to read this blog and will change their attitude.
Trust me, nothing will change. The best change wil be a transfer ! you are talking about our civil service!!
@ Williams: I think if the MO actually reads this blog, she will change/ continue anyway, regardless of whether or not the hospital is named. It is more probable that she won’t care. =(
Update: My father went back for another procedure and there was an MA there who asked him, “Cancer ke?” ….. As a result, my poor father came home all depressed, thinking he’s going to die, voicing his intentions to make a will etc. In fact, there’s no diagnosis as of yet (still waiting on it), and even if it is cancer, it doesn’t have to be malignant, no? It’s really insensitive, crude, and judgmental, even, to just literally set eyes on a patient and ask him crudely if he has been diagnosed with cancer. The MA doesn’t even know anything about my father’s condition! I hope our medical friends will learn to be more sensitive (at least, those that weren’t prior to this) after reading this. If it is a real diagnosis, then OK, I do not expect someone to pass me a tissue and pat me on my back and give me a shoulder to cry on. It just angers me a lot to have some young hotshot pronouncing random, uncalled-for fabricated opinions matter-of-factly and ruining a man’s spirit for nothing. My father is still really depressed now. Thanks a lot for breaking a patient’s spirit, MA.
When I was a house officer, I remember continuing all medication for a newly admitted patient with CKD who was prescribed NSAID at the KK. My nephrologist stared me to death when she realised my mistake. It was one stare that I will never forget in life.
I remember when I was a house officer, I continued all medications for a newly admitted patient with CKD who was prescribed NSAID at the KK. My nephrologist stared me to death when she realised my mistake. That was one stare that I will never forget in life.