My first part of this topic received tremendous amount of viewers, reaching almost 1500 views/day since 07/01/2013. That shows how many were interested in the topic. I am sure by now they would have got the true picture of the pathway to become a Cardiothoracic surgeon and why there are so few of them in the country. I am not sure how many budding doctors would still want to become one after reading the article. It is always better to decide after you start working when you know the reality of a medical life.
Now, let’s look at Neurosurgery. This is another common question that I am always asked by budding doctors. Again, TV programs showing glamorous and rich lifestyles of neurosurgeon get them carried away without knowing the reality. Whenever someone ask me about neurosurgery, I always ask them to take a walk into any neurosurgical ward in any state hospitals and let me know after that, what you felt when you were walking through. Personally, it is depressing. Many budding doctors think that they are going to be operating on brain tumors and do wonders! Well, that is not the reality. Recently there was a comment in my blog of a budding doctor (just finished SPM) who wanted to become a neurosurgeon just because she heard that neurosurgeon are the highest earners!! Gosh, what kind of students are we producing? They really got no idea about the world out there. In government service, all specialists are paid the same based on your grade.
Brain tumors account for less than 1% of all cancers and 1/3 of it are malignant cancers. Most of these malignant cancers have poor outcome despite surgeries. The incidences are also low with less than 7 per 100 000 population. So, from here, you will know that these are NOT the bulk of cases that neurosurgeons are dealing with. The major bulk is actually motor-vehicle accidents with head injuries! Malaysia has the highest number of road accidents in this region. Thus, head injuries contribute to almost 70-80% of patients in neurosurgical units. The remaining are contributed by Intracranial bleeds (bleeding in brain) and finally brain tumors. BTW, most surgeries involving brain tumors will end up with neurological complications like epilepsy, limb weaknesses etc, even in good hands. Brain tumours involving children is the most depressing. I know a Neurosurgeon whose own child died of brain tumour!
Most intracranial bleeds have poor outcome as well. That’s the reason when you walk into any neurosurgical unit, you will see many patients who are bedbound, speechless and comatose. Many of them end up going back as a “vegetable”. Very few survive and go back fully conscious. However, there are some intracranial bleeds such as Subdural, Subarachnoid and Extradural bleed that have good prognosis if early intervention is done. This is where most satisfaction occurs. The procedures involved are usually simple, like burr hole, craniotomy and EVD. To be frank, these procedures are done by neurosurgical MOs in government hospitals and sometimes by general surgeons. So, you really do not need a Neurosurgeon to do these simple procedures. Nowadays, even interventional radiologists are trained to do cerebral angiogram and clipping of aneurysm !
Neurosurgery involves a lot of training and skills. This is needed mainly for surgeries involving brain tumors and spinal surgeries. These are delicate surgeries. There are a lot of advancement in microsurgery involving the brain and spinal cord. However, most of the time there is nothing much that can be done and the outcome is generally poor. I remember once I was talking to a Neurosurgeon about a patient who had massive intracranial bleed. The GCS was below 7. The neurosurgeon said that ventilating and doing cerebral resuscitation could save him. I asked him what would be his neurological recovery. The answer: well not much, his GCS likely will remain low and he will go back bed bound! So, what is the point? I am not undermining neurosurgeons but the budding doctors should understand that being a neurosurgeon is not about doing wonders. I know many who even dropped out while in training as they felt it is not worth it.
The entire state of Johor has only 2 Neurosurgeons in private sector and that’s all you need. In fact, the 2nd Neurosurgeon just started 1 year ago. Since 1980s, there was only 1 Neurosurgeon in private sector for the entire state of Johor. There was only 1 Neurosurgeon in JB Government hospital till about 2 years ago when another 2 joined him. It is a stressful job and in private sector, you need to come and see the patient at any time of the day as long as the patient has head injury. Looking at the road accident rate in Malaysia, likely you would be called almost every other day. I also know neurosurgeons in private hospitals who do unnecessary procedures just to get some money even though they know the outcome/prognosis is poor. You can save lives in the expense of poor neurological outcome aka “going back as a vegetable” to the dismay of the relatives who had spent so much of money. That’s the reality in medicine.
Now, let’s come to the pathway. There are 2 pathways to become a Neurosurgeon in Malaysia, the shorter route and the longer route:
a) Longer route
– 2 years Housemanship
– 2-3 years MOship
– 4 years Master’s in Surgery
– 6 months gazettment
– 1-2 years waiting period
– 4 years Neurosurgical subspecialist training
– another 3-5 years experience before being able to perform surgeries on your own.
b) Shorter route
– 2 years housemanship
– 2-4 years waiting period (min of 6 months experience in General surgery and 18 months experience in any other recognized field after housemanship)
– 4 years Master’s in Neurosurgery by USM
– 6 months gazettment
– 4-5 years experience before being able to perform surgeries on your own
Master’s in Neurosurgery by USM has a very limited number of posts offered, usually less than 10. So, the chances of you getting into this program are slim on first try. You also need strong cables and preference is given to those who are working in neurosurgical units.
Whatever said, we still need a lot of neurosurgeons in Malaysia. BUT, please remember that the working life is not as simple and grand as what is shown on TV programs. The reality is different. It is a hectic life, needs a lot of skills and training, depressing and generally have poor outcome except for some instances.
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What is the pathway to become a Cardiologist, Rheumatologist and so on? Perhaps it would be good if you can write a detailed article as well, for other subspecialities.
it has been written. Please read my other blog entries under For Future Doctors.
Don’t forget some neurosurgery operations can take you 24 hours to operate on only one patient
good write up sir.you made clear point about reality……but please add it there for USM neurosurgery.. canditate need to have MRCS……
MRCS is not compulsory but gives added advantage.
Dr. Paga, a very good and informative article, thanks.
For anyone interested in embarking on this speciality I would highly recommend that they read this book ‘Monday Mornings’ (a novel)
penned by Dr. Sanjay Gupta MD, a neurosurgeon and chief medical
correspondent at CNN. Here he describes the trials and tribulations
of neurosurgeons in their personal and professional lives. A very
interesting and enlightening read. Although fictional the personal
experiences related cannot be further from the truth.
Am no doctor, but am halfway through this book. It will be made into a tv series as well! There are actually a few books written by doctors which are very good. Emily Transue’s “On Call” is also noteworthy.
‘the other day in frontal lobe’ by dr.katrina
‘gifted hands’ by dr ben carson
Both are very well written book by neurosurgeon
The USM route is better directed and in theory should produce just as good a neurosurgeon in a shorter time than the traditional longer route. From my own experience in surgical training, I believe that the shortest training scheme to independant surgical competence in most specialties would be:
1) 2 years HO
2) 2 years MO/Core Specialty Training (in relevant surgical specialties, so ideally in neurosurgery case, 6mths each of general, neurosurgery, ENT and Max-Facs or Plastics)
3) 5 years of Masters/Higher Specialty Training
4) 1-2 years of subspecialty fellowship
ie: 10-11 years after graduation should be enough for a trainee with sensible brains, good hands and tireless work ethic.
This of course assumes that the trainee is willing to work hard, avail him/herself of as many opportunities as possible and has excellent hands-on supervised training in a high volume workload centre. In other words, no crying about staying late, sticking rigidly to stipulated shift hours and hopefully the good fortune of supportive trainers.
Needless to say, this magic formula rarely plays out for anyone and most people will take a longer time to get through it. In the UK, the average is 13.5years after graduation. This is partly due to massive competition for Higher Specialty Training posts meaning that it is rare for anyone to go straight from CST to HST.
Due to the need for technical skills, a surgeon cannot cheat the golden rule: it takes an average of 10,000hrs to become expert at something. And we are all bound by the universal restriction of the 24hr day. If you want to have a life outside of surgical training and insist on working rigidly by your legislated shift hours, be prepared to take longer to acquire the required skills.
Is it worth it? Well, that depends on why you made the choice in the first place. Those of us with passion for our craft have the privilege of getting up in the morning with a smile on our face, knowing we are going out to make a living through doing something we enjoy. How many people can truly say that?
I had the (mis?)fortune of rotating through neurosurgery for 4 months of my Basic Surgical Training over 15yrs ago. A few of the Consultant Neurosurgeons were remarkably talented, but I have never seen surgeons so emotionally distant from their patients in any other surgical specialty. And who can blame them when half the wards are filled with young patients who should be in the prime of their lives, but due to disease or injury, are unlikely to ever recover much in the way of meaningful cognitive function.
It is the most soul-destroying specialty I have ever experienced in all of medicine and surgery.
One final insight into minority nature of Neurosurgery. The MCQ exams for the final FRCS in the UK used to be sat on the same day and venue for all specialties. The day I sat mine, in the exam hall there were approx:
1) 250 General surgeons
2) 200 Orthopods
3) 60 ENT
4) 40 Plastics
5) 20 Paediatric surgeons
6) 15 Max-Facs
7) 5 Cardiothoracic surgeons (this is a dying specialty BTW)
8) Big fat ZERO Neurosurgeons!
Haha, BUT there seem to be so many Malaysians who seem to interested to become neurosurgeons, even before entering medical school!!
Hollywood glamour mah! And TV Series like “A Gifted Man” only serve to propagate the myth!
A Gifted Man is probably the most ridiculous medical drama on TV.
A young chap in first year medical school is already 99% sure Neuro and Onco will not be considerations for specialty when the time comes.
Dear Jon J,
Mind elaborating to what extent is cardiothoracic surgery a dying specialty? Based on your observations and what has been happening in the hospital.
Has been listening to various people saying that CT surg is a sun-downing specialty but not from a surgeon him/herself! (and certainly, not a CT surgeon)
Queen
This is based on new developments in interventional cardiology. Minimally invasive procedures (e.g. percutaneous cardiac valve replacements) are being performed by interventional cardiologists with equal or better outcomes.
We will always need cardiothoracic surgeons but the demand is definitely shrinking.
good evening doctors,
i have a question regarding age and residency !!
What is your opinion if a student wants to go to surgery residency at the age of 30 y.o?
Will age be a limiting factor for him to pursue any specialty involving surgery at this age?
what do you mean by residency? Malaysia do not practise residency.
i meant , is the any age criteria for further studies into master program in malaysia?
yes, must be below 40 at the time of enrolment
If u mean by master in surgery, if I am not mistaken the age limits for master is 35( for kkm). please check with pusat latihan Kkm
thank you Liang..i will check with more peoples and KKM as well
beside brain, neurosurgeon also operate on spine,which has good outcome.But i am not sure whether it is mostly done by neuro or othopod in malaysia.
Both can operate on the spine BUT
– orthopods would be more competent at performing spinal deformity surgery (e.g. scoliosis correction)
– neurosurgeons would be more competent at performing intradural surgery (e.g. spinal cord tumours)
I suspect Malaysia is no different from the UK as it inherited their system
In Malaysia, most spine cases except for spine tumors, are done by Ortho spine surgeons.
i once read a book written by a neurosurgeon,she mentioned that there are neurosurgeon out there using deep brain stimulating procedure to enhance cognitive performance(memory) in a ‘healthy’ patient. This is an emerging trend in developed country,it is something like ‘facelift’ in plastic surgery
I don’t think this is an approved procedure under medical ethics. You can go to jail if a report is made. A far as I know, DBS is only approved for tremors, Parkinson’s disease and dystonia. It is NOT without side effects. Many new trials are going on.
How bout for schizophrenia in old patients?
it is also used in psychiatric disorder like schizo,even depression.
but,not sure it is still under trial or have become norm in States
If I am not mistaken FDA has not approved it for these purposes yet.
I doubt there are much DBS in malaysia as the procedure is too expensive , almost 100k and there are not many surgeon know how to do it( even the neurosurgeon )
Hello Dr,
Thanks for the great post. What do you think about budding doctors who wish to become an oncologist?
wait till they enter an oncology ward! It is more depressing than neurosurgery. Furthermore, there is no money in oncology in private sector. The cost is just too high for anyone to sustain. That’s the reason you don’t see many oncologist in private hospitals.
to aspiring neurosurgeon from ‘malaysia’:
dr.pangalavan just showed the reality side of this profession (mostly negative).
if u never give up even after knowing the reality, then this prove that u are really into neurosurgery.GOOD LUCK
Dr Pagal,
Please excuse me for something off topic. It is generally perceived that Private Medical Centres try to exhaust as quickly as possible the amount in insurance policies leaving many patients not having enough to complete their cost of treatment. Many eventually end up (after the money is no more) in UMMC etc where the costs are a lot cheaper.
Maybe you can elaborate more on this issue.
TQVM.
Yes, I must agree that private hospital are profit orientated and thus they try to get as much money as possible.
ONly doctor’s charges are regulated by government BUT not hospital’s charges.
Furthermore most private hospitals belong to GLC which means semi-“goverment”!!
….course of treatment…
Sorry for this maybe stupid ques but why a neurosurgeon has to work like 24 hours in private practice?also for cardiothoracic surgeon.? I thought in private u can always set ur hours of working etc? Assuming that procedure doesnt last 24 hours of course…….
And if you have to work 24 hours, why people say they are not in demand specialozations? Sure more of these surgeons are needed right? 😀
A couple of reasons:
1. if you operate on your patient, you are still responsible for their care while they recover in hospital. There is no MO to go and sort out the post-op complications for you. It is not uncommon for neurosurgical cases to go back to theatre in the first 24 hours post-operatively.
2. secondly, no patient = no money. The private surgeon will therefore make him/herself available when a new patient comes in to hospital, even in the middle of the night.
If there are 2 neurosurgeons in town instead of 1, then they share the patient load and each earn less money. Private practice is becoming saturated. There is nothing to stop someone going private in a particular town/city but that just means everyone’s income is diluted and you have to make yourself available for even longer hours to make it worthwhile.
It is true that the population is increasing and becoming relatively more affluent, but this is only really true for a few urban centres and the rate of doctors going into private is probably higher than the population increase anyway.
Patients don’t come according to your time! In private, you are alone with no houseman or medical officer. You are self employed.
So, you are oncall 24hrs a day , 7 days a week. This goes for all speciality in private hospital. It is not about running clinic! Elective surgeries can be done during office hours but emergency surgeries can’t wait. Even after your surgery during office hours, patients still need to be seen at night and if any complication occurs, you have to be around since there is NO houseman or Medical officers in hospital to assist you.
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How much is the room rent in private hospital as consultant in private hospital must rent ?
Can a consultant who works at public hospital in the morning and/or in the afternoon and work at private hospital in the evening ?
How about house officer /registrar locum work ?
the current ratio doctor per population in Malaysia is 1 doctor for 600-700 people
how much is the current ratio ( all kind of ) specialist ( consultant ) per population in Msia ?
There are many vacancy in UK for service/ NON-training post ( non-recognised by Royal College-post for staff grade doctor ) though this doctor learn a lot while working. what is the advantage and disadvantage of this post ?
why there is shortage of doctor in this hospital ?
http://www.theborneopost.com/2012/04/30/1600-doctorpatient-ratio-by-2015-liow/
Thanks
Most of the answers are in this blog! You should spend more time reading than asking questions which of no relevance to the topic above.
Room rent varies from RM2K in smaller hospital to RM 10K a month. You also need to pay 10-15% administrative fee to the hospital from your consultation charges.
Gov consultants are allowed to do locum after office hours with permission from HOD. They should not be on call at gov hospital on the day. Houseofficers are NOT allowed to do locum as they are not fully registered.
Current ratio is 1: 800. No data on specialist yet.
Taking service job means you are a chronic MO.
Shortage occurs due to maldistribution and NOT lack of doctors. Klang valley has ratio 1:400!!
http://pagalavan.com
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Well, I think me minister need to get his facts right. As what I understand we are having about 6000 grad per year Excluding those from oversea. Further more by 2016 from my understanding is going to be 8000+ per year. I think the main reason there is shortage of dr in certain hospital is because of faulty of distribution of drs. If u walk into hkl now, there will be at least 10 HO in a ward.
Dr Paga,
Among your classmates from UM’s MBBS, who is most successful and what did they do?
How do you define success?
– money?
– fame?
– respect?
– family?
– achievement?
Nav,
Exactly. Many associate success with the amount of material wealth. It is so wrong IMHO. Anyway, can be a BN politician, even a Ketua Bahagian would do, if $$$$ is the defining criteria.
As how our society defines it : a mixture of material wealth with respect.
Sad, but true. Unfortunately no one calls a happy grass cutter with a beautiful wife and 5 kids “successful”.
What do you mean successfull?
Perhaps you can answer in a few categories.
A) Very respected
B) Very happy
C) Very wealthy
D) Would take up MBBS again if given a second life
Trust me : NO ONe is very happy and wealthy as a doctor! Do you see any doctor being listed as millionaires? Even the wealth(for a comfortable financial situation) comes with a lot of stress and with NO life! If you talk to any doctors: almost all of them will say that they will not do medicine if given a 2nd chance! There are some who enjoy working and spending the whole day in the hospital but these are abnormal species who got no life. You will notice a lot of doctors nowadays are still single! Whatever said, if you do medicine for the passion of it without thinking about money, than you may enjoy it better. But reality will hit you later when you have married life etc.
Dr Pagal,
No need to answer these types of questions. A waste of time and resources. Just my 2 sen.
I think these new med students should focus on how to be politicians after they do their housemanship…. like Dato’ Chua Soi Lek. He’s doing fine on my standards. Hahahaha.
Dr. Pagavalan,
I must commend you on your wonderful blog.
I want to do neurosurgery training as a MO in Sabah/Sarawak. I could not find any suitable sources that states which hospitals have a neurosurgical unit. Of course Kuching and KK has it. I’m wondering if other smaller hospitals have it. Your help is greatly appreciated.
Only big state hospitals have neurosurgical units.
Dear Dr. Pagavalan
You have a wonderful blog.
I am a MO interested in doing neurosurgical training in Sabah/Sarawak. I cannot find a comprehensive list of hospitals there that offer neurosurgical training. Do you know? Thanks in advance
Do you think study medicine (MD) in ukm is better or should I study medicine in NuMed in nusajaya as the cert will be from UK? But then ukm has its own hospital so the practical will be in their own hospital compared to NuMed. Referring to the overload of ‘HO’ BTW.
Definitely take UKM!!
NuMed degree is not from UK, it’s from Malaysia and not recognised anywhere else!!
Good day, Dr. Thank you for the good writing. I am currently in Form 4 now, and has been pursuing the dream to b a neurosurgeon since I was in Form 1. Reading this, which medical school should I go to? I really have no idea about what to take and what not. Is it too early for me to think of being a neurosurgeon? What early steps should I take? I’ll be sitting for my SPM next year, nonetheless. I hope you can enlighten me of what I can do to contribute to this neurosurgery department in Malaysia. Thank you and have a nice day ahead, sir.
Think about getting into a good medical school first. Everything else comes later.
Why Neurosurgeon? When young people have such ‘ambitions’ it usually means they harbour a misguided idealised picture, often from movies/tv dramas or books. It’s not real.
Hi Dr.P, Well, first of all I would like to ask, since our country having too many doctors in upcoming years, is it better for a doctor to continue being MO or start pursue a specialization. What’s your opinion?
What criteria a doctor should have for a specialization generally.
And how a doctor should know which area of specialty is the best for herself/himself.
Thank u.
All these has been answered in this blog. Please read all the information under For Future Doctors page
Hi Dr.P, I would like to know yr opinion. Since there r going to be a lot of doctors in upcoming years, is it better for a doctor to continue being MO for the rest of the life or start pursuing specialization. What are the criteria for a doctor to be a specialist and how to know which area of speciality is the best suit for oneself. Just would like to know why u choose to be a specialist in this field u r in now. Tq.
dear dr,
i’m junior dr who r interested in neurosurgery. is there any preparation should i make in order to hve clear pathway?n what should i do so that i take the right path after my ho-ship?
The pathway has been described above!
Dr Paga, can you please enlighten me regarding pathway and prospects for interventional radiology in Malaysia?
Be a radiologist first then sub specialise in interventional radiology. The pathway is the same as any other specialisation
Dear Dr. Pagalavan, Thank you for those highly insightful posts. I was researching on the no. of craniotomy procedures done in Malaysia each year. Since prevalence of brain tumor isn’t adequately documented, I was looking at the number of neurosurgeons in the country and the average no. of craniotomies performed by each surgeon every year. How many craniotomies would you think does a neurosurgeon perform on an average per year in Malaysia? As per a certain document by Ministry of Health, there are about 90+ neurosurgeons in the country – would that be a valid estimate? Many thanks in advance for your help.
I am not very sure about the figures.
I have been following your post Dr P. Highly informative. I am a Malaysian doctor working in Australia. Whilst I have no experience working in Malaysia, my discussion with fellow colleagues here indicated similar viewpoint with yours. Young minds need to think hard before embarking on this long journey. Sub-specialization is the dream of many but at the end a few will achieved it. Think hard and long. You are encourage to dream big, live your passion, go for the gold or whatever you want. But have a backup plan that you can fall on to if things does not work out.
exactly
Thank you for being honest