There are a lot of information about medical education in this blog. As long as there is a demand, businessman will take every opportunity to make money out of our society’s ignorance. I had always opposed the idea of privatisation of medical education. It should never be privatised. Many countries which privatised medical education eventually landed up producing sub par graduates. Businessman will only think about money and would not be bothered about the quality of medical educations. It use to take years to build a medical school but in this “bolehland”, we can start a shop-lot medical school within months! UM which started in 1964, were taking only 180 students by 1992 but we have less than 5 years old medical school taking 200 students ! We are truly a Bolehland!

I came across this interesting article published in New England Journal of Medicine  on 30/10/2013: Are We in a Medical Education Burble Market? . Despite the high medical education cost in US, the income of doctors has been sluggish since the early 2000s. Can the medical schools go on charging high fee when many doctors are finding it difficult to survive in US as I had written before? Many struggle to come out of debt even after years of working and training. The increasing litigation rate has not made their lives any easier. The article is a good read and likely the same situation will happen in Malaysia very soon. When the oversupply hits the country and when many doctors find it difficult to make money and cover their debt, only then people will realise that there is NO money in medicine. Eventually, they will stop sending their children to do medicine and the fee will gradually drop. The bubble will  burst ! In fact, it has already started with many medical schools finding it difficult to get students.

Another interesting article, from the US as well, was about a physician who left her medical practise. The topic was ” Why I left Medicine: A Burnt out Doctor’s decision to quit”. I use to say that there are 2 groups of  doctors out there. One is a group with pure passion in medicine and want to do the best for every patient. Another, is a group which treats medicine like any other job. They just want to come to work on time and leave on time. They don’t care less of what happens to the patients the moment they leave the hospital/clinic. Unfortunately, the dedicated and passionate group of doctors are the one who will get burnt out! That’s the reality. These doctors will spend most of their time in the hospital trying to make sure their patients are doing well and they even think about their patients while they are at home. These will create havoc in their family life and eventually lead to divorce, mental illness and even suicidal tendencies.

At the end of the day, many will realise that it is just another job to make a living. No matter what passion that you have, it will eventually boil down to your family and life. At one point I did almost give up medicine when I had huge debt to settle, a family with 2 kids to feed and without even an own house and furnitures. At that point, passion will be secondary. What matters most will be on how you want to bring up your family without debt. That’s the reason I keep saying that you should not take huge loans to do medicine. It will take a lifetime to settle the debt with car and house loan coming along the way. Unfortunately, many feel that they are going to make tonnes of money after graduating, and that clouds their mind.

Please read the articles below.

HAPPY DEEPAVALI TO EVERYONE…………………..

By Diane Shannon
Guest Contributor

When I introduce myself as a physician who left clinical practice, non-physicians ask me why I left. They’re generally intrigued that someone who sacrificed many years and many dollars for medical training would then change her mind. But physicians, almost universally, never ask me why I left. Instead, they ask me how. They call and email me with logistical questions, wanting to learn the secret of how I managed the transition out of clinical medicine (read “escape”).

Earlier this month I attended a conference on physician well-being at the Massachusetts Medical Society where I heard an alarming statistic: the suicide rate among women physicians is more than two times that of women in the general population.

It may be dramatic and self-serving to frame my career change as a way to avoid suicide, but I can attest that medicine was not conducive to my health. As an internist, working in adult outpatient clinics around Boston, I had trouble leaving my work at work. I’d go for a run and spend the entire 30 minutes wondering if I’d ordered the right diagnostic test. I suffered from chronic early morning wakening, even on my weekends off. I startled easily. I found it impossible to relax. I worried constantly that I’d make a mistake, like ordering the wrong dosage of a medication, or that a system flaw, like an abnormal lab report getting overlooked, would harm a patient. I no longer remembered the joy I’d felt when I first began medical school, and I couldn’t imagine surviving life as a doctor.

I no longer believe it was weakness or selfishness that led me to abandon clinical practice. I believe it was self-preservation. I knew I didn’t have the stamina and single-mindedness to try to provide high-quality, compassionate care within the existing environment. Perhaps, due to temperament or timing, I was less immune than others to the stresses of practicing medicine in a health care system that often seemed blind to humanness, both mine and my patients’.

That’s not to say that I don’t miss practicing medicine. I do. I miss engaging in meaningful interactions and being of service, reassuring an elderly woman that we could make her emphysema easier to endure, bearing witness to a cancer patient’s grace in the face of death, supporting a college student facing an unexpected pregnancy. I miss spending my days in deeply meaningful work. But given my choices at the time, I have no regrets.

I recently interviewed Mark Linzer, M.D., who researches physician burnout, and learned that the underlying causes are fairly predictable. Linzer and his research team found that four factors are associated with higher rates of burnout: time pressure, degree of control regarding work, work pace and level of chaos, and values alignment between the physician and administration. I experienced all four, but I think the greatest source of stress for me was the high level of chaos. I didn’t trust that patients would consistently receive the care they needed. Orders were sometimes incorrect, illegible (in the days before electronic medical records), or overlooked once written. An intravenous catheter left in too long led to widespread infection. Care providers forgot to wash their hands and spread serious infections from one patient to the next. EKGs and x-rays were misread. I’m someone who tends to imagine the worst. In the maelstrom of a chaotic work environment, I was worn down by worry.

Tactics to prevent medical errors have advanced since I practiced medicine. Checklists now remind care providers to replace intravenous catheters. Hand sanitizing gels and handwashing reminders are commonplace in hospitals and clinics now. Electronic ordering systems prevent handwriting errors and signal care providers about drug interactions and duplicate orders. It’s possible that with these improvements my greatest source of stress is now less of an issue, but physician burnout remains a widespread problem.

A 2012 study found that almost half of the practicing physicians surveyed had one or more symptoms of burnout. An online poll in the same year of more than 24,000 physicians found that only 54 percent would choose medicine again as a career, compared with 69 percent in 2011. From personal experience, I know the importance of creating a system in which physicians can fulfill their potential and connect with patients. I believe that until we see physicians as humans, prioritize their well-being, and create systems in which they can provide safe and compassionate care, we cannot expect them to heal others.

Hospital leaders are beginning to understand this equation. At the MMS conference, a panel of hospital executives spoke about the additional pressures on physicians within the current economic climate. I found it encouraging that the hospital leaders saw physician burnout as a serious problem and that many of the changes they were using to combat burnout were relatively simple. At one medical center, leaders attend patient rounds on a regular basis to better understand the physicians’ experience at the frontlines of care. They hold retreats to listen to physician complaints—then follow up on identified issues. Another leader sends thank you notes to physicians each time the hospital receives a complimentary letter from a patient. At another hospital, leaders decided to allow physicians to have more say about their daily schedule at the outpatient clinics. These were not costly interventions, and according to the executives, they seem to be helping.

Some of the solutions to physician burnout may be relatively simple and inexpensive — administration taking the time to understand physicians’ work experience and the barriers they encounter daily. Others are complex and resource-intensive, such as revamping the reimbursement system to measure and reward high quality compassionate care rather than the volume of procedures, tests, and physician visits.

Whether simple or complex, none of the solutions will be easy to execute, especially in the midst of the seismic changes taken place with health reform. But I believe that it’s possible to create a health system that supports physicians in their quest to provide high-quality, safe, compassionate care. I don’t think we can fix the U.S. health care system by expecting superhuman performance from humans under super-sized stress. We will only succeed if we instill safety and compassion for patients and providers in every aspect of care. If I suppress my humanness to survive in an environment that requires such a sacrifice, how will I be able to see yours?

Many groups across the nation are working on ways to infuse more humanity into health care. One example, the Schwartz Center for Compassionate Healthcare, founded by a health care attorney diagnosed with advanced lung cancer at age 40, helps health care organizations set up meetings where care providers can speak openly about the feelings of distress triggered by their daily work. If I’d had a safe place like “Schwartz Center Rounds” to express my emotions — fear, overwhelm, anger, guilt –perhaps I would have developed the resilience I needed to continue practicing medicine.

Given that I recently celebrated my fiftieth birthday and am happily ensconced in a writing career, it is unlikely that I will return to clinical practice. Sometimes this realization saddens me, but I no longer feel that leaving was weak or selfish.

Instead I believe that because I’ve survived in the trenches and now have a bit of perspective, I can help advocate for changes that will allow other physicians to practice medicine in a way that is life-giving to themselves and the patients they are privileged to serve — the way I had hoped to practice when I first donned my white coat.

Diane W. Shannon, M.D., MPH, is a freelance writer who focuses on performance improvement in health care. She lives in Chestnut Hill.

Are We in a Medical Education Bubble Market?

David A. Asch, M.D., M.B.A., Sean Nicholson, Ph.D., and Marko Vujicic, Ph.D.

October 30, 2013DOI: 10.1056/NEJMp1310778

In November 1636, the prices of tulip bulbs in the Dutch market rose rapidly from their normal level to the point where a single bulb might sell for 10 times the annual earnings of a typical worker. Just as quickly, in May 1637, tulip-bulb prices returned to their previous values. The causes of this dramatic rise and fall remain in dispute. The event occurred during the Dutch Golden Age, when stock exchanges, central banking, and many of the fundamental structures that govern contemporary capital markets and the approaches deployed by MBAs today were developed.One modern economic analysis suggests that the precipitous decline in tulip-bulb prices resulted from a February 1637 change in the way that futures contracts were enforced, which immediately reduced the value of those contracts by 97%,1 but this analysis doesn’t explain why the prices had shot up in the first place. Clearly, tulipmania was a bubble market fueled by speculation rather than intrinsic valuation. After all, why would people be willing to pay 10 times the average annual wage for a single tulip bulb unless they were confident that they could sell it to an even greater fool willing to pay even more?

Bubble markets are created when an asset trades for increasingly higher prices as it is bought by people who are hopeful about its future value and then sold to others with even more optimistic views of that value. Recent examples include the U.S. housing bubble, in which home prices rapidly rose until 2007 and then just as rapidly fell, and the dot-com bubble, in which prices of Internet stocks rose until 2000 and then plummeted. Bubbles burst when some new sense of lower intrinsic value appears. The last buyers are stuck with something they paid too much for and can no longer unload. It’s like being caught without a chair when the music stops, but whereas even the losers at musical chairs knew that at some point someone would be left standing, bubble markets are usually recognized only in retrospect — the losers never saw it coming.

Are we in a bubble market in medical education? In medicine, students buy their education from medical schools and residency programs (which pay wages that are lower than the value of the work that residents provide in return). This education is transformed into skills and credentials that are then sold to patients in the form of services. So long as it is believed that patients, or whoever purchases health care on their behalf, will keep paying more and more for physicians’ services, students and trainees should be willing to pay more and more for the education that enables them to sell those services.

A simple measure of this market economy is the ratio of the average debt of a graduating student to the average annual income in the profession on entry into the workforce. There are more precise ways to measure the return on investment in medical education — for example, the net present value of the stream of cash flows out (for education) and in (for services). But that value isn’t very intuitive for most prospective students. In contrast, debt-to-income ratios reflect what students must borrow rather than what they must pay and, given whatever other assets they may have, how much in the hole they have to go. Thus, these ratios may better reflect how students actually feel about buying education.

Figure    1FIGURE 1Ratio

of Debt to Income, According to Medical Specialty. shows these ratios for selected medical specialties over the past 15 years and reveals that the ratio has become less favorable for students overall but particularly unfavorable for students entering family medicine or psychiatry. Although the cost of becoming a doctor is roughly the same whether you go into pediatrics or orthopedics, you earn much more in orthopedics.

The graph is instructive in another way: the debt-to-income ratio reveals the connection between what physicians can charge patients and what schools can charge students. Just as tulip bulbs can be sold at high prices only to people who think they can resell them at still higher prices, schools can sustain their high tuitions only if students can be convinced of higher returns in the form of payments from future patients. So, the amount that schools are able to charge students is inextricably linked to how much we pay doctors now and how much we plan to pay them in the future. Medical students can take on enormous debt only because the costs of that debt can be easily passed along to others down the road.

So are we in a medical education bubble? We would realize we have been in one if a sudden collapse in what patients are willing to pay doctors made it impossible to sell medical education at current prices, causing applications to fall and some medical schools to cut tuition to continue to attract qualified applicants. Figure 1 might be seen as suggesting that we are approaching such a collapse in primary care fields and psychiatry. But that is not likely to be the case. First, at least at the level of undergraduate medical education, schools charge a single price to students whether they go into family medicine or orthopedics. Although it isn’t necessarily clear to students or schools which students will choose what fields, the income of the average doctor can sustain the debt of the average doctor even as the differences among specialties create pressures for primary care and psychiatry.

Second, as high as the debt-to-income ratios may be for primary care and psychiatry, they are even higher for some other fields — notably, veterinary medicine, optometry, pharmacy, and dentistry, as shown in Figure 2FIGURE 2Ratio of Debt to Income, According to Occupation.. For veterinarians, incomes have risen slowly even as student debt has exploded.2 Yet although such company may ease the misery of primary care physicians, it does nothing to solve the underlying problem.

The problem is this: if we aim to reduce the costs of health care, we need to reduce the costs of medical education. We don’t have to believe that the high cost of medical education is what causes increases in health care costs in order to develop this sense of urgency. We just have to recognize that the high costs of medical education are sustainable only if we keep paying doctors a lot of money, and there are strong signs that we can’t or won’t. Only about 20% of health care costs are attributable to physician payments, and many of the current efforts to reduce costs are aimed elsewhere, such as hospital payments, and have only indirect effects on physicians’ earnings. But physicians’ and dentists’ earnings have been sluggish since the early 2000s.3,4 Even if prospects for physicians’ income fall fast, a burst bubble can be averted if schools see it coming before their students do and lower their prices.

The general lesson is that if we want to keep health care costs down and still have access to well-qualified physicians, we also need to keep the cost of creating those physicians down by changing the way that physicians are trained. From college through licensure and credentialing, our annual physician-production costs are high, and they are made higher by the long time we devote to training.5

Although it seems unlikely that we’re in a bubble market for medical education, we may already be in one for veterinary medicine. That bubble will burst when potential students recognize that the costs of training aren’t matched by later returns. Then the optometry bubble may burst, followed by the pharmacy and dentistry bubbles. At the extreme, we will march down the debt-to-income-ratio ladder, through psychiatrists to cardiologists to orthopedists . . . until no one is left but the MBAs.