Since my last article on 10/11/2013, I read quite a number of letters in the newspaper regarding the issue of oversupply of doctors in Malaysia and the deteriorating quality of graduates. There were 2 letters over here and here which was written by lay persons who were deeply concerned about our “doctor’s mill” and “obsession in doing medicine”. Something that I have been screaming about since the last 4 years or longer!
What interest me most was the statement from Datuk Dr Jayaindran who is the Head of Department of Medicine in HKL and a Deputy DG. Even though he decline to admit directly that there will be surplus of doctors, if you read in-between the lines, it is very clear that we are heading in that direction. He admits that the local medical schools are producing about 4000 graduates a year with another 1-2000 returning from overseas (remember, close to 50% of the medical schools in Malaysia have not produced graduates yet). However, he goes on to say that we have about 10 000 posts available? I got no idea from where he got this figure but even if it is true, based on his own calculation of graduates, it should be filled in less than 2 years! He also admits that there will come a time where the job will not be automatic and the graduates will have go through the necessary process and wait in line………….
It is also interesting to note that not only we have the highest number of medical schools per capita population in the world, we have now the best housemen: patient ratio in the world. We have conveniently beaten UK with 800 years of medical education with a ratio of 1: 3 compared to 1: 12 in the UK. Welcome to the true BOLEHLAND!! And now, the MOH will be discussing with MOE to increase the minimum entry qualifications !! So, are we admitting officially that our entry qualifications are low and any tom, dick and harry are becoming doctors? Are we admitting that the quality of students who are doing medicine is low ? No wonder the outputs are generally of low quality as well!
Finally, the madness is now hitting the sky. MOH is coming up with a brilliant plan of sending housemen to polyclinics and district hospitals for “training”, in line with the changing needs of our healthcare system and disease pattern!! Why can’t they just admit that they are running out of post/jobs! Again, we will be the first in the world! Today, our great Health Minister, who is a doctor by training has declared that housemanship training will soon be conducted at polyclinics, likely as early as next year ! As far as I am concerned, this is the most stupidest idea I have ever heard. Housemanship training is not about seeing primary care patients. This is done after completing ward-based horsemanship training. Of course, being a Miniter , he has to toe the line……….. Remember, our PM’s advise to Wathyamoorthy!
Despite admitting that the quality of graduates are going downhill, they seem to be introducing more and more programs which are going to make it worst. Let me tell you an example which I just saw few days ago. An 82 year old lady who is known to have Diabetes and renal impairment came to see me with lethargy, poor oral intake and feeling unwell. She is under a Klinik Kesihatan follow-up with the following medications:
1) Metformin 1g bd
2) Frusemide 40mg od
3) Hydrochlorothiazide 50mg od
4) Spironolactone 25mg od (just added 2 weeks ago for high BP !!)
5) Aspirin 100mg od
I think this is a good MCQ question. What do you think would have happened to this patient ? Obviously, this 82 year old lady is dehydrated with a Creatinine of 330 and Potassium of 6.2 mmol/L !! And this is a doctor who has completed 2 years of housemanship. An 82 year old lady with renal impairment taking all these medications which are contraindicated in renal impairment? I have said many times that doctors can be life savers as well as killers, with a license to kill! The situation is only going to get worst! They can’t even supervise their own MOs but want HOs to undergo training in KKs! God bless this country……………..
The madness indeed has hit the sky……………..
Ministry reviewing entry qualifications
THE Health Ministry is looking into the possibility of increasing the minimum entry qualifications into medical colleges in a move to improve the standard of healthcare in the country and the competency of doctors.
The ministry, together with the Ministry of Education, has embarked on a study to review the existing entry requirements.
According to the Malaysian Medical Council website, the minimum entry requirement into medical school currently is five Bs at SPM level in biology, physics, chemistry, mathematics or additional mathematics and another subject.
“We’re investigating whether the minimum qualification needs to be re-looked. Nursing colleges started with three credits which was later increased to five.
“Similarly, we are looking at this possible scenario for those applying to medical colleges,” said the ministry’s deputy director-general of health (medical) Datuk Dr Jeyaindran Sinnadurai.
On claims that many junior doctors are not as competent or passionate about their job because of insufficient training, he admitted this was partly true.
“We have had several meetings to address the training of house officers (HOs). For example, their training used to run for 12 months, but now it has been extended to 24 months.”
He said this was because those trained overseas did not have similar exposure to patients, as local graduates did. Hence, it was necessary for them to relearn various aspects of all the six mandatory disciplines in medicine.
“Many are very stressed out because they have not been exposed to this type of clinical practice in their medical schools and it comes as a culture shock.”
He also said the flexi-system introduced some time ago for house officers had some limitations in that it did not give the HOs ownership and accountability for their patients.
“To overcome this we have made several modifications and are confident that it will address these areas of concern.
“With our proposed new system, we’re certain that HOs will have adequate supervision to ensure they take ownership of their patient and be accountable for their management. This will result in them working 65 to 75 hours a week, which we think is acceptable,” he added.
To ensure adequate exposure to clinical procedures and other ward-based work, the ministry is working on implementing a one HO to four patients ratio.
Dr Jeyaindran said that when he was a HO in the early 1980s, it used to be a 1:20 patients ratio. While the original ministry quota was 1:14, today it’s 1:3 patients. Other countries, such as Singapore have a ratio of 1:8 while in the United Kingdom it is 1:12.
“Still, some HOs are complaining about too much work and too many hours. It was recently brought up that HOs shouldn’t work more than 60 hours a week.
“However, they should consider their housemanship as a period of training, not focusing on how many hours they worked but the amount of experience that was gained.”
He said of the 144 government hospitals, 48 are designated as training hospitals for HOs, with close to 35,000 beds.
The ministry is hoping to open two more training hospitals soon.
“Over and above this, as non-communicable diseases (NCD) are beginning to be a burden to the healthcare system, we’re looking at HOs to be trained at primary care clinics (klinik kesihatan) under the supervision of family physicians.
“This pilot project will start early next year. We need to realign the training of our future doctors based on changing needs of the nation and evolving disease patterns.”
Dr Jeyaindran, however, does not foresee medical graduates becoming jobless in the near future, despite the fears expressed by the MMA.
“Admittedly there will come a time when they will have to wait a while to find suitable training posts. They will not get a vacancy straight away. They’ll have to apply and wait their turn. It’s a worldwide phenomenon.
“It’s not a minibus, you can’t shove in as many people at one time as you like. And, when a graduate applies to the government, he or she has to go through the process; it’s not about not having enough posts.”
He said the ministry was also studying the current status of medical colleges, particularly the number of students admitted per year.
“There are close to 360 medical colleges all over the world. Locally, we are producing about 4,000 medical graduates annually.
“This does not include the 2,000 to 3,000 who come back every year. But we don’t really know the numbers because many are privately funded, mostly by their parents.
“The study has already been mooted and the outcome will be out next year.”
On accusations that there aren’t sufficient postings for HOs, Dr Jeyaindran said there was enough capacity.
“We have 9,500 medical postings and 10,000 available medical posts, so there is capacity.
“When we re-look the numbers, 9,000 might be the optimal figure but we are changing gradually, it must be a progressive move.
“How fast we do it will depend on the outcome of the two studies.
“The data will help us make rational decisions. We have to ask ourselves what is a safe number to attain in delivering safe healthcare; it’s a numbers game.
“We are getting there but it may take a longer time.”
He added that as of now, there were no plans to reduce the duration of HO training.
“We are still maintaining the need for HOs to undergo two years of housemanship and two years of compulsory service.
“If you come from an unrecognised college, you must sit for a compulsory exam. Unfortunately, it was decided that this medical qualifying exam can be taken almost anywhere.
“Before, it was only available in Universiti Sains Malaysia (USM), Universiti Malaya (UM) and Universiti Kebangsaan Malaysia (UKM).
“MMC strongly feels that the standard should be the same.
“Although we have many local colleges, the final assessment is very different from university to university.
“Building two, three or four more hospitals is not the solution, and MMA’s suggestion to have training hospitals for medical colleges is not the answer either.
“We must have specialists of sufficient seniority; we want to get it right the first time and not make hasty decisions.”
Read more: Ministry reviewing entry qualifications – General – New Straits Times http://www.nst.com.my/nation/general/ministry-reviewing-entry-qualifications-1.396547#ixzz2kuMUDh1O
More Training Centres Needed To House Newly Graduated Doctors – Dr Subramaniam
Also present was Malaysia Medical Association (MMA) President Datuk Dr N.K.S Tharmaseelan.
Subramaniam said new doctors may also undergo their housemanship at hospitals under the Defence Ministry.
— BERNAMA
Pagalavan's Avatar 
no no no t0oo much for HO in health clinic.. they not even good in hosp.
It is very dangerous to place House officers in polyclinics although there maybe some sort of supervision from Medical Officers and/or FMS. Bear in mind these medical officers may be too busy and may be also fresh from housemanship and they are not suitable to monitor these HOs while there may not be many FMS.
In developed countries, a doctor will never be left on their own to practice even after completing housemanship They will still continue working under specialist/consultant supervision even until at a specialist registrar level. In Malaysia, it is a different story altogether. This is very dangerous for the patients. The 82 yr old story is a classic example.
By the way, I noticed that KK has very poor monitoring systems. Patients are started on ACEi for hypertension but their next follow up visit in 3-6 months later!
Malaysia Boleh mah
Looks like I am not going to any KK any time soon.
Malaysia is going to be a developed nation by 2020 so the general population should also make an effort to know the medicine given is ok or not ok.,it’s pointless blaming all the time ,I think it is Malaysian culture I was surprised the knowledge an auto driver had regarding diabetics in India.
So the 82 year old lady should not rely on her healthcare provider then?
Also please elaborate on the relevance of “developed nation by 2020” to knowing medicine prescribed to patients, short of second guessing the doctor every single time. It’s bordering on self prescription and self medication.
About India, it is well known there are plenty of jobless medical grads there.
This is a true non biased account of what may happen when there is an oversupply of doctors and lack of quality postgraduate training plus lack of jobs.
Although the author is non Malaysian in origin- I believe we are heading down the same path.
http://pubs.sciepub.com/ajms/1/2/1/
If the doctor doesnt know if the meds are suitable, what chance do patients have?
I suggest Malaysia to ‘supply’ their medical doctors to other ASEAN countries who are in need of doctors. At least it’ll make them less ‘manja’ working in countries like Myanmar, Vietnam or Cambodia.
The time will come
I don’t think they recognise, or want Malaysian trained doctors. In any case, movement of doctors is always from backward to advanced, low to higher pay. So, no, Malaysian doctor will not move to these places. They want to go to Singapore, etc. Hence the persistent questions from would be and existing med students, about working overseas after graduating. The problem is, the advanced/high pay countries do not recognise Malaysian qualifications.
Defence ministry hospitals are struggling with lack of specialist. One particular centre had a specialist who is doing locum outside 90% of time hence their patients are sent to other kkm hospitals. It is also due to this fact that the bed occupancy rate is very low with minimal admissions( the MOs there had no choice but to refer patients elsewhere)Now they wanna send housemans to these places to look after ghosts I guess.
Yup
I find it funny that no one mentions East Malaysia. There’s a constant shortage of housemen there. I suppose the govt needs to start by funneling some of our over-supply to the East.
It has started
There is no more shortage of HO in the designated HO training hospitals, but there is unevent supply. So a situation exist when there are times the hospitals are flooded with HO, and then times when there are very few. This is a problem with the non-standardised starts for HOs under the MOH. Not inadequate bodies.
Talking about East Malaysia, if you have strong cables. You can basically know where you get your postings.
Chances are not Sabah or Sarawak, unless you insist to go.
Many kids of VIPs are already know the postings even before applying or still in Master programme. Then again, this is not something new to us.
I’d expect Selangor to be the worse, and most saturated…
Good luck for those Selangor IPTS grads hoping for a H.O. placement in any of the training hospitals in Selangor…
You’d need a miracle for it to happen.
there is no such thing as Selangor grads suppose to do HO in Selangor. IT can be anywhere.
Quite a number of young doctors wanna take up public health thinking of clinical posts are all saturated and PH is a last choice with easy paper work.
The fact is, public health specialists trainings are no longer that easy. University of Malaya has not produced more than 10 DrPH grads since its introduction. The current Public Health Specialists are all with double Masters. Among them, NOT all are willing to guide the upcoming juniors who are going to equipped with doctorate degree.
To make the matter worse, Public Health juniors are being criticized for not publishing articles in journals by Uni and are being told not up to the standard as compared to those with double Masters in field work.
This is a matter of clash of ego.
Similar scenario also happens in neuroSx, PlasticSx, PeadSx where the current consultants are very critical with those grad via the direct entry programme…given that they have done their General Sx before persuing SubSx.
HOs and even MOs posts are NOT secured in MOH…that is for sure.
In responding toNov 14 article on More to life than becoming a doctor. I have the responsiblity to iron out that studying a pure science subject (Biomed/ Bio tech) requires you to pour in tremendous amount of time to study, study and study until you found yourself a renowned professor to learn from, published a handful of good papers, and gain a PhD.
Some think that upon graduation from undergradand masters one can easily secure a job in a lab, and that will be the story for the rest of their lives. Yet the truth is they will have to find the right ” back door” and study much longer to minimize the struggle when it comes to maintaining a good reputation.
Engineering (oil/ petrolum.. ) make sure you have a solid technical and English foundation, and also be fit!
Denise, agreed with you that not only you must be fit in oil and petroleum engineering if you want to be one, your scalp must be strong and extra healthy too!! My nephew and a few I know are complaining that their hairs are falling due to the harsh off-shore conditions in the middle of sea, and they are only in their early 30s, already half bald.
It is very hard for my friend to get the right candidate to fit the shoe.
As few Malaysians with oversea MBA / Master in Eng & few more Dip in various fields eventually turned down a MERE USD2.5k to 3k offer as a junior..
LIfe is not easy
Dr. P,
May I know what is the route to become a rheumatologist in Malaysia?
Do we have to get MRCP first? And what are the steps after MRCP?
Des
Same as any other subspeciality training in internal medicine. Please read my article on “step by step approach to specialization in internal medicine”
Dr P,
You quote other doctors earning in their private work in your articles.
How much do you earn in your private work each month?
It is not really how much you earn but how much time you spend everyday in your hospital.The higher you earn, the more time you will spend in the hospital. It also depends on the number of physicians in your hospital. The more the number, the less you earn. The income changes every month!
Rosemary Sarah said “Many kids of VIPs are already know the postings even before applying or still in Master programme. Then again, this is not something new to us”
I am not very envious of these kids of VIPs. Backdoor and cables may assist some to reach associate professorship, subspecialty training, and choice consultant positions in big cities. However, as they say, getting pass the door is easy, staying in the room is a challenge.
If you’re a a/prof in UM, you are directly responsible for the publications hence the global ranking of the uni
If you’re a surgeon in Putrajaya or GHKL, you are directly responsible for quite a number of VIP patients who stay around these places.
Etc etc.
You catch my drift.
Hi dr, any comments about studying Bachelor of Science (Hons) Chiropractic in IMU and be a chiropractor in Malaysia?
Chiropractice is a new field in Malaysia and difficult to find one out there. Usually you have to open your own business as unlikely private hospitals or government sector will employ you in Malaysia.
[…] the 6th posing of housemanship will be done at primary care clinics. I had written about this over here. I do not want to elaborate any […]
Dear Dr. Paga,
As a medical student, I humbly seek your advice, 🙂
Regarding the case of the 82 y/o lady with diabetes and renal impairment,
Isn’t the diuretic medications (in this case furosemide, thiazide and spironolactone) actually indicated in renal impairment to facilitate urine output and reduce creatinine, urea, and other electrolyte levels in the body, which would often accumulate as a result from decreased urine output secondary to reduced glomerular filtration rate due to renal impairment? Unless the patient has stage 5 renal impairment, in which case the only options are hemodialysis or kidney transplantation.
However I do agree that prescribing 3 types of diuretics is overkill and dangerous.
I’m also surprised that the patient did not had cardiac arrhythmias with K+ level of 6.3 mmol/L
I am not sure which year you are in but your understanding of renal impairment and management need clarification. There is no such thing as these diuretics are “indicated” in renal impairment to facilitate urine output and reduce creatinine, urea and other electrolytes. I am not sure where you read this or being told as such. Firstly, diuretics are only given in renal impairment when there is evidence of fluid overload/retention. Not all renal impairment patients are fluid overloaded. Many with Creatinine around 200-400 can have normal urine output and do not need any diuretics. And it is never used to reduce urea and creatinine levels. You need to understand the mechanism of how different types of diuretics works.Spironolactone is contraindicated in renal impairment as it can cause rise in K level leading to death! This is the reason I keep saying that doctors can kill patients if they don’t understand the pathophysiology of disease and mechanism of how medicine works. AS for why she did not develop arrhythmia: a K of 6.3 usually do not cause any cardiac arrhythmia. Furthermore, arrhythmia usually happens when there is an acute rise in K and not when there is a gradual rise as the body can usually compensate quite well. I have even seen patient with k of 7-8 sitting infront of me and talking to me!
Dear Dr. Paga,
Thank you very much for your advice and taking the time to reply my message, you are right.. I’m sorry, I was wrong.. 😅
Spironolactone is a K+ sparing diuretic..
It is CI for renal impairment.
Diuretic therapy for renal impairment is supposed to be used only in events of fluid retention/overload. And even then to be cautiously monitored with daily body weight changes and fluid restriction. Rampant use of diuretics will lead to fluid volume deficit, leading to further impairment of renal function.
I always thought that K+ levels higher than 5.0 mmol/L is dangerous as it would lead to arrhythmias.. I did not know that the body could compensate for a gradual increase.. 😅
Thanks for kicking me back to the right path. 🙂
I will study harder.. 😣