It is now beyond any reasonable doubt that we are heading towards oversupply of doctors within the next few years. Almost 10 years ago I predicted it will happen in 2016. The waiting period for housemanship posting stands at about 4-6 months now, some extending to about 8 months in popular spots. With ALL medical schools producing graduates from 2016, we may hit 1-year waiting period by 2017. While the government is obliged to provide housemanship as it is part of compulsory training, it is not obliged to provide a job to everyone after that. Health Facts 2015 ( KKM_HEALTH_FACTS_2015) which was just released last month shows that we had achieved a doctor: population ratio of 1: 661 as of December 2014. This was initially targeted only in 2016! A total mess by our government! Doctors may soon join the 200K unemployed graduates.
2 years ago, I did mention that there might come a time where the government may consider using private hospitals for housemanship training. I also mentioned why it should never be implemented. Interestingly, behind closed doors, this issue was discussed by MOH with the Association of Private Hospitals (APHM) 2 months ago. While our DG did not deny that such an issue was discussed, APHM came out to say that it is not the best option (see below). They have also rightfully pointed out that we should address the root of the problem first!
Private hospitals are profit driven. It is consultant-based service but consultants are NOT employed by the hospital. Each consultant is just renting a room in the hospital and providing service for the hospital. That’s the reason we are not exempted from GST as we are not employees but contracted service provider. Since it is a one-man show, how much time would a consultant have to teach or guide the housemen. Secondly, private patients come to private hospitals for privacy and better service. They definitely do not want any “trainee” doctors to be seeing and managing them. The hospitals definitely do not want to be answering complains which is already piling up in all hospitals as patients are becoming more demanding. As what Dr Jacob mentioned in the article attached, who will indemnify these housemen and who will pay their salary? Why would a private hospital pay a houseman who is not going to bring them any return/profit! Oh, please don’t bring “social responsibility” crap into the picture. We are living in a capitalist world where what matters is profit and return of investment. Most hospitals are trying to cut their expenses to increase their profit, not the other way round. Same goes to medical schools. The government do not subsidise patients in private hospitals.
While private hospitals may have all the specialties needed for housemanship training, do they have a good case-mix to train doctors to be competent? Other than some big private hospitals (> 200 beds), most private hospitals are rather small-sized (less than 120 beds) and do not manage complicated cases. Frankly, the type of cases that I see in my hospital is totally irrelevant to training of housemen. Most of my cases in the wards are Dengue, AGE, Pneumonias, Bronchitis and some uncontrolled Diabetes and Hypertension. IN actual fact, most of these cases do not really need any admission. Admissions are needed, as they would not be able to use their medical card if they do not get admitted. If we really follow a tight protocol/criteria on admission (as in GH), most private hospitals will be half empty.
With increasing private healthcare cost (also due to GST), most cash paying patients are finding it difficult to seek or continue treatment at private hospitals. In fact close to 90% of patients that I see in my clinic/ward are paid by insurance or employers. This takes me to a recent article in Malaysian Digest. However, I find the statement on the number of doctors in private and government is rather inaccurate in this article. The more accurate numbers can be seen in Health facts 2015 attached above (Government 33K, Private 13K). The article has rightfully claimed that more and more patients are heading to government clinics for treatment. Due to increasing litigation rate in the field of O&G, the Ministry of Health had recently, in a letter dated 10/09/2015 increased the fee for O&G procedures and also added some new fees. This will increase the total cost for normal delivery and caesarean section by 100%. How many would be able to afford the increase? Most obstetrics cases are cash paying as insurance do not cover maternity cases. Of course, it will be the doctor’s choice to give any discounts.
On the other hand, our current generation Y seem to be collecting more and more debts. I had always said that taking huge loans to do medicine do not make any economic sense. A recent survey showed that close to 75% of Gen Y between the age of 20 and 33 have at least 1 long-term debt with 37% having more than one. It was an interesting survey (see below) which concluded that Malaysia’s Gen Y are living on the edge with huge debt!
I feel it is time for some medical schools to close shop or merge to reduce the numbers. A common entry examination or a more stringent entry criteria should be introduced. Till then, the madness will continue………
Many reasons private hospitals cannot train housemen, says industry group
BY JENNIFER GOMEZ
Published: 19 August 2015 9:00 AM
Private hospitals cannot be the solution for medical graduates who have no placements for housemen training due to a string of issues, the Association of Private Hospitals Malaysia (APHM) told The Malaysian Insider.
Speaking on the supply of newly-graduated doctors exceeding the placements available for housemen in government hospitals, APHM president Datuk Dr Jacob Thomas said the association has had talks with the Ministry of Health (MOH) and the Malaysian Medical Council on the matter of housemen in private hospitals but there is an impasse on a number of issues.
These include the question of who would indemnify trainee doctors against medico-legal issues and concerns whether there would be adequate supervision of housemen in private hospitals.
“Who will indemnify these trainee doctors against any mishaps or medico legal issues?
“Private hospitals might also want to interview and select the housemen they want to allow to be trained,” he said.
Dr Thomas added there were also issues over payment, such as who would remunerate the specialists who had to teach and take these housemen on ward rounds.
“Will these specialist be paid?
“Private hospitals manage with just sufficient staff, so additional medical officers and housemen on the payroll will incur higher expenses and result in increased private healthcare costs and higher patient charges,” he added.
Deal with root cause
The Malaysian Insider had reported on the rising number of medical graduates waiting three to six months for their housemen placements, a situation caused by the high number of medical graduates.
According to Ministry of Health records, there were 3,564 medical graduates reporting for duty as housemen in 2011, 3,743 in 2012, 4,991 in 2013, and another 3,860 last year.
Many graduates held qualifications from recognised medical colleges overseas and their number has increased from 877 in 2008 to 1,600 in 2011.
In 2012, there were 1,563 graduates from foreign medical colleges and this grew to 2,403 in 2013.
To Dr Thomas, one of the root causes of the problem of insufficient housemen placements was the high number of medical graduates each year.
This led to the issue of quality control, with the capabilities of graduates requiring further scrutiny, he added, because medical schools have mushroomed.
“Maybe some colleges should merge. We had a shortage of doctors in the past and had targets to meet.
“So, many medical schools mushroomed, but now it has to be re-looked once more. This problem will never be resolved otherwise,” he said.
Criteria for housemen training centres
The Health Ministry is open to having private hospitals provide housemen training to graduates, as long as they fulfilled certain criteria, the ministry’s director-general Datuk Dr Noor Hisham Abdullah said.
He said the ministry had already raised the possibility of implementing housemen training in private hospitals but said it needed to be explored further.
“This needs further study in terms of acceptance by patients and its long-term viability,” he told The Malaysian Insider in an email reply.
The criteria to be a houseman training centre includes the hospital having at least six basic specialist services, including internal medicine, paediatrics, general surgery and orthopaedic.
It must also have an adequate clinical workload and mix of cases in order to provide substantial exposure of different medical scenarios to housemen.
The hospital is also required to pay the salary of house officers as well as bear medical indemnity insurance to cover any medico-legal issues.
“There is also the acceptance of private patients to be examined by house officers, as they (patients) are usually those who prefer privacy and pay higher fees to be seen and treated by specialists,” Noor Hisham said.
The Malaysian Insider had earlier reported the DG as saying that training spots were tight because 30% of housemen do not finish their training in the stipulated period of two years.
Noor Hisham had explained that some of these house officers did not complete their training in the required time frame for various reasons, such as being on leave, their inability to complete their logbook, as well as absenteeism from work without approved leave and incompetency.
“Currently, the percentage of housemen who do not complete their housemanship training within the stipulated period is quite acceptable as it is not merely due to competency issues.
“However, MOH is working on various mechanisms to reduce this percentage,” he said. – August 18, 2015.
Malaysia’s Gen Y in debt, living on the edge, survey reveals
Published: 15 October 2015 11:08 AM
Malaysian young adults are accruing debt at an early age, a survey by the Asian Institute of Finance (AIF) has revealed, while some 40% are spending more than they can afford.
The survey among Malaysian “Gen Y” respondents between the age of 20 and 33 were living on the “financial edge” and were facing money stress, with the majority living on high cost borrowing of loans and credit cards.
“Our study reveals that 75% of Gen Ys have at least one source of long-term debt and 37% have more than one long-term debt obligation. Long-term debt obligations include car loans, education loans or mortgages,” AIF said in its report “Understanding Gen Y – Bridging the Knowledge Gap of Malaysia’s Millennials”, released today.
“To offset this debt, they are relying on high cost borrowing methods – 38% of Gen Ys reported to taking personal loans, while 47% are engaged in expensive credit card borrowing.”
Their debt woes, AIF said, were the result of “impulse-buying” behaviour, besides easy access to personal loans and credit card financing.
“The impulse buying behaviour of this young consumer is tied to the basic want for instant gratification, which is exacerbated by easy access to the world of online shopping. As a tech-savvy generation, these young adults draw on technology for everyday tasks.
“This includes seamless online purchasing, which encourages the ‘buy-now-pay-later’ behaviour amongst this generation of consumers. Reliance on credit cards for online purchasing has further encouraged this behavioural trait,” the report, targeted at banking, financial and learning institutions, said.
The report said around 16-17% was spent on maintaining lifestyles, 24% on loan repayments and 30% to 31% on living expenses, with little difference between male and female respondents.
There were also indications that there is a steady rise in loan repayment levels as Gen Ys go up the income bracket.
Of the 1,011 young professionals interviewed, 60% were single while the majority (43%) earned between RM1,500 and RM3,000. Some 32% earned between RM3,100 and RM4,500, and 8% earned below RM1,500.
The survey also showed that 40% of respondents were spending more than what they could afford, while only 30% said they were living comfortably within their current income.
“This approach therefore feeds on their impulse-buying behaviour. As a result, many of them stay in debt using credit card lending much longer than they ever intended.”
“Only 30% of Gen Ys surveyed said they live comfortably within their current income, suggesting a generation that is experiencing financial stress. It suggests that they have little knowledge about how to make wise purchasing decisions,” the report said.
Despite this, AIF said Gen Ys were much better at saving then it was believed, as 64% said they saved a portion of their income every month, with the majority keeping aside at least 20% of what they earned.
“The survey findings also reveal that Gen Ys’ appetite for savings grows with age. The highest proportion of savers was the 27 to 33 years age bracket (57%). Studies on Gen Y savings habits also show that, although they do develop good saving habits, these savings tend to be focused on short-terms goals.”
However, AIF expressed worry that youths seemed to be skeptical of professional advice by financial advisors and planners, with only 37% seeking consulting such services on money matters.
Instead, more youths (51%) tended to discuss these things with family and friends.
“This lack of engagement with financial advisors probably stems from their skeptical view of the value of financial advice itself as many of them believe they can find this information more easily by themselves. Again, this is a reflection of the DIY world they grew up with.
“The majority (63%) of Gen Ys who did not opt to seek advice from financial advisors or planners cited ‘prefer to do it on my own’, ‘not interested’ and ‘too expensive’ as the top 3 reasons for not using the latter’s services,” the report said.
Those that do seek advice from experts ask about savings and investments (56%), advice on mortgages or loans (41%) and retirement planning (32%).
As a recommendation, AIF said Gen Ys should look into consulting qualified financial advisors to get the information and confidence they need to make educated investment decisions.
“Grab opportunities to gain financial management knowledge from mainstream channels such as from higher learning institutions,” it said. – October 15, 2015.
– See more at: http://www.themalaysianinsider.com/malaysia/article/malaysias-gen-y-in-debt-living-on-the-edge-survey-reveals#sthash.fN5iYH70.dpuf
Pagalavan's Avatar 
malaysia seems to be hanging on tough on lots of issues lately.Boy! what i would give to see the day when good times rolls in!
I am a recent grad who had a chance to chauffeur a top admin of a private medical college located in the central region not long ago. Took the opportunity to mention the possible sub-par training in clinical skills (practising venupuncture, setting in a line, breast self-examination, DRE!!!) and exposure to a good case mix that their students may face (no free access to all private patients, resident MOs or HOs in the wards if they have any questions to ask, etc.) should the college insist on going ahead with their plan to allow their own private hospital to be grounds for training for students. Asked him how to improve the situation and provide a better learning environment for students, if they choose to go ahead with their plan with the private hospital and he said, in vague terms, “We’re still looking into it and talking to various parties about that”.
I was infuriated, having experienced the best qualities that a clinical school should have to merit a good training centre for students, but I decided to keep my cool with him. I’ve done two DREs throughout my clinical years – is there even a single patient WITH a rectal mass who WOULD allow a student to palpate it?
We need a no-nonsense alpha who would not think twice to shove into the bin all the capitalistic demands made that would bastardise the sanctity of all strong, responsible systems that were laid by responsible men and women back in time.
Seriously, do you think all these businessman give a damn on your training? It is not their problem once you graduate. It is MOH’s problem.
Sorry, i cant comprehend what you said; you are sad or proud you did 2 DRE during entire clinical studies?
I don’t believe in feeling proud, sad or smug in doing little or many clinical examinations. I do what I can to grow and not let myself regress in the wards.
The reason i asked was because quite number of rectal mass was missed by HOs because they do not know what to look for. Their perception is, PR = melenic stool or not. I made it s point to repeat all the DRE by myself prior to scope. Most patients will be kind enough to allow PR if you explain to them the reason. Of course, one should know where they are heading instead of driving up the finger blindly
Well sir, we were taught the techniques to palpate a rectal/prostate mass and test the puborectalis tone, but we were left to look for DRE experiences ourselves. Looking back, I could have spent more time in the scope room doing DREs and getting feedback on my performance back in Surgery.
Although, I would concur with you that some HOs do not know what to look for. To quote a personal experience, I couldn’t appreciate the slightly swollen axillary nodes beneath a patient’s underarm despite having the patient tucking her arm in AND have the HO point out where the nodes were with her own fingers. It was utterly demotivating, and I am still figuring out how to acquire this skill.
Thank you for your kind explanation, sir.
With the bombardment of GST, toll hike, high debt, high unemployment, 1MDB issue, white elephant projects and many others. Malaysia still one of the world most competitive countries.
The thinking of additional medical officers and housemen on the payroll will incur higher expenses and result in increased private healthcare costs and higher patient charges is not convincible. The government might consider paying the private hospital for every houseman they absorbed.
Leading hospital operator IHH Healthcare had a 20% jump in net profit. There is no monetary issue here. Just increase the fees for insurance covered patient as usual. http://asia.nikkei.com/Business/AC/Hospital-operator-sees-20-jump-in-net-profit
The salary of the houseman could be borne by the government. In fact, if the monetary issue like pay or extra income is sorted out e.g. tax free, I guess the private hospital would be happy to take in the houseman.
Malaysian has no place to seek medical treatment if the private hospital takes up houseman. You either take it or leave it. In addition to that, the private hospital may create a scenario like patient admitted to the environment without houseman would be charged higher. Those ok with houseman would be at current rate as the environment still better than government hospital. It is like recent toll hike, despite you complain, you still have to pay.
End of the day is the consumers are paying higher and higher medical insurance premium, hospital get higher and higher profit. Not enough money? get the 1 care project started. The winner is still hospital operator eventually.
It is easier said than done. If the government can pay the housemen, why not the government create the post by themselves. The fact is government is also unable to create any post due to their financial constraints. As for insurance paying the bill, please be informed that insurance companies are also trying to reduce their expenses on medical card. It is a loosing business for them. Eventually they will collapse as any increase in premium will also reduce their number of clients. BTW, most insurance companies are becoming very strict nowadays and refusing to pay some of the charges. Some overtime charges are not paid and no collection can be done from the patients either.
Despite all this, it is not just a matter of taking an housemen. Housemanship is a training process. What type of training and doctors are they going to produce??
total madness, chaotic and screw up system, how would you feel if your mother is in this crazy system and cnt afford overseas treatment, the whole system had torn apart! ! you are basically sending ur love one to death road under the hand of all these sub par doc!!! i already heard alot of horrible news about that!!
The system can be restructured and reformed, and must be centered on primary care; both public and private. It has been repeatedly shown via evidence, any health system based on primary care, shows better outcomes. The key is in engaging the primary care stakeholders effectively and this includes treating private GPs (probably the most poorly tapped health resource in this country) like partners in the system. Training thousands of new doctors will do nothing to improve the health system in the long term other than filling up posts in rural areas with ease.
THis will need a complete restructuring of the healthcare system. When 1Care system was mooted, the very GPs were against it. However, no proper explanation was given by the government regarding 1Care anyway!. Untill the entire health care system changes, the current situation will remain.
So instead of having many uncontrolled hypertensives and diabetics requiring dialysis, a system centered on primary care would have detected these individuals early, and instituted wholistic treatment approaches that would have cost a fraction of the dollar to the state, and keep them away from chronic expensive treatment.
The number of patients requiring expensive chemo/radio would be controlled as patients with cancer would be detected at an early stage; requiring at the most an excision biopsy or organectomy.
The solution to the healthcare problem is management; and the catalyst to managing health systems is better economics.
we all know the importance of primary care but we got a screw up government that keeps producing doc for money and have clueless about health care, even if you give them all the resources and specialist in the world they will mismanage and corrupt all the money, the next 10 years or more will be incomprehensible because all these subpar doc will be out there to kill!!! God save these country !! that is what the whole blog is about!!
Ha, ha, ha. Have you successfully counselled an overweight diabetic to diet or an asymptomatic hypertensive to take regular meds?
The world is changing. 5 out of 10 patients I see every day do not listen to your advise!
this statement will look nice on paper but in reality, it is different. I know many patients followed up by our Klinik Kesihatans and GPs who have developed complications and their disease were never under control. It will only change if there is a single system that will take care of the population without the people needing to pay much.
Dear Dr, sorry to veer out of topic but I must clarify that at klinik kesihatan level, the bssk screening is perpetually running and despite overwhelming number of NCD cases per day, patients are still able to get quality healthcare, lab tests, medications. Its all in the attitude of patients whether they want to be proactive in managing their own health. Sometimes it’s very frustrating to see patients who don’t give a hoot & at every review, any advice given goes out the other ear. More complications keep coming. Blame the food, culture, act of God etc.. There are some who do care for their own health. Those are the ones who will not end up in haemodialysis.
Yes, that is what I am saying. Most patients don’t listen to you nowadays as they feel they are healthy. That’s why I keep saying that the rhetoric that “I want to help people” is outdated.
Doctor, I’m a houseman working in SGH. Initially I was considering AMC then work there straight. But my parents said give it a try for HO then think about that, worked about 2months now. Now I’m diagnosed with depression with the amount of negativity in the wards, from everyone, everywhere. very hard to keep up with work with my condition. A new environment will definitely change my situation. I’m considering AMC now. Can I do that even after quitting HO?
You must first understand that passing AMC DO NOT mean you will get a job in Australia. Please read my blog entry over HERE. I know quite a number who had passed AMC exams and not able to get any job in Australia. So, don’t waste your time waiting. The other option is to change hospital for your housemanship.
Do you have a PR visa in Australia? If not, you will likely not get an internship job even if you have passed the AMC qualifying exam. There is a shortage of intern jobs in Australia, and even some international students graduating from on shore Australian medical school could not be placed.
If however, you are a PR, then you get priority on internship placement, once you are eligible for provisional registration after passing the AMC exam.
Do also note that it takes a long time to go through the exam, due to high failure rates and limited slots for the clinical component.
Dear Dr Pagalavan.
Something amiss about the Health Fact 2015.
I made a simple comparison against HF 2014.
1. The total number of doctors reduced from 46.9(as at December 2013) t0 45.5 (as at December 2014)? Thats about 1.3K doctors missing. Did they all quit?
But the non MOH numbers are missing in the 2015 report. As at December 2013 it was 6270. Not sure why this number was left out.
I believe the correct total figure should be slightly in excess of 51800 doctors – which means an additional 5000 doctors entered the landscape in 2014.
2. The special medical institutions under the MOH had a significant reduction in the number of beds.
3. looks like 30 private hospitals closed shop in 2014 taking away 1000 beds. What happened?
4. Four maternity homes have closed shop in 2014.
Kind regards,
Deva
Yes, you are right. Every year I see some discrepancies in their statistics. I also commented last year about their 2013 health facts data which did not fit ( about 2 000 HOs were missing). Yes, you also right that about 6-7K doctors from non-MOH centres are missing. So, the actual numbers will be bigger and the ratio smaller. If you notice the ratio has gone from 1: 633 in 2013 to 1: 661 for 2014, which is odd.
Yes, there have been some small private hospitals which has closed down. Maternity centres are closing down slowly due to strict enforcement by MOH that they must have a full time anaesthetist and paediatrician. New centres can’t open without anaesth and paeds.
Thanks Dr Pagalavan.
I reckon the requirement for a neonatalogist must have been spurred by the baby Samantha (and perhaps a whole host of other Cerebral Palsy cases). Though personally im not sure that the presence of a neonatalogist would make a significant difference in the outcome. In fact my fear is that the neonatologist may end up sharing part of the blame.
I’m doing a research on medical negligence payouts for CP cases and actually shocked to find out that the bulk of recent settlements have been by the MOH.
between 2012 and 2015 – total payouts (both private and public) has exceeded RM 35 Million excluding interest with RM 2.5 Million being the defacto average. Which is a significant figure. With interest on those damages the figure could almost be double as some of the cases were deliviries dating back 10 years from the date of decision/settlement.
Still curious about the 1000 missing beds though.
Again many thanks for your thought provoking analysis. I come from a family filled with doctors – and an uncle of mine(also a doctor) has been strongly discouraging us(my generation) from doing medicinie if ‘big money’ was the only motivation (when i was much younger – i,e about 15 years ago) – luckily we heeded his advice – but many thought that he was talking nonsense then.
Kind regards,
Deva
Interesting info. Yes, the government has been paying the bulk of it. But most of it are settled out of court.
Dr paga, what are your thoughts on the Msc of internal medicine held by University of Edinburgh?
That is not a specialisation qualification.
This is a research based degree. It does not make you a specialist!
Does it help with cv in any way? Is it worth doing?
CV for what?
To enter into fellowship programs in the future? Employability as a specialist or consultant?
Nope unless you are going into research or already in the system (in UK). IN Malaysia, it is of no value
I wouldn’t bother. There isn’t such a thing as a “fellowship programme” in the UK context.
There isn’t a fellowship program? I’m sure there are quite a number of clinical fellowships in various fields being offered in the UK.
On another note, Dr Paga, what are your thoughts on MRCP Ireland as opposed to MRCP? Do you have much experience in it? Is it harder?
That depends on what do you mean by fellowship? Are you talking about attachments? In UK and in US, fellowship means different. Both MRCP are equally tough
hello doctor pagalavan. I did a basic medical degree from recognised college from India and completed my masters in surgery programme in India.
Now I have been offered Master of surgery plastic surgery programme in USM,Malaysia provided
1.I get full registration from MMC
2.complete 6 months of clinical attachment with them
3.Passed viva or exam for entry
4.IELTS more than 6
A few questions
Will i be paid monthly as M.O?If so any idea about payscale
Any security for future job as plastic surgeon after finishing programme?
Are you a Malaysian?
no sir I am Indian citizen
new to Malaysia
I think you need to ask the university. Each university is different. As far as I know, you will not be paid.
IN Malaysia, your chances are slim to get a job unless USM is willing to appoint you after you graduate.
thank you doctor
Even if there is offer of employment, the MMC is unlikely to agree to registration, as fresh Masters graduates are deem with insufficient experience to comply with the requirements for registration of foreign specialists.
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[…] had written about using private hospitals as housemanship training in November 2015. It is not feasible as the system does not allow it to be used as such. Our DG has made some […]
i have finished my medicine rcsi this year,i am think doing neurology in either ireland /uk
any suggestion how and where to do it best,
You need to first get a job\internship there!
Did you not apply to the UK FY programme last year, so you could have started early this month?
I believe Ireland still prioritises posts according to irish/eu citizens/ internationals, in that order for their internship program.