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Archive for the ‘Education’ Category

I have finally reached another milestone ……… as of 13/01/2020, my blog is 10 years old! Over the past 10 years, I have written hundreds of articles and even published 2 books from these articles! I probably achieved my wawasan by educating the public on what medical field is all about and how the world is changing.

My last article was written on 24/12/2019, just before the new year started. It has been almost 5 months now and the world has changed. In just a short period of time, our lives have gone upside down and we are still looking at months down the line before everything comes back to normal. 2020 suppose to be the year where Wawasan 2020 should have been achieved, transforming Malaysia into a developed nation, but unfortunately we are in a mess with recession coming soon, if not already. We have had 5 months of political drama and a brainless RNA virus terrorising the world. Let’s start with where I left you on 24/12/2019……

Critical Allowance

Based on JPA circular dated 20/12/2019, critical allowance for all new appointments into MOH will be removed. As I mentioned in my article, it is rather unfair when those who are already in the system will continue to receive the allowance but the new ones will be without the allowance. I said unfair because everyone is doing the same job and same amount of work. It does not make any logical sense, while I did predict and expected the allowance to go one day when we have more body than post. Following this announcement, there were huge outcries from various organisation and members of the public. Thus, on 9th January 2020, this proposal was postponed for further review, scheduled to be updated by end of this year. REMEMBER, it is only postponed and not cancelled!

U41 Contract Renewal

As I have written in several articles towards the end of last year, the number of permanent appointments given out following completion of housemanship has been dwindling down from about 500 for the first batch(December 2018 cohort) to almost 0 in subsequent batch(May 2019). This is again not unexpected. KKM simply do not have enough post to offer everyone. The slides below is self explanatory…..

It is very clear that KKM do not have any post to even offer permanent positions. Thus, almost everyone will be given an extended contract which will be the final contract before you say sayonara to KKM. The issue of being offered U41 post instead of U44 has not been resolved either, despite promising to do so in November 2019 by the cabinet, KKM and JPA. The new contracts are still renewed at U41 as of April 2020. On 29th October 2019, I wrote this :

The best is yet to come: those who receive extension of contract can remain at the same place where they were transferred as a floating officer! In another word (the way I interpret this), your life in civil service ends there within another year aka completing 4 years of compulsory service. It’s just a diplomatic way of putting it !

Interestingly, this is now proven true when the newer contract renewals categorically says that ” this will be the last contract!” ………

So, basically whoever received the U41 contract extension of 2 years, after their 3 year initial housemen contract, have to start planning their future. I believe this clause was added after the Sarawak doctors debacle that was publicised widely in newspapers in January 2020. These were doctors who returned from overseas in 2017 and was given a 2 year contract to complete their compulsory service. Unfortunately , they were told that their contract would not be renewed. To be frank, no contract is permanent. A contract is a contract and the employer can decide not to renew your contract once it expires. It is the same in any profession including the medical profession. Even in private hospitals, the hospital can decide not to renew your contract if they feel they do not need your service anymore or simply, if they don’t like your face!. It has happened before and there is nothing you can do about it. There is a clear difference between ” termination” and “non-renewal of contract”. While the Sarawak doctor’s contract were finally renewed, to avoid any such scenarios happening again, JPA has now clearly stated the above clause in the newer contracts. So, now no one can claim ignorance.

What about those who received a permanent post? Again, they were given a U41 post! However, they were told that this is due to technical reasons. The U41 permanent post will be backdated to the day they started housemanship and soon, they will receive their promotion to U44 backdated to the day they completed housemanship. Whether this has happened with all the chaos that is going on now, I do not know! We shall wait and see.

In a sudden turn of events in April 2020, about 102 permanent post were created in Sarawak. This could be part of about 1000 post that suppose to be created over the next few years as I wrote in December 2019. So, about 102 of them were sent an urgent email early April 2020 offering them this permanent post in Sarawak and NO appeal will be entertained……..

Whether there is a political reason for this, I got no idea. Based on the report by Codeblue, about 28 of them declined the offer and decided to stay on their final contract appointments. We just have to face the fact that the government will never be able to absorb all graduates. With the current economic situation, the scenario will only get worst. No job is guaranteed in this world. What is happening in Malaysia, is also happening in many developed countries but at-least, these countries have a better control over the number of graduates being produced, unlike Bolehland.

COVID-19

The world is yet again faced with another Pandemic. I would say that this is the 4th viral outbreak I am facing in my 23 years working as a doctor. It started with SARS in 2003 followed by H1N1, MesCOV and now COVID 19. Facing these viruses or any infectious diseases are part of our occupational hazard. I know many doctors who have contracted infectious diseases and some even succumbed to the illness. So, those who think that doctor’s job is sitting in a cozy room and earning big bucks, please think again. We are not only at risk of being infected with a disease but also high litigation rate and verbal insults.

We may be considered as a hero at the moment for tirelessly facing this pandemic. But trust me, once all this is over, we will be back to square one. No one will even remember what you did. That is the reality out there. But COVID 19 also thought us a lot of other lessons. The Earth is breathing better and animals seem to be enjoying their life. We must understand that the entire ecological system on Earth lives in a balance. It evolved over millions of years keeping everything in an absolute balance. The very fact that we produce CO2 and plants converts it back to O2 proves this balance. BUT humans are always greedy. We feel we can do anything to mother earth and get away with it. I had always said this to my children ” Never play with nature, take care of it. If not, nature will always get back to you!” COVID 19 just proves how nature can get back to you. A simple brainless RNA virus can shut down everything on EARTH! Viruses have been around before humans came about. So, never play with nature. Stop destroying nature and learn to live in harmony. As Sir David Attenborough said in one of his famous documentary “ If you kill a whale in the ocean, the entire ocean ecology changes!” If there are no animals which eat insects, the world will be overrun by insects, which by the way have the highest population number in the world.

What else has this pandemic thought us? Good hygiene and social distancing keep doctors away! Many would have realised that there has been 70-80% drop in the number of cases attending private hospitals and GP clinics. Some GP clinics have even decided to close their clinic as their income has dropped drastically. It is better to close than to continue to maintain the running of the clinic. Private consultant’s income has definitely taken a beating. With lock-down, there were hardly any accidents. People were afraid to go to hospitals as they were worried of getting infected in the hospital. Social distancing, stay at home and good hygiene has drastically dropped the rate of infectious diseases like URTI, respiratory infections and gastroenteritis which generally forms the bulk of private hospitals admissions. Elective cases has also been postponed. It just shows that any job can be affected if something like this happens. It happens in all outbreaks but COVID 19 has been the worst. The only job which will continue to be not affected are civil service jobs! The government has no choice but to keep civil service running and paid. While you may end up taking a pay cut eventually, you will still get paid. In fact you will even get Raya goodies!

BTW, KKM has also offered 6 months contract jobs for those who are interested to be the frontliners. Specialist will be paid RM 12K/month and MOs will be paid RM 6K/month. I understand the offer is not available anymore. I heard some GPs did take up the offer.

Democracy

On 9th May 2018, everyone thought that Malaysia has woken up. In my article titled ” Towards Malaysia Baru?” on 4th June 2018, I wrote this

With all the euphoria that we are having now, it is just too early to say how this new government will perform. Statistic shows that Pakatan only received 48% of the votes with BN & PAS taking 52% of the votes. Pakatan won in many areas due to split votes. PAS benefited from split votes in Kelantan and Terengganu. Personally, I feel that the Pakatan government is not really in a very stable situation. Tides can change by next election if they do not outperform the previous government by leaps and bounds.

Again my words have come through! One of my friends told me to stop predicting anything as everything I predict seem to be happening again and again. The Sheraton move on 27/02/2020 and subsequent fall of PH is something I expected to happen sooner or later. The politics in Malaysia is as such. Everything is tied to race and religion. Whoever plays the right card, will win. Who cares about corruption and good governance? Whatever said and whatever mockery that has happened to Malaysian democracy, the country seem to be going downhill. Years of brain drain and racial politics will only take this country to the dungeon. With COVID 19, fall in oil price and dry coffers, we are surely heading into a recession and disaster. Never in world history I have heard of a 1 day Parliament sitting with nothing more than the royal address! It is the joke of the century.

After 10 years of writing this blog, I hope readers would have learnt something. My predictions are all based on facts and statistics. It is not rocket science!

Have a blessed Ramadan and SELAMAT HARI RAYA………………………. a different Raya I must say………….

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11th of June 2019 was supposedly a uniting day for all our GP friends in Malaysia. It was the day when our new Minister had a town hall meeting with almost 1000 GPs from all over Malaysia. It all started when the Minister made a statement about a month ago that the Cabinet has approved drug price control and currently under review for implementation. This triggered an uproar among the GPs whose consultation fee is already regulated and capped under Private Healthcare Facilities and Services Act (PHFSA) 1998. Schedule 7 which controls consultation fee for GPs has capped the maximum price at Rm 35! This has been as such since 1998 but the act came into force in 2006. The hospital doctors on the other hand had a review in 2013 and Schedule 13th was amended with roughly 15% increment, starting 2014.

What are my views and take on these issues? Well, my comments, even in the past, had created a lot of negative feedbacks from fellow doctors. But as I had always said, I call a spade , a spade! Just look at the public feedback in Facebook etc when the above town hall meeting was reported. Videos of our GP colleagues venting their frustration was shown live and recorded by various media. Did you really expect the public to show sympathy? The answer is a BIG NO! For the public, doctors are sitting in a cozy air-conditioned room and earning tonnes of money! Only when their own kid ventures into becoming a doctor, hoping to live a glamorous life, they realise the actual life as a doctor! The hours of work, training, exams, risk taken, litigation etc before you can even think of earning a decent living.

Having said that, generally a doctor can still earn a living as long as they can get an internship post and complete their training. However, the era of earning tonnes of money and being “rich” is gone and going…….Our income will be similar to any other profession, allowing us to live a life. If you are still thinking that spending RM 500 000 to RM 1 million to be a doctor is going to give you a luxury life, think again! Jobless scenario is already happening in many countries.

Now, coming back to GPs. The day you open a private clinic, it is a business, period!Same goes to private specialist. In any business, there are gains and there are loss. Some businesses closes down and some businesses thrive and even become global players. Business is a business, nothing differentiates you than anyone else. Unfortunately , health is an essential service. Health and Education are 2 components in any country which should be the government’s responsibility. I have said and maintained this statement since I started this blog. Many may not know that the PHFSA 1998 was actually tabled and passed in the Parliament in anticipation of corporatisation of health care in this country. The corporatisation of healthcare aka National Health Financing Scheme was suppose to be implemented in 1999 as the last corporatisation exercise of Dr M! Everything was ready on paper.Unfortunately, the sacking of Anwar Ibrahim and subsequent reformasi etc totally shut down the plan till today.

Frankly I don’t agree with controlling of consultation fee. Let the market force decide. BUT healthcare is an essential service and thus the government need to be responsible. Thus, in Malaysia, they control it via the Malaysia Boleh way! Same goes in any other country as well. You may think that in other countries, the government do not control the consultation fee. On paper , yes but they do control it in another voluntary way. Their National Health Financing Scheme(NHFS) that pays for all the consultation/procedure fee do have a limit and standardised payment system. Anything more than that, the patient has to pay out of their own pocket. Public being public, obviously they will choose a doctor that only bills what the NHFS pays. NO one will ever want to pay out of their own pocket! In some countries, the doctors can only accept what the NHFS pays which is basically a fee control mechanism where everyone technically is a civil servant. Even in Australia, many patients prefer to visit the “bulk-billing” doctors (accepting Medicare fee) rather than cash billing doctors.

The GPs were arguing that they are only allowed to charge a maximum of RM35 for the last 21 years. Now, just look at the comments from the public in FB etc. You, me and all members of the public knows that a simple consultation and medication by a GP will cost RM 50-70 and in some cities, can even reach RM 100! Patients are smarter nowadays. Even my patients will go to a pharmacy and ask for the cost of the medications. Similarly, many cash paying patients would do that and will know the actual cost of the meds given by the GP. So, do you think they believe that you are charging only maximum of RM 35? You may argue all you want about the cost of running the clinic etc, but a business is a business! NO one cares whether you are running at a lost or not. No one believes the notion that you are providing a service to public. Didn’t you become a doctor to help man-kind and provide service (aka free service)?

I found that one of the main issue that was discussed the other day was about TPA (Third Party Administrators). Many were arguing that TPAs are only paying RM 10-15 per consultation and wants the government to make sure that they pay RM35 per consultation. Now, let’s go back to my statement above. It is a business! TPA goes around to negotiate the best deal in town. So, the person who is WILLING to take the offer will sign an agreement with the TPA. A business deal! So why are we complaining? You signed it and agreed to it but complain later? We all know that many GPs are dependent on TPAs. Almost 60-70% of a GP’s income comes from TPAs. Without TPA, many more GPs will close shop. This is similar to private hospitals. 95% of hospital admissions are medical card holders. If insurance companies go bankrupt, all private specialist will be out of jobs! That is the fact. So, TPAs can “tarik-harga” . Unless the GPs can unite and state their demands, no TPA is going to entertain your request. By 2021, the market is going to be flooded by GPs when 50-60% of doctors(roughly about 2000-3000 per year) completing their compulsory service not going to be absorbed into civil service. You think the TPA is going to symphatise you? They will be having a jolly good time of GP shopping! And don’t forget the “uberisation” of healthcare where even those who are waiting for housemanship seem to be giving “online” or phone advise!

Even if the government removes the fee schedule, how much do you think you can charge a patient? How much a patient is willing to pay out of his/her pocket? Under-cutting and bad-mouthing is going to be rampant and again TPAs will have the same modus operandi. They will continue to negotiate a deal for the cheapest possible GP. That is business and everyone wants to make the maximum profit.So, if you agreed and signed for it, you have no basis to complain. The government is not going to interfere with that.

I really felt that most of the arguments that were forwarded during the town hall meeting were emotional in nature. I was watching it live on FB and was putting myself as a member of the public. What I saw was just doctors arguing to make more money! And that was exactly how the public felt as seen in many comments on FB etc. Bringing politics into the picture made it even worst! Whatever political ideology we have, we should keep it among ourselves and should not display it publicly, as we are dealing with members of the public who may have different political ideology. Even more shocking and surprising for me was when one of the speakers rejected Universal Health Care! Lucky the MMA president came with a statement 2 days ago that MMA and all medical associations had signed Declaration Titiwangsa in support of Universal Health Care.

When 1Care was mooted in 2012, the GPs went against it as well, mainly because of dispensing separation. It was scheduled to be implemented in 2014 but the 2013 election results made it to be shelved indefinitely. We have to admit that it is the dispensing rights that the GPs have which is giving them the survival. With limited consultation fee, they make profit from dispensing medications. IF this is removed, more GPs will close shop and become unemployed. This was the reason why GPs were shocked and reacted when the Minister announced last month that drug price control mechanism will be implemented. To me, I support the drug price control mechanism. We have to look at the public and see what benefits them. Working in a private hospital, I very well know how the hospital mark-up the medication prices. Some are up to 100% mark-up, especially for inpatients. That’s the reason I don’t like to give generic medications to patients as the organisation that makes the most profit will be the hospital. The cheaper the drug, the higher the mark-up. I rather ask the patient to buy from a pharmacy via a prescription slip from me. As for a GP, having a price written at the box may reduce their overall charge.

Now, let’s come to the solution! WE have to change and move forward. We can’t be harping on the same model that we have been doing since the 1960s! The world is changing and many countries have moved on to new models. Whether these new models are better or worst is something to be decided later. We have to move to a win-win situation, for the GPs, doctors in general, government and the public. Our healthcare system is not sustainable. I have said this many times before. Two parallel system running concurrently, competing against each other for an essential service is doomed to fail. We have a public system totally funded by tax payers and a private system almost 80% funded by insurance (aka out of pocket). The insurance companies are also bleeding in billions and the only reason they are still providing medical cards is because it is mandatory under Bank Negara rules. If not, which company wants to continue a loss making business?

The way forward for a GP to have a lifeline is to have a National Health Financing Scheme which will integrate  public and private healthcare system. This is the only way you are going to survive and have a decent living. You may not make tonnes of money but at least you can earn a living. With the NHFS, GPs will be paid by the scheme with an agreed fee. GPs can charge extra with removal of fee capping but how many patients will be willing to pay out of pocket is something we need wait and see. Eventually, most GPs will do bulk billing! It will come with a price. Dispensing separation will become inevitable with NHFS, where subsidised or fully funded medications by the NHFS will have to go through a dedicated pharmacy. But the overall cost of running a clinic will drop as you do not need to employ staffs to dispense or to run an in-house pharmacy. GPs have to form group practices like in many other countries. The NHFS may have to pay higher fees for a specialist GP which will make more GPs to upgrade themselves. Sometimes I feel very sad when I attend CME talks to see the same GP’s faces all the time! And guess what, most of them are senior GPs! The younger ones are hardly seen as they are busy trying to run their clinic.

With the NHFS paying the consultation, procedure fee and medications, there are bound to be audits. Again, this is nothing new as most countries with NHFS do such audits. You will have feedback audits, prescription practise audits and even average consultation fee audits. The number of patients you can see a day may be limited in the context of quality care. Prescription of certain drugs like opiates, steroids , antibiotics etc will be monitored. At the moment, these are never audited and the GPs can do whatever they want. Do we even have the data of total usage of antibiotics by GPs in Malaysia? We do have data from KKM and private hospitals but not from GPs as there are no laws to mandate GPs to be audited for such usage. IN any system there should be check and balance and doctors are not or should not be exempted. Unethical practices will rise if these issues are not kept in check, as what is happening increasingly in private hospitals.

There is no point arguing with the government when it comes to essential services. A government’s duty is to provide such service to public. Just see what happened when education was privatised! We made someone rich by making the public to go into debts!While the NHFS will have to get the money from the public in the form of premiums plus funding from the government, at least it will distribute the health service to a united system. Patients can go anywhere without paying anything and the GPs will be able to get the load with lower overhead cost, enough to have a job to survive.

Either we change to live a reasonable decent life or we die a slow death……. it’s our choice.

 

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Lately I have been slow in updating my blog as I have been extremely busy and travelling overseas quite frequently. As our children start to begin their university lives, our life changes as well! Yesterday I saw an interesting article in The Star which quoted Prof Adeeba, the Dean of UM Medical Faculty as saying that medical graduates are not prepared for their job. The same article quoted that 30% of housemen do not complete their Housemanship in 2 years, according to Health Minister. Don’t these sound very familiar?

I have been talking about this for almost 10 years now, in fact longer than that, if you have read my MMA articles as way back as 2004. The above statement was made during the UM’s MEDxUM conference held in UM last weekend. I was actually invited to give a talk on bullying and harassment but unfortunately, the notice came late and I was not in the country last weekend.

For years I have been saying that medicine is not a “glamorous”, easy life and good money job! The public would like to think as such until they see their own child “suffering” after graduating. Then they blame everyone else except themselves. I am not saying that the system has no issues but every system in the world has issues. BUT being a doctor means you have to work and work to gain experience and further our studies. Our education do NOT stop after the 5 years MBBS degree. It goes on and on, till you go 6 feet underground, not to mention the number of exams we need to sit etc. It is a life long learning and our teachers are our patients.

Last week, our Minister said that Housemen can be called at any time to help out. Currently housemen working hours have been reduced to 60hrs per week compared to 70 hours before. Shift duties have been going on for few years now. But each hospital would have their own problems and as such every hospital would have their own rules and regulation. The priority is that, the service must run. Many people were unhappy with what the minister had said BUT service comes first. This rule does not apply for doctors alone. It applies to every single civil servant. Any civil servant can be called to duty at any time. During disasters etc, not only doctors are called but also police, bomba, welfare department etc. It is the duty of the government to make sure that the rakyat is taken care. That’s why you are called civil “servant”. You are a servant to the government and the people. The government(aka the people) pays you to take care of the “rakyat”. As a doctor, which you chose to be, your duty is to serve mankind. Isn’t that what most budding medical student would say during interview? Furthermore, the word “Houseofficer” actually means that the doctor stays IN THE HOUSE and is available at all times! That’s the reason it was mandatory for us to stay within the hospital compound during those days. Unfortunately, with increasing graduates, hospitals could not provide the necessary accomodation to all housemen and allowed them to stay elsewhere/home.

If you have pure passion for a profession, you will even do it for FREE! Unfortunately, along the way you will realise that life is more than that. You need to earn a living. You will need to serve your loan, children etc. When you are a student, all these are taken care by your parents and thus you are “stress free”. Reality hits you much later. As a doctor, you need to sacrifice a lot. Hours of work, spending little time with family and even “neglect” family members. The public do not understand all these till they have their own child in the system. Then they go on writing complain letters to the newspaper for their “adult” child who by right, should be able to take care of themselves!

More than 10 years ago I predicted that the time will come when doctors will have to wait in a “Q” for Housemanship, it will likely be given under contract and majority will eventually would not even get a civil service job. All these had surely and slowly come true. Many had emailed, messaged and even called me to say that all my prediction has come true. I have also met some junior doctors, Housemen who came to see me and had read my blog when they were students. They all admitted that every single word that I said about the system, life as a doctor, predictions were all on the dot! Some of them regretted doing medicine.

Next year will be another year to watch, as the first batch of contract doctors/housemen would be finishing their contract. Their contract started in December 2016 and would be completing their 3 years contract this year-end. Majority who had completed their housemanship had applied for a permanent post early this year but I was made to understand that they are yet to get any reply. Their contract can be extended for a maximum of 4 years to complete the compulsory service. Thus, by end of next year, we will know how many will still continue as a civil servant and how many would be left in the limbo. The 1st batch of Pharmacists contract ended end of last year and many were left without a job. Suddenly my hospital received tons of application for pharmacist when we only had 1 post to offer. The rough figure I was quoted was that only 30-50% of the doctors will be absorbed into civil service permanent post. These percentage would gradually decline later as more and more doctors are produced. Even those who get a government job, you can be sent anywhere in Malaysia. Either you take it or leave it! So, what will the rest do? Those from well to do family may end up opening a clinic. You may see a clinic in every other shop-lot by 2020, Wawasan 2020 achieved!

For those who are complaining, you should thank your lucky stars that you even have a job (under contract). Just bite the bullet and do it. Life is never easy and the world do not wait for you. The world is moving and changing daily. I even had some who are planning to return back to Malaysia from UK. They were told that ” tiada urusan pengambilan pada masa ini“. The problem is the fact that MOH do not even have enough post for those who are finishing housemanship in Malaysia, how are they going to provide a job for those who are returning from overseas? Obviously you will be at the bottom of their list and not their main problem. The MMC circular 2 years ago had already given a guideline for those who are returning from overseas. I had posted it in my blog in 2017.

I still have parents who believe that their child can work anywhere in the world with their local medical degree! I find it rather annoying at times. They just refuse to read or take advise and blame the system. Medicine is the most regulated profession in the world. Some countries still practice the “recognised degree” list and some have moved on to “common entry exam” format. MMC still uses the former. If your degree is not recognised in the country where you intend to practise, you need to sit and pass the entrance exam. These exams are not cheap and majority do not pass on 1st try. After spending huge amount of money, there is no guarantee that you will even get a job. Most who do get a job end up working in a rural/remote areas under a “non-training” post. Even Australia has closed their doors to foreign doctors who passed AMC exams. They do not provide internship anymore as they do not have enough post for their own graduates. However, if you have some years of working experience from your home country/elsewhere, you can try to apply for a supervised GP job. Even that rule is changing starting 11/03/2019 as below:

“Visas for GPs initiative

The Visas for GPs initiative will manage growth in Australia’s medical workforce by regulating the number of doctors entering Australia to work in the primary healthcare sector through the skilled migration program. The Visas for GPs initiative will commence on 11 March 2019.

All employers nominating a position that will be filled by a doctor who needs a visa to work in the Australian and New Zealand Standard Classification of Occupations (ANZSCO), occupations listed below will be required to obtain certification (a Health Workforce Certificate) from a Rural Workforce Agency (RWA). A Health Workforce Certificate is a letter issued by a RWA confirming the genuine need to fill a primary healthcare position at a given location in Australia by a doctor in the following three occupations:

  • General Practitioner (ANZSCO 253111)
  • Resident Medical Officer (ANZSCO 253112)
  • Medical Practitioners not elsewhere classified (ANZSCO 253999).

Employers will be required to attach a Health Workforce Certificate to their nomination application for any of the following employer sponsored visas:

  • Temporary Skill Shortage (subclass 482) visa
  • Employer Nomination Scheme (subclass 186) visa
  • Regional Sponsored Migration Scheme (subclass 187) visa.”

The idea is to reduce the number of overseas trained doctors for GPs by 200 yearly for the next 4 years. It is estimated that if they do not do as such, Australia will have an oversupply of 7000 doctors by 2030. Gone are the days when you can sit for AMC Part 1 and then go to Australia to work as a GP/MO before sitting for Part 2. And for those who think that you can sit for the FRACGP via the Academy of Family Physician of Malaysia and go to Australia to work, please be informed that the rules have changed from January 2019. Those who enrol into the program from 2019 will only receive icFRACGP(International Collaboration) and would NOT be registrable in Australia till you complete further modules. How these further modules will be conducted is not made known at the moment. Must you be employed in Australia under supervision or is it done online? If you need to be employed in Australia under supervision, then the above VISA rule will apply which also makes it more difficult as there would not be any FRACGP holders in remote areas to become your supervisor. Even for people like me who had worked 22 years as doctor and have been a specialist for 15 years, I cannot work in Australia as a specialist as my degree is not recognised! Even if I am assessed as “substantially comparable” by the Royal College of Physician of Australia, I need to find a job which can provide me with 2 peer reviewers to peer review me for 12 months before even being considered for specialist registration. To find such a job is almost impossible and you need to find it within 2 years of the assessment. Not to mention the amount of money you need to pay to do all the assessment!

So, for those who feel that spending Rm 300-500K locally would give them a job anywhere in the world, please understand that the world is changing rapidly. Even Singapore has reduced the number of intakes of foreign medical graduates since the last 2 years as they have their 3rd medical school producing graduates since 2017. Only UM and UKM degrees are recognised in Singapore and I heard many who applied the last 2 years never received an offer unlike 10 years ago when Singapore first recognised these degrees. BREXIT may also change some rules in UK.

I started with ” The Storm is coming…..” in 2011 and upgraded it to “Hurricane is coming…..” in 2012. The Hurricane is now sweeping through the nation and the world…………

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It has been a while since I last updated this blog. In my last article, I promised that I will be writing a series of article in relation to the changing world of medicine but unfortunately I met with a small accident in September while going to work. While I was OK and only hit a divider on the highway, my car was damaged and currently still in workshop. It is really frustrating when you don’t have your own car to travel around. This entire fiasco kept me busy for the last 3 months with Deepavali early this month and some travelling to do.

Medicine is or “was” a noble profession. It started as a science to help humans, to discover diseases and ways to treat them. Early doctors were trained purely by apprenticeship with no formal training or degrees. They did their own research at the back yard and came up with new techniques, findings and even treatments. In the 19th century, our ancestors believed that doctors need some form of self regulation and proper training modules. Thus, registration and regulation of doctors started. General Medical Council began in 1858.

Doctors are the only people on the planet given the rights to collect and record clinical history and confidential informations of a person. It is the only profession which can take detail information about a person which include certain intimate or sensitive details and social circumstances. You need to know every detail about a patient, from travelling history, problems at home, social history, sexual history etc etc. Only then we can formulate a diagnosis and provide treatment plans. The patient trust us to keep these informations as tight as possible and not to release the information to a 3rd party or even to his/her relatives which may even include his/her partner without the patient’s consent. This is where medical records safe keeping and confidentiality comes into the picture. Every medical council in the world has guidelines on these issues. Every doctor should read and understand these guidelines as not to breach ethical and professional bounderies.

Doctor-patient relationship is a unique relationship. We should keep professional boundaries at all times. This is the main reason why we should not be treating our own family members and close friends. Emotion would not allow us to provide the best standard of care to our loved ones. We will be in denial and would not give the best advise. On the other end, patients can become a vulnerable victim to a doctor. Only a doctor knows sensitive information of a patient and thus can easily be blackmailed by a doctor. This is one of the reason why professional boundaries are important to be maintained. This is also the reason why we must be regulated!

The advent of social media has created a totally new set of problems. Many doctors do not realise that social media can blur their professional boundaries. Facebook, Twitter, WhatsApp and many other messaging platforms have created new problems in the medical profession. Let’s look at WhatsApp. Doctors nowadays easily give their phone numbers to their patients, send confidential informations such as blood results etc via WhatsApp to the patient and even discuss their problems via WhatsApp. The doctor believes that he is tying to help the patient but forgets the fact that it can be construed as blurring professional boundaries! Imagine if you message the patient at 11pm at night and the patient is a married lady with some social issues, like problem with her husband etc. Imagine if the patient starts to communicate with you via WhatsApp for her personal matters, presumably seeking advise in relation to her relationship issues etc. This can definitely lead to something more serious like the case over HERE and  HERE. Furthermore any confidential information send via WhatsApp etc can be considered as a breach of confidentiality as it is leaving your premise. You got no idea who can see those messages even though the phone number can be the patient’s. It is always advisable to ask the patient to come back to your clinic for any discussion or issues. Never discuss any issues over the phone or via text messages. In India, a reason court ruling determined that telephonic consultation without seeing a patient that lead to death can be considered as culpable negligence which leads to being charged as culpable homicide!

Another issue is Facebook(FB)! Many doctors have FB profiles and some of us are active on Facebook, posting various personal matters and views. Way back in 2011 , BMA (British Medical Association) had already issued warning in the UK that interacting with patients at social networking sites such as FB can lead to blurring of professional boundaries. WE must, at all times maintain the doctor-patient relationship status. Making a patient a “friend” on FB blurs this boundary. Once you become a friend of a patient on FB, the patient can access many personal information regarding yourself, they can probably see your family members photos, your political and religious inclination and even comments that you might have made regarding a patient that you just saw in your clinic. IN fact, I have seen many doctors posting and discussing patient’s history and details in FB. While you may not mention the patient’s name but if that patient is your friend on FB, he will definitely know who you are talking about. Many Medical councils and boards in the world have produced “social media guidelines” and the common advise has always been ” never friend a patient on social media including FB, Twitter etc”. To my knowledge, MMC is yet to issue any guideline on this. KKM did issue a minor guideline 2 years ago after the labour room picture fiasco. Not only a patient can see the “life” of a doctor but the doctor can also “spy” on the life of his/her patient. In 2017 there was even an uproar in Pakistan when a doctor requested a patient to become a friend in FB! It was deemed as a form of sexual harassment and the doctor lost his job!

Whenever I talk to younger doctors in regards to this, I see a shocking face! Many doctors out there do not even know their own ethical boundaries with patients. Some even attend patient’s personal family function and interact with patients as though they are family friends. Yes, you may think that it is nothing wrong BUT as a doctor treating such patient, you should never cross the line. If the patient becomes your family friend then you should politely decline to be their doctor, to safe-guard the medical profession and doctor-patient relationship. THIS is a good article to read “Unhealthy relationship with patients”. I reproduce one of the excerpt here:

Maintaining professional boundaries

 

Avoid situations that may be misconstrued by the patient – for example:

  • Giving a patient a lift home in the car
  • Seeing patients outside the surgery without a clinical reason
  • Telephoning the patient without a clinical reason
  • Having personal transactions with patients, such as lending money
  • Conducting non-emergency consultations outside normal surgery hours
  • Having conversations with patients of a personal nature.

Medical examinations can be misinterpreted by patients, and they can be left feeling that proper boundaries have been crossed so when conducting examinations:

  • Explain if an intimate examination needs to be conducted and why
  • Explain to the patient what the examination will involve
  • Obtain the patient’s permission before commencing
  • Give the patient privacy to undress and dress
  • Keep discussion relevant and avoid unnecessary personal comments
  • Encourage questions and discussion
  • If you can sense that the patient feels uneasy, offer a chaperone or invite the patient to bring a relative or friend.

Be aware of your own vulnerabilities:

  • Develop skills in saying ‘no’ whilst maintaining compassion and rapport.
  • Be aware of the impact of isolation and take steps to have as much peer interaction as possible
  • Do not to be seduced by comments that may appeal to your ego ‘you’re the only person who listens to me and understands me.’

Some of the things you need to consider include:

  • Making friends with patients or treating friends as patients can lead to unreasonable patient demands
  • Politely decline invitations from patients to be Facebook ‘friends’
  • Living and working in close rural or cultural communities means you may be invited to social and community events. You don’t need to decline every invitation you receive but do consider the nature of the event before accepting. And, you must always maintain professional boundaries if you choose to attend
  • Accessing patient records for the purpose of making social contact breaches the patient’s right to privacy.

I realise that many junior doctors and even some of my own colleagues do not understand their boundaries. They take it for granted especially doctors in private sector. These doctors feel that it is a form of marketing strategy to be friends with patients in FB, to attend functions organised by patients and make friends with patients as though they are your family friends. Some even question me when I advise them not to do so. It is ethically wrong fo a doctor to breach a doctor-patient relationship. At all times, we should maintain our professionalism and treat a patient as a patient! Never do more than that except in an emergency situation.

I see a very dangerous trend of doctors accepting patients as FB friends etc. Please be VERY careful! It can be harmful in both ways. With increasing medico-legal cases in court, it can only harm you further. We are not any different than judges who have to refrain themselves from many social events.

It has been a busy year for me. I may not be able to update another article within the next 1 month. Thus, I wish everyone a very HAPPY NEW YEAR 2019…………………

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Three years ago, I wrote an article with the above title. I thought of revisiting the title again, as there are a lot of negative publicity with the medical profession over the last few weeks. It all started on 29/07/2018 when a front page article was published by the Star.

 

The front page title was followed by an article which supposedly exposed an HOD who has been sexually harassing junior doctors. Currently KKM is conducting an enquiry into this matter and the said HOD has been asked to go on leave. While I do not want to speculate on the truth of the matters raised, I am not totally surprised either. “With Great Power, comes Great Responsibility” but unfortunately, Great Power also comes with great corruption! It is not unusual for someone in great power to abuse their position. It happens in almost every field. Even in Hollywood and Bollywood, actresses have been sexually harassed. The recent expose of Harvey Weinstein sexual harassment scandals rocked Hollywood and subsequently many more exposures came to light. Whenever someone is in a vulnerable position, the superiors with ultimate power tend to take advantage. Have I seen it happening in medical field? If I say NO, I will be a liar. However, most of what I have heard are verbal in nature. Please be also informed that there is a difference between sexual harassment, sexual abuse and assault.

On 9th May 2018, for the first time since independence we saw a change of government. What happened after that? Expose after expose showing how the country’s and the people’s money were misused and abused. I have lost track of all the exposes since 9/05/2018. Why did it happen in the first place? The answer is the same: with great power comes great corruption! Anyone who stays in power for too long will bound to misuse their position. It is human nature. That’s why politicians will never try to give up their seat. The same thing happens in any organisation. When someone becomes the HOD and remains so till retirement, he becomes untouchable. He becomes so powerful that every single thing needs his approval. From approving leaves, giving SKT marks, approval to attend courses, signing for exams, approving claims, signing off housemen etc etc, almost everything needs his/her signature! What a powerful position! On the other hand, the HOD can go missing anytime, hardly does any clinical work, goes overseas conferences under pharma sponsorship etc etc and NO ONE will ever complain or take action against him/her! I have seen HOD’s who only came to work twice a month and was sitting on a JUSA C level! The rest of the days, he/she is contactable at home! I have seen HODs who hardly does any clinical rounds but will appear in the ward everyday when a VIP gets admitted. It really fits into the term ” Makan Gaji BUTA”. How many HODs even put in their leave application forms but yet they are on-leave?

When someone is that powerful, things like sexual harassment etc bound to happen. Many years ago, I wrote in the MMA magazine that HOD’s post should be rotated! When I was doing my attachment in Singapore in 2007, it is the policy of the hospital that HODs can only hold the post for a maximum of 2 terms. One term is 3 years. So, after 6 years, the baton must be passed to the next person. This next person may be a junior to the current HOD by years BUT the rotation will still need to be done. The whole purpose of this policy is to prevent abuse and at the same time, give the junior doctors an exposure to administrative work. Somewhere in the late 2000s, there was a circular from the then DG, Tan Sri Ismail Merican suggesting that the HODs to be rotated every 5 years among the JUSA salary scale. Unfortunately, there were huge objections from the HODs themselves and the suggested plan never materialised. Human nature: power! And absolute power corrupts absolutely!

IN 2014, I wrote an article about bullying. In fact, i had written several times on the issue of bullying and thus, I would not elaborate on that matter in detail again. There is a thin line which differentiates bullying from scolding. We cannot assume that every scolding is a form of bullying. Medicine is about life and death matter. A simple twist of the pen can cause death. Thus, seniors scolding juniors will happen no matter how hard you try to prevent it. However, it should not be done in front of the patients/relatives.Bullying on the other hand has nothing to do with scolding for making mistakes.Bullying includes actions such as making threats, spreading rumours, attacking someone physically or verbally, and excluding someone from a group on purpose. Unfortunately, it looks like now, every scolding is being considered bullying. Medical life is a stressful life, both physically and mentally. When you work in such a stressful situation, scolding bound to happen. However, with increasing number of doctors, shouldn’t it get better? Where did we go wrong? Why despite having increasing number of doctors ( I heard some hospitals have close to 4 MOs in a ward!!), there seem to be worsening situation of “bullying”? BTW, real bullying do occur and it occurs in every profession and in every country. This article talks about bullying in Australia and this in NZ. Nothing unusual but the type of bullying varies from one centre to another. We can never prevent it completely as we are working in a stressful job.

My answer is simple, which I had written since 2004! The quality of graduates had deteriorated! When quality deteriorates and graduates do not even know basic medicine, scolding aka “bullying” will become more rampant. From what I gather, the quality has deteriorated to the extend that sometimes, the consultants do not even bother to ask the HOs anything, as it is pointless! How did someone graduate when they do not even know how to take a history, examine and come to a diagnosis? It is the very basic of medicine that you go to a medical school for. How did someone even passed the final exam? Again, this is what you get when you commercialised medical education. Do you really think that the medical schools are interested in producing the best quality of graduates? All private universities are profit driven. Only profit matters. With such a low entry requirement to enrol into a medical school, we still have almost 100% passing rate! Can anyone beat that? Australia with such a stringent entry criteria, still have about 5-10% drop out rate! UK has almost similar figures. India went through the same phenomenon when they commercialised their medical education in late 1970s. Corruption, lowering entry requirement and high pass rate with dropping standards forced Medical Council of India to introduce a common entry exam! Now, every student who intend to do medicine must sit and achieve certain level of pass marks to be eligible for medical course. Only after that, you can apply to the universities: public and private.

I just hope MMC will seriously look into this matter and introduce some form of either a common entry or exit exam to maintain the standards of medical graduates. If not, we are be going backwards! Many still do not know how medicine has changed and still changing. I will continue these series of articles over the next few months. My next issue under this heading will be “doctor-patient relationship” and professional boundaries. With social media everywhere, do medical students or junior doctors know where their boundaries are?

Happy 61st Merdeka ……………

 

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It is about the time of the year when you see a sudden surge in my blog visits. It happens every year after the SPM results are announced. Once again I will get emails and comments asking me all sort of questions which has been answered many times before. I have written countless number of articles since 2010 in this blog which is still available for people to read. Somehow I feel, our current generation do not like to read much and wants quick and easy answers. I would blame the education system which never encourage students to read and explore the world. There are so many things happening in this world and the world is changing rapidly day by day. Our society is still living in cocoons.

Once again I would encourage everyone to buy and read my books before deciding whether to do medicine or not.  You can see instruction to buy my books over HERE and I can still sell it at a special price of RM 85 per-set. Do not jump into medicine just because you got 9As, your parents & relatives said so or you think you are going to make big money etc. The number of doctors/graduates quitting medicine is increasing day by day all over the world. Only the toughest and those who got real passion and willing to sacrifice, will survive.

Many people believe that medicine is the only profession where you can help people. Frankly there are many people out there who are helping people more than doctors. At the end of the day, medicine is just a profession to earn a living. It is a service for a price! The society now perceives doctors as someone who is paid to provide service and not ” helping people”.  Would you “help” and treat people if not paid? Not to mention the viral damaging remarks made against doctors and clinics being circulated in FB and Whatsapp! It is becoming a norm. The best part is , you as a doctor CANNOT reply to those comments as it is considered breach of patient confidentiality! You will be called up by MMC for disciplinary action.  Many do not know that once a disciplinary action is taken by MMC, you will not be able to even apply for a job anywhere in this world even if your degree is recognised in that country. This is because, every medical council in the world will request for ” Certificate of Good Standing (CGS)”  from the country where you are working currently. Once there is a disciplinary action taken, it will be listed in CGS. So, likely you will be disqualified from getting a job.

Not to forget doctors being assaulted in India and China! The video below shows how a doctor is being assaulted in India! It is becoming so rampant in India. It all started with commercialisation of medical education and medical business! The public now had lost trust on doctors. IN western countries, it is manslaughter charges as I had written in my last post.

Frankly, do patient really listen to you nowadays? Five out of 10 patients do not even bother to follow your instructions. They come to you with complications years later and expect you to cure them. No one bothers to take care of their health and most doctors nowadays are treating complication of life style habits. They insult you if you don’t give MC but can happily go shopping while smoking! I can write tons of examples but suffice to say that people just consider you as another person who is doing a job. Only the senior citizens in 60s and 70s seem to appreciate you nowadays. You see more older people thanking you than any young people. The young people just consider you a service provider for a fee ( I pay you, you do your job)!

What prompted the title of my article is a message that has been circulating in Facebook and WhatsApp. It is a well written piece but I got no idea who wrote it. Please see below:

WHAT IS THE DARK SIDE OF BEING A DOCTOR IN INDIA and ? MALAYSIA

“Loneliness”

Profound loneliness. You can be surrounded by friends, family and colleagues, but in reality, you are quite alone.

If your family does not consist of doctors, they hardly understand the difficulties that you go through. They sympathize with you, yet are unable to grasp the reality of your training and career. Why you must spend days and weeks and even years apart from them. Why a lot of their calls are unanswered by you, while you are busy during rounds or managing patients.

Your old school friends do not really understand how hard the years have been. Why you couldn’t attend all the weddings you were called to. Some just attribute it to arrogance. Some understand. Only a few are driven enough to maintain a relationship where you hardly meet, talk or hang out. Nobody realizes that you hardly have time for yourself, leave alone the closest of friends.

When you do meet your old buddies, from various different fields, you can feel a fence that has formed around you. You smile, and nod your head. Yet, you are some distance away. The conversations seem a bit trivial compared to what goes on everyday in your other life. It is like viewing the rerurn of a tv show you had loved at some point of time.

Your college friends don’t stay with you for too long. Forever branching and specializing fields of medicine mean everyone either ends up in a different college, City or country eventually. You do drop each other a message once in a while, especially if you can remember who it is that you are missing. Conversations do not progress beyond a few words, as both of you are busy beyond compare. Time and distances lighten the strongest of bonds.

Your partner/spouse/girlfriend/boyfriend understands your trials and tribulations with difficulty. A similar profession leads to conflict, ego struggles and comparisons. A different profession causes irritation and indignation at your personal priorities. You keep training and hardly find time for them.

Your patients may love you for your bedside manner and clinical acumen but neither do you form friendships nor expect any support in times of trouble. You keep a distance. Always. Proximity causes lack of objectivity. And, patients rarely come out in open support of their physician.

Your colleagues in the same branch view you as competition. So much so that they would be secretly relieved to see you fail. You colleagues in other branches form cordial, friendly relations. You meet once a year for joint conferences and sometimes discuss patients which have been referred. You can expect a bit of professional support but nothing emotional or personal.

The hospital you work in couldn’t care less about you. You are indispensable to them, until you are replaced.

Not all this is true for everyone in all scenarios, but, yes, you learn to live with this reality.

Add to this the constant fear of litigation, abuse, violence and disciplinary action.

It can get very lonely at the top for doctors sometimes. And the higher you go, the further away you are from everyone.

If this is not part of your story, being a doctor, you really are blessed.

 

Trust me, the article above is what most doctors go through in their life. At the end of the day, no patients will ever come to your defence if something happens to you. Do you see anyone coming to the defence of Dr Bawa Garba and Dr David Seelu in UK? None! Your own medical council will attack you in the name of public safety. That’s the life of a doctor. The untold story that I have been writing for the last 8 years. Only do medicine by knowing all these issues! If you think housemanship is torturing, wait till you see the real world of medicine.

I hope all SPM leavers would not just jump into medicine just because you got 9As. Read and learn to know the world and how it is changing. Do medicine only if you are willing to put up with all these struggles. If not, please do not waste your money and time.

 

May we make a right choice for GE14…………          Have a blessed Good Friday……..

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The world of medicine is changing rapidly. For those who are aware what is happening around the world, we know how the perception of public towards medical profession has changed. Unfortunately, there are many out there who are living in cocoons, do not even know that sooner or later they can be charged for manslaughter!. The recent case in UK involving Dr Bawa Garba has sent shock waves around the world. A senior trainee paediatricians were given suspended jail sentence of 2 years for gross negligence amounting to manslaughter. GMC ( the guardian of medical profession) appealed to High Court to struck off her registration despite Medical tribunal giving only 12 months suspension. Two weeks ago, the court allowed GMC to struck off DR Bawa Garba from medical registry. A detail reading of her case will remind us that what has happened to her, happens on a daily basis everywhere in this world! Unfortunately , the world is changing.

Many still believe that medical indemnity will cover their butt if and when they make any mistake. Unfortunately, any negligence leading to death can now be charged under manslaughter and no more a civil negligence case. IN Malaysia, similar case is currently ongoing involving our very own DPM’s son in law’s death. The doctor who gave sedation is now being charged for manslaughter which can carry a prison sentence of up to 10 years. If he is convicted, it will set a precedence for any other such cases in the future. Similarly, another doctor was charged in December 2017 for circumcision gone wrong. He is being charged under Section 338 of Penal code for causing grievous hurt which can give you 2 years of imprisonment.

IN the US, just 2 months ago, an anaesthetist was charged for murder, “killing” a patient undergoing plastic surgery procedure by giving overdose of an anaesthetic agent. In fact, the first time a doctor was charged for second degree murder in US was in 2015.

Doctors around the world are rallying behind DR Bawa Garba. The fact is , the case just portrays how the healthcare system has failed. She was overworked, just came back from maternity leave and covering 2 person’s job without a supervising consultant. Sounds familiar? Unfortunately, the court do not take into consideration of all those shortfalls. It just concentrates on the negligence part and sentenced her accordingly. Any gross negligence leading to death is now considered a manslaughter! Is anyone still living in dreamland thinking that doctors are “gods” in the eyes of public? You are treated similar to anyone else when you cause a death due to negligence. Nothing special.

DR David Sellu’s case in 2013 is another good example. A well renowned colorectal surgeon of 66 years old was sentenced to 2 and a half years imprisonment for causing death of a bowel perforation case. A patient who developed bowel perforation following a knee surgery, deteriorated while waiting for surgery and subsequently succumb to sepsis. This happened in a private hospital with limited facility for emergency anaesthetist and OT. Thankfully, after 15 months spending in jail, the court of appeal reversed the decision when new evidences emerged regarding the lack of facility and why he could not do the surgery immediately. Unfortunately, damage is done and he had spent 15 months in jail together with other criminals convicted of rape, murder etc! After saving lives for 40 years, at the age of 66 he was treated as a criminal and even labelled as Dr Death! He was also subsequently subjected to GMC’s suspension. This is a good article to read as well : https://health.spectator.co.uk/david-sellu-a-surgeon-wrongly-jailed/

These cases have created a new term : ” Medical Manslaughter“! The list of such cases in UK till 2014 are listed in this article and attached below.

 

Looking at those cases above, we will wonder that these are nothing unusual in day-to-day medical practice. It happens on daily basis. Sometimes complications can never be predicted. Errors do occur and it is not entirely due to the doctor’s fault but the system as a whole. There are many factors that can cause such negligence to happen or how the complications are treated. Unfortunately, the court only considers the healthcare professional’s mistake. This applies to paramedics as well. Nurses have also been charged for manslaughter. This WEBSITE has some information of other health professionals who have been charged similarly.

 

The above video made last year is worth watching. Doctors are humans and do make mistakes. However, the society is not willing to accept these mistakes anymore. I had written much about civil litigation that is increasing day by day. Criminal charges are now increasing day by day as well. As long as you are proven to make gross negligence leading to death, you can be convicted for manslaughter. This can be as simple as giving a medication !  For example, if you give IV Pethidine for pain and the patient stopped breathing and dies, you can be charged for “murder”! And subsequently, the medical council will struck you off the register!

As I had always said, the world of medicine is changing. Modern medicine is infected by virus of mistrust as written over HERE. Commercialisation of medicine is one of the reason behind these issues. A profession which started during ancient times as a science to help people has been systematically and gradually converted into a multi billion dollar business. A business to suck people’s money in many developing countries. Generally, countries which have a universal healthcare system will have lesser number of negligence and complains, as patients do not pay much. Unfortunately, NHS in UK is dying day by day due to lack of funds and overcrowding.

If criminal charges against doctors left unchecked, we may be seeing many doctors behind bars despite saving many lives! I wonder whether AI will come to the rescue? Can AI be charged in court for making a mistake? These are the reasons why many doctors are feeling the overwhelming stress at work(burnt out) all over the world. After years of training and money spent, a simple mistake will land you in court. What use to be civil has now become criminal offence. I can only see more and more doctors retiring early and leaving medical practice. Many do not even encourage their offsprings to do medicine.

What I foresee is that the society will dig their own grave. More and more people would not do medicine. Many doctors would not take high risk cases. Consent forms will become as thick as “Harrison’s Book of Medicine”. Finally, mistakes will be hidden and notes will be fabricated!  The art of medicine is already dying due to CBM (Cover backside medicine) but eventually medicine itself will undergo a silent death………..

Gong Xi Fa Chai everyone………

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On the eve of the official release of Star Wars Episode 8, I thought of writing something new, since I had not updated my blog over the last 3 months. Medicine has a long history, going back to the time of Hippocrates(460-370 BC). He is known as the Father of Medicine. Hippocratic oath was one of the most widely known Greek medical text. It forms the basis of medical ethics.

Medical profession is the most widely regulated profession in this world. Degree recognition, disciplinary actions and standard setting is part and parcel of medical life. Our ancestors decided that medicine can be easily misused and thus a proper regulatory body must be formed to prevent any ethical abuse. I had written enough about these issues since 2010. Unfortunately, as I had written in my previous post, the commercialisation of medical education and healthcare system had led to “prostitution” of medicine. Doctors sell their soul to businessman for profit. Some say it is a “win-win” situation but to me, the day a doctors charges a fee for service, the nobility of being a doctor disappears in the eyes of the public. The businessman uses that to do business and the private healthcare is born to squeeze the people. There are 2 things that a government should never commercialize: health and education! The day these 2 sectors are commercialised, that’s the day you will see deterioration of the system. Almost all countries that commercialised these 2 sectors are seeing the outcome of such move. That’s why most developed countries other than US maintain their healthcare and education system under their government’s control. One of the major side effects of commercialisation, is litigation! And when litigation increases, who takes the brunt of it ? Not the hospital but YOU!  The businessman will just wash his/her hands off and disavow any knowledge of your existence!

Medicine is regulated by multiple rules and regulation. It all started with the Medical Act 1971 which regulates registration of doctors, recognition of degrees and disciplinary actions against errant doctors. The Poisons Act 1952 regulate the import, possession, manufacture, compounding, storage, transportation, sale and use of Poisons. Many doctors still do not follow what the poison acts has mandated them to do, like labelling of prescribed drugs etc. Dangerous Drugs Act 1952 specifically regulates the import, export, manufacture, sale and use of opium, dangerous drugs and related materials. This act is more related to opiates and benzodiazepines. Many doctors have been caught selling these dangerous drugs over the counter.

In 1998, the infamous Private Healthcare Facilities and Services Act (PHFSA) was passed. The regulation came into effect in 2006. Prior to this act, any doctors can open any shop-lot to run their clinic/provide service. With the enforcement of the act, anyone who intend to open any medical services clinic have to comply with the rules and regulations stated. The size of the doors, mandatory equipments, storage of medicines etc all all regulated since then. Together with PHFSA Act 1998, the fee schedule was made into a law! The 13th Schedule determines the maximum fee a doctor can charge to a patient for consultations and procedures. Unfortunately, it DOES NOT control the fees charged by the hospitals! The last review of this fee was in December 2014 after 1998! Again, we lost to businessman!

IN 2012, the Medical Act 1971 was amended. The regulations came into force in July 2017 which mandates compulsory registration of specialist, compulsory CPD points for renewal of APC and NSR as well as compulsory indemnity insurance. I had written about this over HERE. The APC fee increased to RM 100/year and there is also a RM 1500 specialist registration fee every 5 years. The doctors also have to pay PHFSA fee for registration and renewal of their clinic license. Just recently, few of the local councils have mandated that clinics must also pay the business license fee to local authority which was deemed exempted before. Not to forget waste disposal fee, minimum wage for staffs etc etc. IRB on the other hand is going after all the doctors to collect more taxes. As long as you sign an agreement under your name, all payments must be declared under personal income tax and not under your company’s tax.

On the other hand, the world of medicine is changing. The beauty of medicine is in making a diagnosis via clinical examination and interviewing a patient. I use to tell my students that interviewing a patient is like a police interrogation to find evidence to charge a criminal. This will be followed by clinical examination which together, will give you a diagnosis almost 80% of the time. Investigations is just to confirm your suspicion and diagnosis. This is called the Art of Medicine. Unfortunately, with increasing use of technology and rising litigation rate has created something known as CBM: Cover Backside Medicine. Why do you need to sit and take a history of headache or cough when you can do a CT Brain and CXR is a few minutes? What is the use of auscultation of the heart when you can ECHO anyone, anytime? For matter of fact, is stethoscope really necessary in this era? Has it become a mere symbol to say “I am a doctor” and that’s it? I have seen doctors who hardly take 4 lines of history and orders a battery of test to exclude whatever diagnosis he can think of. What is the difference between you and a technician? If that is so, why do you need 5 years of medical school? We see private hospitals promoting their latest gadgets to the public to make money. The public now beliefs technology more than a doctor!

Gone were the days when a doctor can palpate an abdomen and diagnose Appendicitis. Now, we need to prove to the patient that it is appendicitis. So, every patient gets a CT scan! If CT scan is normal, insurance may decline the case and patient may refuse the surgery. Interestingly, the Radiologist get pressured and reports it as appendicitis! It is a “win-win” situation I guess. The day medicine was commercialised which in turn caused litigation to rise freely, the pressure builds up for the doctors to prove everything. Unfortunately, in medicine, not everything can be proven by blood test or radiological investigations. At the end, doctors become technicians who orders investigations no matter how accurate his diagnosis is.  The trust is gone. Matters are made worst by article such as THIS. All these issues are affecting doctors all over the world. Depression among doctors, burnt out phenomenon are common in many countries. A recent article in BMJ ” Why has Medicine become such a miserable profession?” says it all!  ” The Dark Side of Doctoring” by DR Eric is also worth reading on how doctors are being used by businessman for profit and why he feels miserable. We have become a glorified prostitute to sell ourselves to businessman. Even US hospitals are feeling the pain of physician burnout. Probably we should also come up with a  “Drop Out Club” like HERE.

Will AI take over medicine one day? My answer is YES. Technology is going into healthcare. I predict radiologist will be the first to extinct. Already Ultrasounds are being done by ultrasonographers in many countries. THIS article talks about the 3 latest advancement in AI. The rise of the machines is coming! THIS article on “AI vs MD” is a long and interesting read. We will one day become like Star Trek and Star Wars where AI will diagnose the condition and even administer the medications. Doctors will merely become a technician. IBM Watson is already revolutionising the oncology treatments.

As Episode 8 of the Star Wars saga (The Last Jedi)  opens tomorrow, it may be the end of the Jedis. The title of the Movie reminds me of the fate of physicians. The Art of Medicine is dying. The beauty of medicine is dead. What is there left in medicine for everyone to be screaming to do medicine? Do people really need us when even now, most do not even listen to our advise? Most do not trust what you say and rather buy thousands of ringgit of supplements, but refuse to pay RM 90 for a consultation?

May the Force be with us……………………… Are we the remaining Jedis who will surely go extinct one day, not long from now………..

 

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It has been a hectic 2 months for me with too many holidays and personal matters to take care of. It has been 8 years since I started blogging and almost everything that I had said and predicted has become a reality. As I had predicted as well, in the end no one takes responsibility and blames each other. IN a typical Malaysia Boleh style, we chase after the numbers and forget about the quality. Many do medicine without being well-informed. Many do medicine without knowing where they are putting their foot into. I had written enough in this blog and even published 2 books to explain all these issues. Despite that, I still get young school leavers who keep asking the same question again and again. I wonder what they are actually learning in schools. Our education system has messed up the student’s brains well enough for most students not to know what the hell is going on in this world. Do you know that most SPM students do not even know who is Abraham Lincoln and why is he famous for? Do you know that they do not know anything about American and European history and history of the World Wars? Ask them who is Mahatma Gandhi! You will be surprised and shocked to the amount of knowledge these students have despite scoring strings of “A”s in their exams! Oh, BTW, according to TITAS textbook which is a compulsory subject for 1st year public university degree program, Mahatma Gandhi is “Tokoh Tamadun India” !! I give up!

With all the hoo-haa that has been going on in KKM regarding the HO issues, one thing for sure is the fact that almost 50% of graduates will not be offered a permanent civil service post after 4 years of compulsory service. Recently, MOH claim they will be introducing a “tagging” for those graduates who are waiting for posting. MOH claim that the waiting period should not be more than 6 months since the introduction of contract post which do not need an interview. However, I am not sure whether they had taken into consideration the increasing number of graduates since 2016 as few more medical schools have started to produce graduates and the final list of recognised medical schools will be out this year when the last few medical schools which started in 2012 becomes recognised by MMC. The number of graduates produced by these universities will subsequently increase over the next few years. Can MOH cope? The answer is obviously NO. One more interesting thing about the “pre housemanship tagging” as proposed by MOH is that it will be done in hospitals without housemen. These hospitals are technically district hospitals without specialist. So, who is going to guide who? Will it become a story of ” blind leading the blind……”? UM has also started a similar program for their own graduates as mentioned HERE but this is done in their hospital

Recently, there was a post in Facebook from a specialist asking a questions on why many doctors are discouraging their children from doing medicine. He claim that despite the increase in litigation, rules and regulation , it is still a noble profession. I do agree it is a noble profession BUT saying that medicine is the only noble profession is wrong. WE must move away from the notion that medicine is the only noble profession in the world. The world has changed. The day a doctor started to charge a fee for service, medicine as a noble profession has died. If you still believe medicine is a noble profession, than you should go back to government service and serve the people. Anyone in private sector cannot claim it is a noble profession as without money, you would not be able to treat a patient. It is a business and nobility takes a back seat or probably not existent. There are so many jobs out there which is also noble. I have an engineering friend of mine who is actively promoting greening of earth and promoting clean environment. Isn’t his job noble? Let’s take Mark Zuckerberg. He created Facebook without charging a single fee to anyone and connected the entire world! Long lost friend became close within seconds! Isn’t what he did noble? What about “Whatsapp” and many other social networking apps which is free? If you say charging a fee for service is noble than a mamak shop which charges a fee for food is also noble as he is providing food to everyone, without which people can die as well. Almost all philanthropist that I know are not doctors. Are they not being noble by donating to charity and foundation to help people? Are they not providing scholarship to needy students to pursue their education? What about teachers? WE should stop saying that we are the only noble profession in this world. A senior consultant friend of mine once told me that Tan Sri T J Danaraj, the founding dean of UM medical faculty once said ” The day  medical education is commercialised and medical practise is commercialised, that’s the day prostitution of medicine starts How true! At the end of the day it is all about money and survival.

Some will say that I will sacrifice my life for humanity and serve mankind till I die. For them, I have the story below:

A Dr graduated to be the best and finest surgeon in the world. At age 30, he got married.
The joy of marrying a surgeon attracted his wife to him.Few weeks after marriage leave he got back to work, thereafter he hardly spent some quality time with his wife.Their relationship began to go sour.

Not that he’s flirting around with other ladies. Not that he now had a bad company. But, at his work place, he was seen as TOO IMPORTANT.Every patient wanted him. The nurses loved him to handle all the surgeries at hand.

One day, he got home very early from work. The wife was glad that he was at least early today. Just as he was dropping his briefcase, his phone rang and the following conversation went on.

Nurse: Sir, we need you now at the hospital. We have an emergency.

He said : I’m on my way.

The wife was angry with him. As usual, he told her, “Sorry”.

This went on for so long.

But one unfortunate day, he had an accident. And….

He died! 

The other doctors and surgeons mourned him. They gave his wife cash to take care of herself.

But, can money replace love? Can some one ‘ replace a whole man?

You know the answer…

Not too long after, the wife went to that same hospital for some check up.

She was shocked to see someone in her husband’s former post. Not only that, she heard someone calling the new surgeon as the best in that town.

She wept bitterly…

Do you know you are replaceable?

Do you know you are NOT too important?

Do you know someone else can do better than what you are doing or what you can do?

Do you know you are cherished now just because you can still perform your right?

Do you know you are celebrated because you are available and useful?

No one’s saying you should not help out. No one’s saying you should not be a celebrity. No one’s saying you should not help others. No one’s saying you should be not punctual

BUT,

Take time to rest. Take time to relax. Spend time with yourself.

As bitter as those truths, many of you fail to accept that…

Tread softly… Go gently…

Your family Values YOU

Only they miss the presence of you not the rest of the world.

 

The above story is the reality out there. In the end, family comes first, unless you decide to live a single life till death. No one appreciate what you had done once you are gone. They will talk about you for one day and that’s the story.

Recently, there was another sad story in our neighbouring country(see below).  Dr Leslie Lam’s story is exactly what is happening out there. These are the side effects of “prostitution of medicine”. The day medicine was commercialised, that’s the day patients start seeing doctors as leeches who are out to suck their bloods/money. You could have saved hundreds of life but a single patient can bring you to hell! The number of complains in each hospital is increasing by leaps and bounds and almost always it is about money. They want their money back because their wound got infected! They want their money back because your surgery was not succesful and had complication etc. If you admit your mistake, they sue you to glory. If you don’t admit, they sue you anyway! BTW, I was informed that the patient who was responsible for Dr Leslie’s ordeal is a Malaysian.

The world has changed. Artificial intelligence and technology is taking over a lot of jobs. Medicine will not be spared. What you see in Star Trek and Star Wars is not far away. Skynet is not far away………….

Are these the jobs of the future(below) ?……… You can ponder upon…….

For those who are sitting for SPM 2017, Good Luck and choose wisely…………

 

Heart doctor Leslie Lam’s ordeal: Three decades to build a name… then ‘gone to bits’

Dr Leslie Lam has been completely cleared of all the allegations made by a patient who claimed the cardiologist performed an unnecessary procedure on him in 2011 for monetary gain.

Leslie Lam, cleared by Court of Three Judges, says his clinic never does things just for money

To this day, he still charges them the same rate of $25 for each consultation. At the same time, he counts among his patients Bruneian royalty who are willing to pay to have him close his Mount Elizabeth clinic for an entire day so that he can attend to them.

“I like to play a bit of Robin Hood,” said the 75-year-old grandfather of three, who has been doing volunteer work in countries such as Myanmar for more than 12 years.

That was why it came as a shock when he learnt in 2012 that a patient had gone to the Singapore Medical Council (SMC) to complain that Dr Lam had performed an unnecessary procedure on him in 2011 for monetary gain.

To Dr Lam, who was completely cleared of all the allegations last Friday, the accusations levelled at him were just “crazy”

After all, his first lesson to medical students doing their internships at his clinic has always been: “You don’t do anything for the patient unless the patient benefits from it.”

THE RELIEF

Today is one of the best days of my life, because suddenly I feel I’m completely free from this unnecessary complaint.

DR LESLIE LAM, in a phone interview after he was cleared.

Dr Lam, one of the pioneers of coronary angioplasty – a procedure in which a balloon is used to open up blocked heart arteries – said he cannot remember ever doing an unnecessary procedure.

He stressed that he often agreed to requests for discounts from less well-off Singaporean patients.

Registered nurse Siti Sundari, 61, who has been working with Dr Lam since 1988, described him as “kind”.

In 2015, after selling the premises that his clinic – The Cardiac Centre – occupies for $10 million, he distributed 5 per cent of the proceeds to his staff. He now rents the space.

He said the complaint weighed on him, resulting in many sleepless nights. His family said that he even became ill-tempered.

“It took me 30 years to build up a name like this, and (for it) to be just gone to bits over something so small, it’s crazy,” said Dr Lam, whose wife is a general practitioner. They have two daughters – one is a housewife and the other a branding consultancy owner.

Good friends advised him to appeal all the way, telling him that his name was worth everything.

Dr Lam, who has had 17,000 patients under his care, said he had had three full consultations with the patient from Malaysia.

In 2006, the patient had undergone a percutaneous coronary intervention (PCI) with three stents at Raffles Hospital. PCI is another name for coronary angioplasty.

Then in 2011, the patient consulted Dr Lam for the first time.

Dr Lam recalled that the patient had argued with him, insisting on doing a CT scan even though the specialist told him it was a waste of money because the scan would not capture the lumen, or the inside of the arteries.

Seven days after the CT scan results, the patient returned to Dr Lam and consented to a coronary angiogram – a type of X-ray used to examine blood vessels.

After the angiogram, Dr Lam advised the patient to undergo a PCI with stenting. During the procedure, the first stent slipped, requiring a second stent to be deployed.

Dr Lam said that in hindsight, perhaps he was too honest in telling the patient what had transpired. “If I had not mentioned it, if I had been dishonest, no one would ever see it.”

He revealed that after the procedure, the patient wanted his money back even though his condition improved. Dr Lam had charged the patient $1,500 for the angiogram and $7,500 for the angioplasty, which he said are considered low.

The SMC brought three charges against Dr Lam: leading the patient to believe he needed to undergo the procedure when there was insufficient basis; failing to perform the procedure with skill and care; and failing to obtain informed consent.

The first two major charges were thrown out by a disciplinary tribunal, which was satisfied that Dr Lam had carried out the correct course of action. Last Friday, the Court of Three Judges cleared him of the third charge.

The ordeal has underscored the importance of documentation and keeping good notes, he said. The brochures in his clinic are now more detailed than before, listing all the possible risks and complications.

Dr Lam said he now goes through the list with patients, ticks off each one, signs and then gets the patient to countersign with the date stated.

During the interview after he was cleared, his phone rang non-stop with calls from colleagues and patients. “Today is one of the best days of my life, because suddenly I feel I’m completely free from this unnecessary complaint,” he said.

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Finally, over the last 1 week, a Malay local newspaper had published several articles regarding the issues concerning medical graduates. This is when the blame game starts. Each authority will blame the other and finally no one will take responsibility. Eventually, it will be blamed on the previous administration and probably we need a RCI to investigate this, 10 years down the line!

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Let me put it this way. For years, many in the medical profession had voiced out their concerns regarding medical school’s approval. I first talked about this in 2006 and wrote an article in MMA magazine. Many accused me of over exaggerating. Dato Dr Chua Soi Lek realised it and issued a moratorium in 2005 which was subsequently lifted in 2008 when the new government got elected. NO one did anything! Tons of new medical schools were approved between 2008 and 2011 till the new moratorium was announced in May 2011. By that time, it is too late. Too many schools were already approved which no one can order to be terminated without legal repercussions.

Who gives the approval? Everyone seems to be washing off their dirty hands. All licensing and the need for an educational program is under the jurisdiction of Ministry of Higher Education. This is governed by Private Higher Education Act 1996. MOHE treats medical education as any other educational program. MMC do not have any authority in approving/terminating any medical program.  The role of MMC is only in 2 matters: assisting MQA in accreditation process of a medical program and recognition of a medical degree. Under Medical Act (Amended 2012), MMC is the only authority who can recognise a degree which enables a graduate to be registered as a doctor. Accreditation comes under MQA Act 2007. Only MQA can issue certificate of accreditation. However, for professional programs, under section 51 and 52 of the act, MQA will work with the relevant professional body in recommendation of accreditation of a program. As far as medical program is concerned, MMC will work with MQA in the process of accreditation. A Joint Technical Committee(JTC) is formed under MQA act, consisting of 5 government bodies(headed by MMC Chairman) who will then undertake the accreditation process. The recommendation of the JTC will then be forwarded to MMC for approval at each stage of accreditation.

No where along this line, MMC can either revoke or terminate a program. If at all, they can only advise MQA or MOHE to terminate the program. This advise may or may not be entertained. For example, even the minimum entry requirement suggested by MMC have to be approved by MOHE. When MMC/MOH suggested the minimum entry requirement to be increased to 5As last year, MOHE did not agree and thus it was never implemented! The only other area where MMC is involved is in the allocation of total student intake of each batch. However, JTC allocates the intake based on accreditation guideline. As long as the college can prove the capability of having adequate lecturers(full + part-time + sessional) and facilities , JTC cannot deny the requested number of intake. On what basis can JTC/MMC allocate lower number of student intake? Legally they can’t do that unless during their accreditation process they find that the college is not ready to take the requested number of students. And if finally MMC refuse to recognise a degree, we will see the politicians and parents standing in front of MMC’s office demanding fairness!

This is not the first or the last time we will see such issues. It has happened in almost every field that we know. Unfortunately, no one in our government will take responsibility or commit hara-kiri. It is a culture of “tidak-apa” attitude. No one thinks long-term. It is always a knee jerk reaction. We can talk till the cows come home but no one listens. Their KPI is making the country an Educational Hub to generate income for the country. Who cares whether there are job opportunities or not? Who cares whether our graduate’s qualities are declining or not? As long as we can produce a graduate with a certificate , it is good enough! Numbers more important than quality.

We are only seeing the tip of the iceberg at the moment. When the first batch of contract housemen, which started in December 2016 finishes their 4 years contract in 2020, we will be seeing almost 2000-3000 doctors being released to private sector every year!. This will average out to about 200 doctors/month being jobless! This is assuming that 50% of the graduates will continue in civil service. However, we must also realise that the permanent MO post are also almost full! Can the government create 3000 MO post every year from 2020? Personally I don’t think so. Thus, the number of MOs getting into a permanent post will decline over the years as the number of post declines. So, the actual number of doctors being released into private sector will be much higher than expected. The GP field will be flooded……..If even now, clinics are closing, what more in next few years. The entire health care structure has to change to accommodate this tsunami.

One of my friend told me the other day that I probably had a crystal ball in my house. Another friend told me that it is scary to see whatever I predicted happening right in front of our eyes. Well, I did not have any crystal ball and I am no Nostradamus. It is just simple mathematics and statistics. Something that we learn in school. Unfortunately, some people never use their brains when they do something for this country. Once a mess is created, it is difficult to turn back. History teaches us that. But then, who learns the real world history anymore? Our school history books have become a political propaganda book rather that teaching the future generations what we can learn from world History!

God Bless this country…………

 

 

 

 

 

 

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