KUALA LANGAT: Medical schools should get serious about offering high quality medical education to lessen the need to send students abroad, said Datuk Seri Najib Tun Razak.

The Prime Minister said fewer schools offering high quality medical education would be a far better strategy than having too many offering sub-standard education.

He said adhering to basic requirement for accreditation was insufficient, adding it was far better to benchmark the quality of medical education with the best schools in the world.

“Once we have achieved that, there may no longer be a need to send our students abroad as they can get equal or better medical education locally,” he said at the ground breaking ceremony of Mahsa University College in Bandar Saujana Putra.

The Prime Minister said, currently, some students were sent to sub-standard medical colleges overseas and this had become a perennial problem.

He added medical schools should also re-examine their curriculum not only to impart medical knowledge and clinical skills but also psychosocial, communicative, interpersonal and people skills to help their students become good healers and safe and competent clinicians.

Najib said the Health Ministry should forge formal relationships with proven medical schools for training opportunities where medical institutions could provide specialist care in smaller public hospitals and the ministry would upgrade facilities to cut down backlog of cases for minor surgery and emergencies.

Najib advised aspiring doctors to have passion and a genuine interest in taking care of the sick, at whatever cost, and be prepared to toil and sacrifice irrespective of time.

“The vocation of health care is not for everyone although we know that many students aspire to become doctors. Good doctors are not only those who are competent and skillful but those who are caring, compassionate and motivated to provide service above self.

“Malaysia requires the services of healthcare providers who are well trained and well mannered. They must be beyond reproach. They must be professionals who are ethical and put the welfare and care of their patients above everything else,” he said.

KUALA LUMPUR: MEDICAL house officers (HOs) or housemen feel they are not getting enough exposure and clinical training under the new flexi-hour shift system aimed at easing their workload, a survey by the Malaysian Medical Association (MMA) has revealed.

The results do not bode well for the nation’s healthcare sector.

The survey by the MMA’s Section Concerning House Officers, Medical Officers and Specialists (Schomos) revealed that 75 per cent of the 908 HOs who took part in the nationwide survey felt that they were not getting adequate clinical exposure and were unable to complete enough procedures as required for their training.

Sixty per cent felt there was no continuity of care for patients, with 52 per cent saying the previous on-call system was better than the existing system.

The results, made available to the New Sunday Times, echo the views of former director-general of health Tan Sri Dr Mohd Ismail Merican, who had said that while the shift system may have improved the quality of life of housemen, it may result in undertrained and untested HOs if strictly adhered to.

In an excerpt of his speech delivered at this year’s MMA Oration, which was carried in the New Straits Times on Aug 23, Dr Ismail expressed concern that with the shift system, there would be no continuity of patient care or accountability. Housemen also agreed that the shift system did not work well, especially in busy hospitals.

SUNDAY SPOTLIGHT: Housemen can rest but learn less

The new shift system has to reduced the long working hours of housemen, which was the main cause of stress for them, and also prevented too many from working infrom overcrowding wards.

INTENDED to solve the woes of exhausted and overburdened housemen, the new flexi-hour shift system itself is turning out to be one of Gordian complexity.

One of the most vocal critics of the shift system has been Tan Sri Dr Ismail Merican, the former director-general of health.

He believed that while it might have improved the quality of life of housemen or house officers (HO), it might result in HOs being under-trained.

In an excerpt of his speech delivered at the Malaysian Medical Association Oration 2012, which was carried in the New Straits Times on Aug 23, Dr Ismail also expressed concern that with the shift system, there would be no continuity of patient care or accountability.

He also noted the lack of interest among HOs in attending professional development programmes because these were held outside their working hours.

“They may attend if their shift duty coincides with the programmes.

“Otherwise, they prefer to stay at home and rest than continuing their medical education,” he said.

Medical education in Malaysia is indeed at a crossroads, said Dr S.R. Manalan, president of the Malaysian Medical Association (MMA).

“It has been much politicised and faces many unresolved problems, such as shortcomings in the selection of students for entry into medical schools, structure of undergraduate training, cost of medical education and the need for dedicated medical educators.”

He said the apparent commercial interest in establishing medical schools because of the increasing demand to produce doctors was also not helping the situation.

In 2009, there were 3,058 HOs. In 2010, the figure rose to 3,252 and last year, there were 3,564.

According to statistics, Malaysia will reach the doctor-to-population ratio of 1:600 by 2015 and 1:400 by 2020.

“The question now is, why do we have to train so many to become doctors and is there a drop in the standard of knowledge and skills of these doctors?”

Dr Manalan said the shift system was implemented to replace the old on-call system. It not only reduced the long working hours of HOs, which was the main cause of stress for them, but also prevented too many from working in the wards.

Working in smaller numbers optimised their exposure to a wider spectrum of clinical cases.

He said following complaints from housemen about the shift system, the MMA ordered a survey and entrusted the Section Concerning House Officers, Medical Officers and Specialists (Schomos) with the task. About 908 HOs took part in the online survey.

“Overall results showed that 85 per cent felt they were getting enough rest in between work compared with the previous system.

“About 52 per cent felt the old system was better than the existing system. On whether there was enough teaching or ward rounds by medical officers and specialists in the shift system, 52 per cent felt there was,” said Dr Manalan.

Not so positive was that 75 per cent of the HOs who felt that they were not getting adequate clinical exposure and were unable to complete enough procedures as required for their training.

Of the total respondents, 60 per cent felt there was no continuity of care for patients.

The MMA presented its findings to the Health Ministry in July. Dr Manalan said the ministry felt the results submitted by MMA needed more study and, therefore, it might do a further survey.

“In the meantime, the MMA executive council’s recommendation to the health minister is that there be a moratorium on the number of medical colleges or house officers until we have enough training facilities in government hospitals and better supervision of the new doctors.”

Equally concerned about the efficacy of the shift system was Prof Datuk Dr Kew Siang Tong, dean of the School of Medicine in International Medical University.

Although housemen were getting enough rest, Dr Kew was concerned with the MMA survey of HOs thinking they were not getting enough clinical exposure compared with the on-call system.

“That’s very significant isn’t it?

“But it’s reasonable because they are spending less time in hospital, less time with patients.

“Then there is a question that asked if the housemen are able to log in more procedures than in the previous system — a very important question — and only 25 per cent of the respondents said yes. That’s a very telling indication about the current system.”

Another factor that pushed for the implementation of the shift system was the big increase in the number of HOs over the years.

“The Malaysian Medical Council used to register a few hundred house officers every year, but now, it’s about 4,000 annually.

“If we follow the old system where everybody works the same hours, there will not be enough place for them.”

But the major concern for Dr Kew, which she believed was shared by many of her peers, was the lack of continuity in caring for patients.

“Now, put yourself as a patient. You’re seeing different faces all the time. You’d be confused and worried when different doctors tell you to do different things.”

It also puts the housemen at a disadvantage, for if they didn’t see a patient from beginning to end, they would not know the patients’ progress.

When housemen don’t get proper exposure, are not confident of their skills and do not know their patients well, this creates extra stress for medical officers as the work burden would be shifted to the seniors.

Another senior specialist opined that if we wanted quality doctors, we should control the number of doctors being churned out.

“If you count, the number of medical schools in such a small country is amazing. Yet, we are also sending students to Russia, Europe and other places. If this glut continues, we will soon have more doctors than nurses and end up like the Philippines. We will have to export our doctors,” he said.

Although conscious of the fact that our doctor to population ratio has yet to reach the aspired 1:400 by 2020, Dr Kew thought the problem might be distributive in nature.

“There are more than enough doctors in the Klang Valley. But if you go to Sabah and Sarawak, there are clearly not enough. So, the medical and healthcare service planners have to look at the problem in its totality.”

The sheer number of housemen had made the previous on-call system unfeasible, but the criticisms on the current shift system cannot be ignored.

Dr Kew, who has trained housemen for years, candidly admitted that she did not know what was the best way forward.

“There are only 37 designated housemen training hospitals in the whole country.

“On the other hand, there are some 4,000 new housemen every year. They need to be paid too and the government’s coffers are not a bottomless pit.

“It’s a difficult problem to solve. It may come a time when there’ll be housemen without jobs because there are only so many vacancies.”

i call this HARASSMENT…… we’re forced to worked extra hours without getting paid extra….. the total hours for that week will be 53 hours … which is far more than the total number of hours a person can work for a whole week which is 40 hours…….

as a result of that , we cannot attend any courses , or go for any events which normally happens on weekends…….. surely the doctors are going to REBELIOUS about this……….

This article (http://www.themalaysianinsider.com/features/article/nearly-half-of-us-doctors-struggle-with-burnout-says-study/) is again a reminder of the stress level that a doctor have to go through. The more developed a country becomes, the more stress a doctor has to deal with. This is simply because of the fact that the population is more educated, demanding, do not respect the doctor as much as the older generations, high litigation rate and reducing income with higher debt.

The good old days are gone. I know many budding doctors gets excited watching TV programmes like House and Grey’s anatomy but trust me, those are just dramas made for profit! Try doing what House does to his patients and I can bet you that you will have hundreds of lawyers letter at your post box!!

I use to tell people that a doctor who really cares for a patient will almost always get stressed out. On the other hand, those who do not care will always have less stress as they don’t bother what happens to the patient the moment he leaves his/her room. It may not be true all the time but it is, most of the time.

Nearly half of US doctors struggle with burnout, says study

NEW YORK, Aug 21 — Job burnout strikes doctors more often than it does other employed people in the United States, according to a national survey that included more than 7,000 doctors.More than four in 10 US physicians said they were emotionally exhausted or felt a high degree of cynicism, or “depersonalisation,” toward their patients, said researchers whose findings appeared in the Archives of Internal Medicine.

“The high rate of burnout has consequences not only for the individual physicians, but also for the patients they are caring for,” said Tait Shanafelt of the Mayo Clinic in Rochester, Minnesota, who led the research.

Previous studies have shown that burned-out doctors are more prone to thinking about suicide and to making medical errors than their peers, Shanafelt added.

The survey included nearly 7,300 doctors who filled in questionnaires about their work-life balance in 2011.

Thirty-eight per cent had high emotional exhaustion scores, which is akin to losing enthusiasm for their job, according to Shanafelt. Thirty per cent had high depersonalization scores, which translates into viewing patients more like objects than human beings, and 46 per cent had at least one of the two symptoms.

Burnout was most common among doctors at the “frontline of care,” such as those working in emergency rooms or in family medicine. Dermatologists and preventive care specialists were less affected.

The researchers compared physicians with a random sample of 3,400 employed people who were not doctors. Based on a modified version of the original questionnaire, 38 per cent of the doctors had burnout symptoms against 28 per cent of the rest.

“The study advances our knowledge by, for the first time, comparing to the general population and showing that physicians are at higher risk of burnout,” said James Wright, chief surgeon at The Hospital for Sick Children in Toronto.

“It’s very clear that when physicians are becoming burned-out it begins to affect their relationships with other healthcare workers and with patient families.”

The new results come with some uncertainty, because only about a quarter of the doctors who received an invitation to participate completed the survey.

It’s not clear why burnout strikes so many doctors, Shanafelt said, noting that excessive workloads are only part of the equation. Other possible reasons include too much paperwork, loss of professional autonomy and a higher patient load to make up for declining reimbursement rates.

“There is a sense that the volume of patients that need to be seen is increasing and it’s taking away some of the time needed to build a relationship and give the best care possible,” Shanafelt said. “That starts to build cynicism, I think.”— Reuters

Ensuring everyone gets good doctors.

ONE of the basic principles taught to all medical students and doctors isPrimum non cere – first, do no harm. It is a reminder that an intervention can lead to harm to the patient, however well-intentioned it may be.

This principle is even more relevant today than in yesteryears.

Healthcare today is complex and more effective than before. However, according to the World Health Organization, the likelihood of harm is high, with a one in 300 chance of being harmed by healthcare compared to one in 1,000,000 chance of being harmed while in an aircraft.

Data from developed countries reveal that one in 10 hospitalised patients are harmed because of adverse events or errors. Similar data has been found in local studies.

The future of patients and their families depend on what doctors say and do. Imagine the good and harm that can result from doctors’ actions and inactions.

The media focus on housemen in recent years raises questions about the quality of medical education and training, as well as the challenges in ensuring that everyone gets good doctors, and by extension, the quality of healthcare patients will be receiving in the future.

Studying medicine

There are more applications for entry to medical schools worldwide. Many young people want to become doctors, whether of their own volition, at the behest of their parents, or for other reasons.

Until 2011, high academic qualifications were the sole criteria for admission to all public medical schools except University Science Malaysia (USM), which required an interview as well.

Since 2011, the Malaysian Medical Council’s (MMC) guidelines require all applicants to local medical schools to pass an interview to assess the applicant’s aptitude.

Although the minimum academic qualifications for entry into medical schools are prescribed by the MMC and the Malaysian Qualification Agency (MQA), there are still reports of non-compliance by some private medical schools. There are also reports that some private medical schools take in more students than permitted.

The situation in foreign medical schools is varied. Medical schools in advanced economies require high academic qualifications and aptitude assessments. However, some medical schools in some developing economies admit students whose academic results would not even qualify them to enter a Malaysian university for other courses which require lesser academic qualifications.

Many such students gain entry through the good offices of the agencies of these medical schools.

It is necessary to emphasise that selection for entry into medical school implies selection for the medical profession. Findings from studies worldwide confirm that although some students have achieved the academic qualifications required for entry into medical school, they are not suitable for a career in medicine.

It is in the interest of the public and such students that they should not gain admission, rather than to have to leave the course or the profession subsequently.

Feedback from some public local medical schools indicate that more than 50% of students do medicine because of parental or peer pressure, glamour, hope of financial rewards later, etc.

Can such students end up as good doctors?

Should the quality of students doing medicine be of concern to the public?

What should be done to those admitted to local or foreign medical schools without minimum academic qualifications?

The message to parents that good examination results do not make a career in medicine suitable for their progeny has to be repeatedly emphasised. There is nothing worse than getting into a profession that is unsuitable for one’s personality.

Medical schools

There are currently 34 medical schools for Malaysia’s population of 28 million, compared to nine and 12 medical schools in 2002 and 2007 respectively. Sixteen new medical programmes commenced in 2009 and 2010.

Data from the Avicenna Directory maintained by the University of Copenhagen, in collaboration with the World Health Organization and the World Federation for Medical Education (WFME), show that countries with similar populations like Australia (23 million), Saudi Arabia (28 million) and Canada (35 million) currently have 26, 16 and 16 medical schools respectively.

Our ASEAN neighbours, Indonesia, Singapore, Thailand and Philippines, with populations of 238 million, five million, 65 million and 92 million respectively have 35, two, 19 and 54 medical schools respectively.

Germany and the United Kingdom have 41 and 38 medical schools respectively for populations of 82 million and 62 million.

The issue is compounded by the fact that the government recognises more than 370 medical qualifications worldwide. This list was inherited from our colonial masters and has been added to over the years.

In addition, graduates from unrecognised medical schools can sit for the Medical Qualifying Examination (MQE) and, upon passing, will be registered by the MMC. The examination, which used to be the final year examination of the University of Malaya, National University of Malaysia and University Sains Malaysia, is now also conducted by 13 other universities.

The recent announcement that there is no limit to the number of attempts at the MQE raises fundamental questions about the quality of some of these doctors. Where in the world can someone be permitted unlimited attempts at any examination, let alone in medicine?

In spite of the marked shortage of medical educators in Malaysia, the expansion of medical schools continued unabated in the past five years, thereby exacerbating the shortage. The majority of teaching staff in many medical schools are foreigners, some of whom do not speak any of the local languages, and some with no previous teaching experience.

It is not only the number, but also the quality of medical educators that is crucial in producing doctors that will make a positive impact on the public’s health. Medical educators are role models for students. It is well known that a deficient doctor is reflective of a deficient teacher; just as a child’s conduct is reflective of the parent’s.

Do the local medical schools take responsibility for the quality of their graduates? Are they responsive to societal needs and act proactively to meet those needs by addressing various issues that include selection criteria and admission policies; curricular improvements with emphasis on the concept of social accountability, medical ethics and human rights; and the quality and quality of medical educators?

Does the quality of medical education focus on the core educational needs of a doctor, providing him with the knowledge, attitude and skills necessary to address public health and clinical challenges?

Is this achievable when medical education is so much driven by the profit imperative?

What is the quality of medical education in recognised local and foreign medical schools, and how robust is its monitoring?

What is the role of agencies of foreign medical schools and how robust is their monitoring?

Housemenship

During the course of the newly graduated doctors’ future practice, there will be continuing advances in medical science and clinical practice, healthcare delivery and financing, increasing expectations of patients and the public, and changes in societal attitudes.

By itself, the basic knowledge and skills taught in medical schools is insufficient. The housemenship period is the time to start developing of the ingredients of the MMC’s “Good Medical Practice” (http://mmc.gov.my/v1/docs/Good Medical Practice_200412.pdf).

The young doctors have to learn to always put the interests of their patients first, and that the doctors’ professional practices affect the experiences of patients and their families. The skills of continuing professional development have to be developed so that their practices can advance in accordance to changes in medical knowledge and practices.

Prof TJ Danaraj, Foundation Dean of Medicine at the University of Malaya, wrote: “There is a worldwide acceptance of the views that the education of a physician extends over a lifetime, each stage resting upon the preceding one, and each preparing him for that which follows.”

Learning during housemenship is significantly experiential. There has to be sufficient quality teachers for this aspect of the young doctors’ training. The teachers, who are usually specialists, have a crucial role to play as they are role models for young doctors.

There has to be exposure to sufficient numbers of patients for young doctors to gain the experience required for independent practice. For example, they have to be exposed to the different ways in which the common conditions, appendicitis and urinary tract infections, present.

Failure to make an accurate diagnosis will lead to threats to life in the former, and long term consequences in the latter.

When there are few patients relative to the many housemen, it will, inevitably, have a negative impact on the latter’s training.

My classmates and I always remember our housemenship year. Some of our specialists were good teachers; some were less so. Some were excellent at expressing themselves verbally; others expressed their skills with their hands. Some did ward rounds before going home, and some even came back at night to do ward rounds.

We learnt from every specialist and from ourselves; what to do and what not to do in differing situations. Time was not a consideration. We finished our work before going home, whatever the time was.

There were instances when we would go to other wards or attend other specialists’ ward rounds, even after work, to learn from cases with interesting features. Those were not easy times. It was hard work, but our enthusiasm made the difference.

There were discussions and analyses which made us better doctors because we learnt from our specialists and ourselves. And, most importantly, we learnt how to learn.

The recent media report that “50% of housemen in Sabah can’t cope, need retraining” (http://www.theborneopost.com/2012/05/17/50-of-housemen-in-sabah-cant-cope-need retraining) is worrying.

Equally disturbing are media reports of claims by housemen that they are overworked, training is minimal or absent and there is “bullying” by specialists.

There are also statements by specialists that some housemen work by the clock and that they do not even know the names of some housemen assigned to their wards and clinics “because there are so many of them”!

What is the quality of housemenship training and how robust is its monitoring? What is the quality of healthcare that patients can expect from the large numbers of housemen who need retraining?

What happens when they become Medical Officers after completing their housemenship? The possible long term effects on the quality of healthcare delivery in the country are indeed mind boggling!

Government agencies

It may interest the reader to know that several government agencies are involved in medical education. The Ministry of Higher Education (MOHE) controls all medical schools. It grants approval to establish a new medical school and through the Malaysian Qualification Agency (MQA), it requires all medical schools to comply with accreditation standards.

The hospitals of the Ministry of Health (MOH) and MOHE provide housemenship training and employment for Medical Officers upon its completion.

There are reports from some specialists that they find it increasingly difficult to cope with the dual tasks of providing care to patients and training housemen, with the former always having to take priority over the latter. Even the Ministry of International Trade and Industry (MITI) impact upon the health sector. There is linkage between goods and services in MITI’s trade negotiations with the World Trade Organization (WTO), ASEAN and other trading partners. The concessions permitting the presence of foreign ownership of private healthcare facilities and practising rights for foreign doctors in Malaysia will inevitably have an impact upon the quality of healthcare provided.

It is regrettable that there is no published national medical manpower planning policy. How many doctors does the country need, and by extension, how many medical schools?

Do the MOH and MOHE provide feedback to medical schools, regarding the skills, knowledge, attitudes and competency of their graduates? What is the quality of the feedback? Do the medical schools act on the feedback?

How many top notch foreign doctors will come to Malaysia to practise on a long term basis? What mechanisms are there in place to assess the quality of foreign doctors intending to practise here? Are there robust and valid assessment mechanisms in place?

Malaysian Medical Council

The MMC’s function is that of recognition of medical schools and professional regulation, based on its Code of Professional Conduct and its guidelines.

The local medical schools are given time-limited accreditation after assessments by teams comprising representatives from the MMC and MQA. However, it is impossible to accredit all the foreign medical schools recognised by the government because of manpower, logistic and financial reasons.

Most governments in developed economies acknowledge their limitations in assessing the quality of medical education. They require all those who want to practise medicine, particularly graduates from foreign universities, to pass a licensing examination.

Many Malaysian doctors who have practised abroad, particularly those above 40 years, have passed these licensing examinations without difficulty simply because of the quality of medical education they received.

Why is there no licensing examination when about half of the doctors commencing housemenship are graduates of foreign universities?

The number of disciplinary cases per 1,000 doctors dealt with by the MMC has increased in recent years. Although it is less than that of Singapore, the question as to whether the increase is due to the public’s increasing awareness of their rights, quality of care or both is not easy to determine.

Like all medical regulatory authorities worldwide, the MMC is addressing the issues of professionalism and performance measurement. This is of relevance as it is crucial to the enhancement of the trust of the public in individual doctors, in particular, and the medical profession, in general.

What this means

Many in the medical profession have stated publicly their concern that there is more emphasis on the quantity instead of the quality of medical graduates. The consequences in other areas of studies may not be significant, but in healthcare, it can be a matter of life and death for a patient or potential patient, which means all the population.

Healthcare delivery is so complex today that it is crucial to have doctors who put a premium on patient safety. If one has to make a choice, the public interest is better served by fewer good quality doctors than larger numbers who are deficient in their knowledge, skills or attitudes.

Society deserves nothing less.

Everyone, whether students, parents, medical schools, governmental agencies and the MMC, has a role to play in ensuring that everyone gets good doctors. However, the onus on medical schools, policymakers and regulators is paramount.

In concluding, everyone, particularly medical schools, policymakers and regulators, should be cognizant of the instructive statements of Hippocrates (460-377 BC), Avicenna (980 – 1037) and Sir William Osler (1849-1919). Hippocrates wrote, “Whenever a doctor cannot do good, he must be kept from doing harm”, and Avicenna “An ignorant doctor is the aide-de-camp of death.” Sir William Osler’s statement, “The best preparation for tomorrow is to do today’s work superbly well” is very apt for medical education and training.

> Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.