Finally, the government is putting a stop to any new medical schools for the next 5 years but would this stop the glut? My answer is a big NO.

The current existing schools are just too many and they will keep increasing the number of students to make more money. Thus the number of graduates will continue to rise and whatever I have said in my blog postings will come true. Trust me!

I think it is important, especially for parents that medicine is not a guaranteed life anymore in the next 2-3 years time. I really hope parents and students will stop thinking about glorified life by doing medicine. I thought the figure for new housemen will reach 6000 by 2015 but based on what is written in The Star today, we have already hit 6000 this year! so , will it hit 8000 by 2015? Remember, almost half of the current 32 medical schools in Malaysia have not produced their graduates yet.

Cleaning house

By RICHARD LIM and LOH FOON FONG
educate@thestar.com.my

Concerns persist regarding the quality of medical graduates and the Government is preparing a number of initiatives to finetune the system.

HOW hard is it to tell the difference between a sleeping patient and a cyanosed one who is on course to meet his maker?

Observing the simple rise and fall of one’s chest would be a good start. Checking for a pulse would be another and observing that the patient has turned blue is an absolute must.

However, the obvious did not happen in the case of one Pak Abu, who was deemed to be sleeping by house officers.

Fortunately, an observant doctor on his last rounds came into the picture and Pak Abu was resuscitated.

The three house officers in charge, who graduated from Russian and Ukrainian universities, were reprimanded for negligence, and things went from bad to worse when it was discovered that they did not know the basics of resuscitation or what an oxygen face mask was.

Mohamed Khaled says agents are not appointed or recognised by the ministry.

The doctor who blogged about this was among the many who had been highlighting the urgent need to ensure the quality of housemen vis-a-vis their increasing numbers which was highlighted in The Star’s front page report two weeks ago.

The phenomena stemmed from the large number of medical students – at home and abroad – as well as the Health Ministry’s decision to increase the duration of housemanship, from one year to two years.

An overcrowding of housemen has occured at some of the nation’s 39 training hospitals, and senior Hospital Kuala Lumpur (HKL) consultant physician Datuk Dr S. Jeyaindran said that a houseman would normally look after four patients now — down from 10 five years ago.

“The concern is that these interns are seeing fewer patients and hence, have fewer opportunities to carry out adequate procedures.

“In some hospitals, there are more housemen than patients,” said Dr Jeyaindran, who is also the head of medicine at the Health Ministry.

 Liow says housemen would be trained at six new hospitals.

Different worlds

Following the influx of housemen, senior doctors have sounded the alarm that an over-emphasis on numbers could come at the expense of quality.

They were particularly concerned with medical graduates from Russia, Ukraine, Indonesia and India, whom they said lacked core knowledge and basic expertise in treating patients.

Although all medicals schools should share a universal purpose – saving lives – differences in pedagogy and clinical procedures put some graduates on the back foot when they return to Malaysia.

And this was the case for a Ukrainian university graduate who endured a torrid time in his attachment at a local hospital.

“Many doctors were unhappy that we (housemen from Russia and Ukraine) don’t follow the British system,” he said.

“The terminologies we used were not accepted although they denote the same meaning. This led some to develop the misconception that graduates of Eastern European medical schools lack the necessary knowledge to perform,” he said.

A source said that the emphasis on the study of diseases was also different to a certain extent, as medical schools in a particular country would naturally cater to the common ailments of its citizens.

 Dr Quek has blogged about quality concerns at private medical schools in Malaysia.

He added that housemen who studied medicine in Eastern Europe lack exposure to tropical diseases and had to brush up on their theoretical and clinical knowledge upon their return.

If there are already so many problems with accredited foreign universities, what should we expect of unaccredited institutions — with poor living conditions, inadequate facilities and lecturers of suspect quality?

And there is the eyebrow raising issue of foreign medical schools accepting students with Arts backgrounds.

The problem is not a new one. In 2005, the Crimea State Medical University was de-listed by the Malaysian Medical Council (MMC) for doing exactly that, among other things.

Giving credit where credit is due, the MMC acted upon complaints by whistle-blowers and the problem was rectified.

Task forces were sent out to check on errant medical schools overseas and warnings were served to foreign medical schools which were found wanting.

Shady dealings

The adage goes, “When the going gets tough, the tough get going.” But who are the tough and where do they go?

A houseman who spoke to The Star on condition of anonymity joked that the tough are those who are hell-bent on receiving an MBBS even though they lack the necessary grades.

 Prof Radin Umar says the NOC is only issued to students who will read accredited medical programmes.

And in that advent, there would only be one logical place to go to – an unrecognised medical school abroad.

This process normally involves the services of agents who talk parents into parting with hundreds of thousands of ringgit to enrol their child into a shoddy institution – pocketing a fat commission fee in the process.

It must be noted that many parents are often fooled by a ruse, and this was the case for one Ukrainian graduate.

“The agent told me that the university would be recognised ‘soon’, but I’ve graduated and it still hasn’t happened,” he said.

Hitting out at the unscrupulous practice, Higher Education Minister Datuk Seri Mohamed Khaled Nordin urged potential medical students to tread with caution whenever agents come into the picture.

“The ministry does not appoint or recognise agents,” he told The Star. “We have no link with them and we are not responsible for their activities in sending low quality students overseas.

 Dr Jeyaindran says in some hospitals, there are more housemen than patients.

“Continuous reminders to the public are given through the ministry’s website.”

Back to the shady world of wheeling and dealing, agents are often identified by their insistence that students would not need to obtain a non-objection certificate (NOC) – a certificate issued by the ministry to qualified students – in order to study at various medical schools overseas.

In the past, such advertisements were even seen in papers, and agents made a killing by preying on unsuspecting – and often the uninformed – parents.

Shedding light on the topic, Higher Education director-general Prof Datuk Dr Radin Umar Radin Sohadi said that the NOC, in effect for the past eight years, was a mechanism to prevent parents from getting cheated by agents.

“The NOC is only issued to students who will read accredited medical programmes overseas.

“Additionally, it is a mechansim for sponsors to award scholarships or loans. In most countries, the NOC is also needed for visa renewal,” he said.

Review of criteria

Although greater understanding of the NOC’s significance has helped matters over the years, a recent case involving Mansoura University in Egypt showed that agents are still very much in business.

A taskforce that was sent to the university discovered that a sizeable number of Malaysian students did not possess the NOC.

 A houseman would normally look after four patients now, down from 10 five years ago, raising concern that interns have fewer opportunities to carry out adequate procedures.

The findings were alarming and the Higher Education Ministry was particularly concerned as Mansoura – fully accredited by the MMC – receives government-sponsored students from the Public Services Department (JPA) and Mara.

It was later disclosed that the students had enrolled with the help of agents, and concerns were raised as agents now had accredited universities in their clientele.

Commenting on the case, a source in the MMC said the agents were pushing their luck by hoping the Government would not reject the graduates as the universities are accredited.

There are currently 926 Malaysian students in Mansoura. The varsity’s homegrown medicine programme has 493 students while the remainder are reading a twinning programme involving the University of Manchester.

Mohamed Khaled said that a joint working group between Malaysia and Egypt had already been set up to discuss and review the criteria of students that would be sent to Egypt for medical programmes in the future.

Under the new ruling, only qualified students – those who possess the minimum academic results and NOCs – will be considered for medical programmes in Egypt.

The ministry’s swift action appears to have effectively countered the movements of agents in Egypt and the establishment of similar committees with other nations might just nip the problem in the bud.

But as they say, change is the only constant and one wonders whether it is a case of check or checkmate for the agents.

The home front

Although foreign universities took most of the brunt, local higher education institutions did not escape unscathed.

A private provider was alleged to have lowered entry requirements in order to fill its initial student intakes, and others were alleged to lack experienced teachers and adequate facilities.

Other concerns include the increasing number of medical programmes offered by private providers, with some offering up to two intakes a year instead of the usual one.

In his blog, Malaysian Medical Association president Dr David Quek said that private providers prioritise public demand over the capacity of delivery in terms of teaching staff and appropriate standards.

Dr Quek said that the increasing number of private institutions had resulted in a shortage of experienced senior clinical staff, and junior specialists who lack experience are hired to teach students.

He added that non-clinical teachers, who cannot be registered as doctors in Malaysia, were imported from neighbouring nations to fill the quota of teaching staff.

As for students, Dr Quek said that many were left on their own to muddle along.

A senior consultant who declined to be named also said that the establishment of private medical schools – at an average rate of one or two a year – over the last decade had lowered the entry requirement of students since these schools required numbers to be profitable.

Others experessed concern that the promotion of Malaysia as a medical hub would add further strain on public hospitals as talent was expected to move to the private sector.

Concerned senior doctors are urging the Government to intervene before it is too late.

Many advocate amending the Medical Act 1971 to make the Medical Qualifying Examination compulsory for all students, as students from recognised schools could also fall short of expected standards.

The removal of the list of recognised basic medical degrees – in the second schedule of the Act – was also proposed.

However, the doctors are divided when it comes to implementation.

Some propose that only graduates from foreign schools should be affected as the entire procedure would be easier to monitor.

However, a consultant said that the standard of final exams in local universities varied widely, and some varsities attempt to pass as many students as possible to look good on paper.

Currently, the exam is only administered to students from unrecognised foreign medical schools.

A senior doctor said the idea of the amendment has been discussed with the Health Ministry, but a solution had not been implemented because local universities wanted to be exempted and prestigious universities in Britain and Australia would likely object as well.

A medical lecturer who declined to be named said that the criteria of the qualifying examination should be made known in advance so that students know what was required of them.

Highlighting the case of a top student from a Ukrainian university who failed the exam, the lecturer said that the different methods of training was an obstacle too big for some.

“No matter how diligent and conscientious students are, the chances of them passing the exam seems next to impossible,” he said.

He said that different examination formats, a student’s unfamiliarity with local practices and the lack of training in medical school were possible causes of their failure.

Concerted efforts

The Government has taken note of the grouses and Mohamed Khaled confirmed that a five-year moratorium on medical programmes in Malaysia was being prepared by the Higher Education and Health Ministries.

“The moratorium is in the final stage of preparation and it will reduce or stop higher education institutions from offering new programmes as the current capacity will be able to meet national targets,” said Mohamed Khaled.

The move is similar to the Higher Education Ministry’s freeze on the number of nursing colleges in the country.

And the moratorium isn’t the only catalyst for change.

The debate on the quality of housemen has made it to the Dewan Rakyat and Health Minister Datuk Seri Liow Tiong Lai said last Monday that six hospitals — in Kuala Krai and Tanah Merah, Kelantan; Segamat, Johor; Lahad Datu, Sabah, Bintulu and Sarikei, Sarawak — would be upgraded to specialist hospitals which train housemen.

With the new avenues, house officers could be deployed in a more efficient manner. Liow said measures had already been taken to ensure quality.

The minister said that the ideal specialist to houseman ratio was 1:5 and each houseman should take care of 14 hospital beds, depending on discipline.

Liow also said that his ministry would be getting 58 contract specialists from Egypt, India and Pakistan next month to supervise housemen.

Liow added that his ministry would look into the possibility of amending the Medical Act 1971 to make the Medical Qualifying Examination compulsory for all medical students.

That said, the relevant ministries have responded with strong statements of intent in the past week and the challenge now is for the Government to strike the right balance.

A balance which ensures that the pursuit of national goals – achieving a doctor to patient ratio of 1:400 by 2020 and the rise of Malaysia as a medical hub – does not compromise the quality of healthcare service in any way.

The road ahead will be tough and if the number of grouses pertaining to the houseman glut are anything to go by, the balancing act will be a fine one indeed.

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For Future Doctors: Housemanship, Medical Officer and Postgraduate Training (Part 3)

 It has been more than 1 month since I last wrote on this topic, the last being on rural postings. I have been extremely busy for the month of October with increasing load of patients in my hospital as well as some domestic house renovation. My house kitchen renovation has been successfully completed but I am yet to complete the painting works, which I am doing myself!

Let’s look at the postgraduate training in Malaysia. I have written about housemanship, district/rural postings and problems of oversupply of doctors in the near future. The issue of oversupply of doctors by 2015 will lead to another very big issue: postgraduate training. Many of the budding doctors and medical students are not aware that the postgraduate training in Malaysia has many limitations and problems. At this point of time, most postgraduate trainings are dependent on Master’s programme conducted by the local universities. Once upon a time, we were totally dependent on UK-based exams and training but unfortunately we lost it along the way. Currently, only MRCP (UK) – Internal Medicine, MRCPCH (UK) – Paediatric and MRCOG (UK) can be done in Malaysia. FRCS (for surgeons) used to be available to Malaysians but not anymore. None of our hospitals are recognised as a training centre for FRCS, which is now known as MRCS. Thus, for any surgical field in Malaysia, you will need to do Master’s programme!

MRCP (UK) – Internal Medicine

Membership of the Royal College of Physicians (UK) is a well-known exam all over the whole. It has a very strong reputation as an entry exam for speciality training in UK as well as in other parts of the world.  It is conducted regularly, usually 3 times a year in various countries. Malaysia is one of the centres for the MRCP exams, all 3 parts.

MRCP Part 1 can be taken about a year after your graduation. It is a theory paper. After passing your Part 1, you need to clear your Part 2 (written paper) and Part 3 (clinical) within 7 years. It is usually coordinated by University of Malaya, where the exams are usually held. Just for your info, the passing rate for MRCP (UK) is always around 45-50% worldwide! You need to have a proposer to sit for these exams, who can verify that you have undergone sufficient training to sit for the exam. If you fail miserably, your proposer will be notified.

Since MRCP (UK) is not a specialist exam in the UK, the Ministry of Health, Malaysia only recognises and gazette’s you as a specialist after undergoing further training of 18 months post MRCP (UK). You will need to submit a log book and recommendation by your HOD before being gazetted. This rule applies for all other overseas degrees which include MRCPCH and MRCOG. You need to undergo this gazettement process in order for you to be recognised as a Physician by the National Specialist Register (NSR).

MRCPCH (UK)

MRCPCH is similar to MRCP (UK) but meant for those who wants to become a Paediatrician. It‘s examination structure is similar to MRCP (UK).

MRCOG (UK)

MRCOG has 2 parts but the second part has both written and clinical component. However, you need to undergo training in O&G department for at least 4 years before being allowed to sit for Part 2 exams. One of the major issues in sitting for MRCOG is the fact that there are not many MRCOG holders in MOH to sign as a proposer for you!

Master’s programme

Now, this is where a big problem is going to appear soon. For all other fields, you are totally dependent on Master’s programme. This includes all surgical fields. Master’s programme is a fixed 4 year programme.

In order for you to be eligible to apply for the Master’s programme, you should have completed at least 3 years of service with good SKT marks of at least 85% and above, recommendation from Head of Department and confirmed in service. You also need to attend an exam or an interview before being selected for certain disciplines.

The major problem that I foresee in the future will be the number of places that are being offered. As of this year, the total number of places available is only 600, all disciplines included. Imagine, with 6000 new doctors coming into the market every year from now onwards, only 10% is going to get into the Master’s programme annually. Furthermore, you must understand that the selection process is never transparent, the typical Malaysian scenario as well as the quota system! Most of it is done by the Universities.

The government is planning to increase the number to 800 next year but the situation is rather critical in the Universities as there are not many Senior Professors to supervise the programme. I must say that the standard of Master’s graduates have dropped significantly over the last 5-10 years. We have Master’s graduates who can’t do surgery but have passed the exams! I just hope that the Master’s programme do not become another “specialists mill” like our undergraduate medical schools!

There are 2 types of Master’s programme, the open and closed system. In the closed system, you will do the entire 4 years within the university, like in UKM Hospital, UH and USM Hospital. The open system may have various programmes, like 2 years in MOH hospitals and another 2 years in the Universities etc. You may even do the entire 4 years in MOH hospitals for some of the fields.

After completing your Master’s programme, you need to undergo another 6 months of gazettement process before being recognised as a specialist. Furthermore, you will be bonded for 5-7 years for receiving scholarship during the programme, which is compulsory!

Subspecialty training

With the advancement in medical field, every discipline now has subspecialty training. As such, everyone will try to do certain subspecialty after gazettment as a specialist by MOH. Generally, the subspecialist training is about 3 years except for certain field like Cardiothoracic and Urology which may take 4 years. Again, whether you get a place or not depends on availability of post and demand for that particular field. For example, the waiting time for Gastroenterology training can even go as far as 1-2 years.

Recently, to overcome this major problem, MOH has taken another step backwards. You can only apply for subspecialty training 1 year after you have been gazetted as a specialist. For MRCP holders, this means 2 and half years after passing MRCP (UK)!

Usually, the subspecialty training is divided into 2 parts, the first part (the first 2 years) will be done locally and the 2^nd part (remaining 1 year) will be done overseas. The MOH will provide a fully paid scholarship for overseas training of 1 year but you will be bonded for 3 years. If you have received undergraduate scholarship and Master’s scholarship, you will be bonded a total of 20 years in service!!

Singapore

One good advantage that we have is Singapore. Unfortunately, only UKM and UM undergraduate degrees are recognised in Singapore. Our Master’s degrees are NOT recognised elsewhere. Thus, we would not be able to work in Singapore with any other medical degrees or even with our Master’s degree.

However, Singapore does recognise MRCP, MRCPCH, MRCOG and MRCS. Thus, if you have any of these degrees, it supersedes the undergraduate degree and you should be able to get a job in Singapore. Singapore is also a recognised centre for MRCS Part 3 training, which you can’t do in Malaysia. So, if you have MRCS Part 1 & 2, you can go to Singapore to finish your MRCS training and sit for the Part 3.

I must say that Singapore’s postgraduate training is more structured and organised with their BST (Basic Specialist Training) and AST (Advanced Specialist Training) programmes. I have written about this in my MMA article “Back from the Future: From 1^st world to 3rd world”.

For all of you out there; budding doctors, medical students, houseofficers and medical officers;  the future is very bleak for the medical field in Malaysia. The oversupply of doctors will get to you sooner or later. My advice to those who insist on doing medicine for passion is to choose an undergraduate course that is recognised internationally. Then, pursue a postgraduate degree that is also recognised internationally. If not, you will end up with a lot of frustration in the future. Jobless doctors in the future will be a reality!

If you have any questions or comments, please feel free to respond.

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For Future Doctors: Housemanship, Medical Officer and Postgraduate Training (Part 2)

It has been more than 2 weeks since I last posted on this topic. I have been quite busy lately with increasing workload in my hospital as well as some renovation work going on in my house. In this Part 2, I will write more about what to expect after finishing your 2 years Housemanship posting in Ministry of Health.

1)      Compulsory Service

I am sure everyone knows about the compulsory service for doctors in government service. According to Medical Act 1970, a medical graduate has to undergo compulsory service with the government for at least 4 years. This includes the Housemanship which is now 2 years. This means that you need to serve the government for another 2 years before you decide to leave the service.

2)      District/Rural postings

As I have said in my first part, after completion of your housemanship, you will likely be transferred to rural clinics or district hospitals. With the recent influx of large number of doctors, almost everyone will be transferred to rural areas, mainly Sabah and Sarawak. You can see this from various letters posted in almost every newspaper recently, embarrassingly by parents of “so-called” grown up doctors!

From my experience, district posting is a wonderful experience. Working alone without anyone to consult immediately, gives you a lot of experience. Remember, other than X-rays and some simple blood test, you don’t have anything else in these hospitals. Usually there will be about 3-5 Medical Officers (MO) in each district hospitals. When you are “on-call”, you are all alone and need to manage the A&E department as well as all the wards including obstetrics cases. It is really scary at times, especially if you are working in district hospitals which are far away from the nearest General Hospital. If you are preparing to sit for any exams then this is the time to do your revision as the workload is generally lower than in general hospitals.

The same goes for those who are posted to health clinics (Klinik Kesihatan). These clinics are usually situated in rural and semirural areas. Most of the time there will be 1-2 MOs in each clinic. The major bulk of patients that you see in these clinics are antenatal and outpatient cases. There will also be a lot of administrative work to do in these clinics including school visits, running various health campaigns and public health talks. In cases of any outbreaks, you will be called to assist in containing the outbreak. Basically you are the primary healthcare providers. Many doctors do not like the administrative work that they are supposed to do, and the meetings that you need to attend!

Even though it is a good experience to do rural/district postings, please do not stay long in these clinics/hospitals if you intend to do postgraduate studies. A maximum of 1 year should be adequate. The reason I say so is because you will lose the momentum to further your studies after some time of good life in these centres. Since the workload is lower, you will get carried away with relax life compared to your housemanship training.

This rural/district postings are usually given extra points when you apply for your Master’s programme even though it does not guarantee a place. At the same time you can use your free time to prepare for your exams like MRCP Part 1, MRCOG Part 1 etc etc. After passing your Part 1, you can request to be transferred to the General Hospital for continuation of your training. Again, this may become a problem in the future as the number of post may be limited and it may be increasingly difficult to get a place in bigger hospitals.

I think people who grumble about going to rural and district postings should just give-up medicine. If you choose medicine to help and treat sick people, then these postings is where you really see the real life of people. You will learn a lot about their social life and the struggle they go through daily which you do not see when you work in general hospitals. You will also realise that people here appreciate you better than urban people. I would advise each and every doctor to do rural/semirural and district postings for at least a year after completing your housemanship.

 Next: Postgraduate training…………………

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Here we go again!!!!!!!!. Another medical school! We already have 30 medical schools churning out thousands of underrated doctors and now we have this news! I am not sure when the government is going to stop all this nonsense. We have the highest number of medical schools per capita of the population. Any university can set up their branch campus here, but the question is , is there enough human resource aka academics to run these schools? The answer is a big NO!

Is it rather ironic that the government which has always prevented the universities from building their own hospitals before, seem to have taken a U-turn in this case. New economic model perhaps! Actually, Monash University Malaysia has already started to build their own private teaching hospital in Sunway which should be ready by 2013 but they will still use JB hospital. So, this will be the second university to do so if at all this plan becomes a reality. It is very difficult to run a private hospital in Malaysia with medical students running around. Patients come to private hospital for better care and comfort, thus most of the time they would not want medical students to disturb them. The situation is different in US as all hospitals are considered private hospitals.

Somehow I feel, this foreigners are not given the true picture of the situation down here. Further more, this foreign universities are not investing any money for the campus etc. All the money comes locally from the government, GLC and local investors. Good example will be Newcastle University in Nusajaya where the entire campus is being  built by Khazanah !

Johns Hopkins University to set up medical school and hospital in Malaysia

By WONG CHUN WAI
newsdesk@thestar.com.my

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For Future Doctors: Housemanship, Medical Officer and Postgraduate Training (Part 1)

I received more than 10 000 visitors to my blog posting on “The General Misconception of Doctors Part 1 & Part 2” since 08/09/2010. I also had many comments supporting my article. Surprisingly, most of the comments were from medical students and young doctors who just started housemanship or just completed. I also had some overseas doctors giving their comment, not sure whether they are Malaysians or ex-Malaysians?

Even though many supported my articles, I also had few asking me to tell them what is in store during housemanship and postgraduate training in detail. Thus I thought it is about time I give them the full detail, to my knowledge, about the current and future situation in Malaysia. There was a person who asked me to write some positive aspect of being a doctor. Well, I only have 1, a total satisfaction of treating a patient till recovery. But always remember, you can only cure sometimes. I have had a medical student who refused to go to the ward after seeing a young boy dying of Leukaemia. Well, this will be a daily affair once you set foot into the medical field. Be prepared to see people die no matter what you do. To comfort always but to cure sometimes should be your motto!

1)      Housmanship

I will divide this section into 3 subsections, explaining what has been happening since 1990s in housemanship training;

1a) Before 2000

Before 2000, the housemanship training use to have 4 monthly rotations in Obstetrics & Gynaecology, Medicine or Paediatric and Surgery or Orthopaedic. After the 1 year training, you will be transferred to rural or semirural areas to serve in district hospitals or Klinik Kesihatans (KK) (health clinics). Most of the time, these rural postings are a wonderful experience but a little bit scary due to lack of senior people to consult or assist you.

One of the major faults in this system is the fact that if you do Medicine, you will miss Paediatric and if you do Surgery, you will miss Ortho. Only O&G was made compulsory. Thus, the government felt it was inadequate. Many will go to KK and District Hospitals without doing Paediatrics/Medicine and Orthopaedics/Surgery. A lot of the time, you need to depend on the senior nurses or Medical Assistants (MA). I must say that during that time, the nurses and MAs were excellent. They were second to doctors, not to be compared with the current generation of nurses and MAs.

BTW, just to mention, the HO’s take home salary before 2000 use to be RM 1648!! Pathetic isn’t it? You won’t even be able to buy a car/house. The car loan interest rate than was 6-8%! You will get RM 20 for each on-call that you do! This “On Call” allowance was only introduced in 1994. Prior to that, you are not paid a single cent for your “On-Calls”, free labour for the government mah……………..

1b)  After 2000

Around the year 2000-2002, a new posting known as junior medical officer postings was introduced after housemanship. This is also known as the 4^th and 5^th HO posting. It was 3 month posting in either medicine/paediatric or surgery/ortho depending on which that you did not do during the 1 year housmanship as above. After completing the 4^th and 5^th postings, you will be posted to rural or district as a Medical Officer.

1c)  Since 2008

Since 2008, housemanship training has been extended to 2 years. This means you will be completing all the major postings before being transferred out.

2)      Life as a Houseofficer (HO)

When I did my Housemanship in 1990s, there were only 2-3 HOs in each ward of 40-60 patients. It was a tough life.  You are the front liners who will see the patients for the first time upon admission. You’re supposed to take the medical history of the patient, do a physical examination, take blood investigations and come to a diagnosis. In fact, you’re supposed to start the initial treatment and management of the patients. There won’t be any medical officers or specialist in the ward. Most of them will come only in the afternoon to see the patients. This means, you’re the boss in the ward and the life of the patient is in your hands! It is a very stressful life, where on top of all the existing patients in the ward, you also need to see all the new admissions. The new admissions can be about 20-30 admissions/day, divided between each of the 2-3 houseofficers.

You start your work around 7.00am everyday especially if you are doing medical or O&G postings by taking the ward patient’s blood. Then, you will be doing the clinical rounds with the Medical Officers and Specialist of the ward. After finishing the rounds, you need to carry out all the orders by the specialist and at the same time, clerk all the new admissions! You also have to run down to radiology department to get urgent appointments, go to the blood bank to get urgent bloods, trace results urgently etc etc. Of course, you may not finish your work by 5pm. If you are “On Call” on that day, you need to con’t your work throughout the night till the next morning 8am. And now, don’t think you can go back to your room and rest! You are supposed to con’t with the work on the next day as usual! You are basically a professional coolie!

As a HO, you need to do at least 10 calls a month, which means once every 3 days. I have even done continuous day calls before, never saw sunlight for 2-3 days! For each calls, we were paid RM 20 then, now it has gone up to RM 100 since 2006 ( please read my MMA article on “Government doctors: Past, Present and Future”). I use to say that you can earn better by working in Mc Donald’s!

Whatever said and done, I enjoyed my Housemanship simply because I had good colleagues who helped each other very well. I also enjoyed learning all the skills and procedures during my housemanship. Housemanship is the only time where you can learn all the necessary skills in doing procedures like CVP line, Chest tube, Peritoneal Dialysis etc etc. Thus, as I said before, if you became a doctor for passion and to help people, then you will enjoy housemanship. But if you choose medicine for glory, good life and money, it is during this time that you will realise that medicine is not for you. That’s the reason why, many will get a mental breakdown during housemanship. They never expected their life to be like this! Many still think that being a doctor is sitting in a clinic and seeing “cough and cold” cases. Being a doctor is more than that.

Of course, the situation has changed recently. With the tremendous increase in the number of doctors produced, we have almost 6-8 HOs in each ward of 40 patients. In fact, surgical department with 2 wards, sometimes has more than 40 HOs!! The workload will definitely be lower but you will lose out in your training. How many procedures would you be able to learn with so many of you in a ward? I have even seen some HOs leaving the medical department without doing a single CVP line or Chest tube. Only those who are eager to learn will succeed. The rests are just given a license to kill……… sorry to say!

3)      Rules and Regulation during Housemanship

There are few rules and regulations that you need to know as a HO. You will be given a log book for each posting. This log book needs to be signed off at the end of each posting by the department. The Head of Department (HOD) has the right to extend the training if he/she feels that you are not competent enough to be released. The extension is for a minimum of 3 months but can go on as long as the HOD feels adequate. Unfortunately, many of the HOD take the easy way out. No matter how incompetent the HO is, they usually let them go as they feel that it will not make any difference in extending their postings and of course less problem to the department. To me, I think it is very selfish for some of the HOD to think like this. Remember, these doctors are the one who is going to be released to the community with a “license to kill”.

As a government servant, you will be given 25 days annual leave. As a HO, these 25 days will be divided equally between the 3 postings that you do in a year. Any extra leaves including MCs, maternity leave and emergency leaves are considered as an extension of housemanship training. For example, if you take 1 week MC during a medical posting, your medical posting will be extended by one week, unless you want to deduct your annual leave allocated for that particular posting. This is one of the reasons why I always advise doctors/soon to be doctors not to get married during housemanship. Pregnancy will not reduce your workload as you need to do the same number of calls with the rest and it will only extend your housemanship even longer.

 Next, Part 2: Life as a medical officer and rural postings……………………………

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For Future Doctors: General Misconception of being a doctor Part 2

My first Part of this topic attracted more than 600 people to visit my blog in a day. Today, I post my second part of my discussion for your reading.

1)      Being a GP

As I have written before in my MMA articles, the future of GPs are bleak. If you think that you just want to complete your MBBS and open up a clinic, then I think you are misinformed badly. Many GPs are suffering nowadays. Many have even closed their shops due to severe competition. GPs, not only have to compete with their fellow GPs but also with private hospitals, government clinics, pharmacy and traditional medicine sellers. The scenario has changed as I have said in Part 1. You are also strictly regulated by the Private Healthcare and Facilities Act which was implemented from 2006 onwards. Many GPs are only earning a net profit of RM 10 000 a month which is ridiculous compared to the amount of work that you are doing. Imagine that you have to work from 9am to 10pm daily including Saturdays and Sundays, especially during your early days. That’s the reason why you notice less and fewer doctors resigning from the government sector to set up their clinic. GPs are now moving from urban areas to sub-urban and rural areas to open up their practises. There may be a better market for GPs in these areas compared to town areas.

2)      Being a Consultant in a Private Hospital

Only in medicine I can earn RM 50 000/month when I work in private hospital? I had many friends and budding doctors who feel that medical specialist earns the highest in private sector compared to any other profession. Again, I would say that you are mistaken. Even though you may be right in terms of the earning capacity but what you are not aware is the fact that the private hospitals DO NOT pay us a salary!

Basically you are NOT employed by the private hospital. You are just running a clinic as a self-employed person in the hospital. Whatever you earn is the consultation/surgical fees that you are charging the patients. In fact, the hospital takes 10-15% of your consultation fee as their administrative fee. Furthermore you also need to pay a rental for the clinic space that you are renting! The rental can range from RM 4000 to RM 8000/month. Yes, if you are an interventionist/surgeon or have a lot of patients, you may earn as high as above but at the same time you can also earn very much less than expected depending on the number of patients that you see for that particular month. You may even end up earning less than RM 10 000/month at times! Again, with more and more private hospitals coming up, the competition will be greater and the income of each doctor in each hospital will definitely drop even further. Remember, if a patient’s hospital bill for an admission is RM 5000, only less than 25% of the bill is the consultation fee which belongs to you, of which the hospital will take another 10%!

Also, when you are in a private hospital you are all alone. There are no junior doctors to help you. You need to do all the procedures by yourself and must be available at all times to entertain any medical complaints from the patients (even in the middle of the night). It is not just a matter of running a clinic! So basically you can only charge a patient when you see a patient for consultation and that is your salary!

And also don’t forget, for you to reach the status of a subspecialists before going full-time private practise, it will take at least 12 years following undergraduate medical education, a total of 15-17 years !! By this time some of your fiends will be earning much more than you and driving bigger cars and going holidays all over the world. Many of my friends who went on to do IT, accountancy etc etc had become company managers and directors by the time I finish my subspeciality. They have started to enjoy their life when I was just beginning to think of earning money.

3)      TV programmes : ER, CSI, House etc

Don’t get carried away by watching TV programmes like ER, CSI and House. Things do not work the way it is shown on the TV. I had one budding doctor who said that she wants to become a forensic pathologist. I am sure she was influenced by CSI. In Malaysia, the reality is, any forensic pathologist just sits in the mortuary the whole day. They hardly go down to the scene of the crime. Furthermore, if you do attend a court case, you will be tortured by the lawyer. BTW, don’t think we have all the high-end technology in our mortuary like what you see in CSI. In Malaysia, forensic pathologist doesn’t work in a police department. You are just another specialist in a government hospital forever, as you won’t be able to go private. Malaysian law do not accept a report by a private specialist.

4)      Patient’s demand and increasing medico-legal issues

Many doctors are being sued nowadays. This happens in most developing or developed countries. Gone are the days where patients will forgive and forget. Even the government is asking all doctors in civil service to take their own indemnity insurance as the government may not be able to cope with the legal suits. The cost of insurance has gone up tremendously especially for surgeons and obstetrician. For Obstetrician, the yearly insurance stands at RM 40 000 – 50 000! So, don’t think that the public has high respect for you and thus they will not take any action against you. A small mistake can land you in court and your entire reputation will be affected, no matter how many life’s that you have saved.

I am sure I would have made a lot of you very depressed by now. Please do not do medicine for the reasons that I have mentioned above. You will regret it later. If you really have passion for medicine then by all means, go ahead. I give the same advice to all parents who seek my advice regarding medicine. But always remember, no matter how much passion you have for medicine, it is still a job for you to earn money for a living. Once you are married and have children, money will be the most important factor no matter what you think now.

The amount of money you are spending to do undergraduate medicine alone can easily be used to start-up a business! Most private medical colleges in Malaysia charges about RM50 000-90 000/year which comes to about RM 250 000 to 500 000 in total, not including accommodation and food. You can easily safe this money, do accountancy/engineering/designer etc etc and use it later to start your own business venture.  Don’t you think it is a better option? To get back the investment that you have made for medicine will take another 20 years, not including the money that you need to spend for postgraduate education!

Let me tell you, the money now is not in professional field. If you are smart and only want to earn money, please try technical studies like architect, interior designer, accountancy etc. This is where the money is! If you are good, you can easily become a manager or director of a company by the age of 35.

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For Future Doctors: General Misconception of being a doctor PART 1

Over the last few months, many budding doctors have contacted me to ask about the future prospects of doing medicine. Of course I gave them a depressing night after informing them of the current and future prospects of doctors in Malaysia. During these discussions I realise that many of these people do not understand a lot of issues surrounding the field of medicine. Thus I was obliged to write this article to wake up these people from their dream of “guaranteed” life if you were to become a doctor!

1)      Guaranteed Job and Good salary/can make money

Many parents still believe that being a doctor guarantee their children’s future. Well, it may be so before but not in another 5-10 years time. You can read about these issues in my MMA articles column. 20 years ago we only had 3 medical schools producing about 400 doctors a year but now we have almost 30 medical schools in the country (the highest per capita population in the world). Last year alone, almost 4000 new doctors started housemanship in Ministry of Health (MOH). The number will further increase in coming years when all the medical schools start to produce their graduates. I believe it will reach a figure of 6000/year by 2015.

This is where issues arise. Even now, the MOH is struggling to place these doctors in various hospitals in the country. We have almost 30-40 houseofficers in each department now not knowing what to do every day. Their training is compromised and they are being released after that without proper training with license to kill! I may sound negative but this is the reality. Even district hospitals are being used to train houseofficers now, starting 2010. As you would have read in the papers recently of parents complaining that their child has been transferred to East Malaysia after completing housemanship, it is a known fact that the shortage of doctors at this point of time is in East Malaysia. As our MOH Director General had said, most doctors will be sent to Sabah and Sarawak from this year on wards.

What’s going to happen in the next few years? Again, my prediction is, there will be surplus of doctors by 2015. There will more bodies than post in MOH by 2015. Doctors most likely will need to queue up to be posted in government service.  You will be sent to rural and East Malaysia to serve. Any appeal will not be entertained. If you think this would not happen, please look at the nurses! 5 years ago, the government began to approve numerous nursing colleges due to shortage of nurses. Now, we have surplus of nurses without any jobs. I know of nurses who are currently working in petrol stations! BTW, the MOH is currently considering introducing common entry exams for all medical graduates. Only those who pass this exam will be given housemanship post. This will happen soon.

Furthermore there may be a pay cut for doctors when all the post are filled. One of the allowance known as critical allowance of RM 750 will be removed once all the posts are filled. Critical allowance is never a fixed allowance and is usually reviewed every 3 years. As you know, the pharmacist’s critical allowance is going to be removed if not already.

I had one budding doctor who said that the reason she wanted to do medicine is because it is the only field where you have a guaranteed job and a starting salary of RM 6000. Well, I have talked about guaranteed job issue above but she is definitely wrong in stating that the starting salary. The starting salary of HO has gone up over the last 5 years; no doubt about it (please read my MMA article). However, the starting salary of HO currently is about RM 3500 to about RM4000 after including the on-call allowance. Remember, your salary only increases about RM 70/year. You will only reach a salary of RM 6000 after 7 years of service as a medical officer, when you are promoted to U48 according to current promotional prospect in civil service introduced end of last year! BTW, other than the difference of critical allowance, a doctor’s salary is only RM 200 more than a pharmacist in civil service!

2)      Medical degree recognition

 If I can’t work in Malaysia, I can go to Singapore or Australia to work, right?

Again, another misconception. Many do not know that medicine is a very peculiar field and cannot be compared to any other profession. In order for you to work in another country, your degree needs to be recognised by the Medical Council of the other country. If it is not recognised, you would not be able to work there. For your information, only UKM and UM degrees are recognised in Singapore. If it is not recognised, you need to sit and pass the qualification exams in the respective country with no guarantee of a job.

Almost all medical degrees from Malaysia are NOT recognised elsewhere. Malaysia Boleh mah! Only Monash University Malaysia’s medical degree is recognised by Australian Medical Council and thus you would be able to work in Australia/New Zealand. Some of the private medical colleges do twinning programmes with external universities from Ireland/UK/India etc. These may be recognised depending on which degree and where you graduate from.

3)      Housemanship & Compulsory service

I have mentioned a little about housemanship above. As you know the housemanship has been extended to 2 years since 2008. Even though it is good for your own training but it does prolong your future postgraduate training. After Housemanship you have to undergo another 2 years of compulsory service before you decide to resign for private practise or pursue your postgraduate degree. It is during this compulsory service that you will be posted to anywhere in the country.

Furthermore, housemanship is not an easy posting. Even though the numbers of HOs have increased tremendously over the last 2 years, it is still a very exhausting job. Many have had a mental breakdown during housemanship. I just heard of a houseman who is on psychiatric MC for the last 2 months! It seems she thought that being a doctor is just like sitting in a clinic and seeing cold cases (probably she thought she can become a GP immediately!)

4)      Hard work and post graduate training

20-30 years ago, being an MBBS holder itself is good enough. You can easily open a clinic and become a GP and well respected by the community. But things are changing. Even GP practise is a speciality by itself in many countries (Master in Family Medicine/FRACGP etc). Malaysia is also moving towards that. Many patients are demanding and would prefer to see a specialist directly nowadays.

Thus it is important that when you join medicine undergraduate degree, please be prepared to continue your education for another 10 years after graduation! In order for you to complete your postgraduate education, it will easily take another 10 years, assuming you pass all your exams in one try! So, don’t assume your education is only 5 years! MBBS do not mean anything now, in fact it is only considered as a diploma!

Getting into postgraduate training is also becoming increasing difficult. The number of places for Master’s programme is very much limited in local universities. The demand is greater than supply and of course don’ forget the quota system as well! Other than MRCP (UK) – internal medicine, MRCPCH (UK) – paediatric and MRCOG – Obstetric, you have to depend on local master’s programme for your speciality. Thus, you have a very limited option. With such a big number of doctors coming into the market now, I can assure you that getting a place for post graduate education is going to be a major problem in 2-3 years time! Be prepared.

TO BE CONTINUED………………………….

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As I have said many times before in my earlier post, we have too many little Napoleons now, created by our great NEP and Mahathir which is taking this country to doom. The below incident that occurred in a school in Kulai, JB is a clear example of what is happening in schools nowadays. These are the reasons why the non-malays are shifting away from the national schools. Racist and religious remarks are rampant in national schools. If we were to take actions on all these bigots, half the civil service have to be sacked, but of course this would not happen! Politically incorrect mah…………………..

“Pelajar-pelajar Cina tidak diperlukan dan boleh balik ke China ataupun Sekolah Foon Yew. Bagi pelajar India, tali sembahyang yang diikat di pergelangan tangan dan leher pelajar nampak seakan anjing dan hanya anjing akan mengikat seperti itu.” By Student of Sekolah Menengah Kebangsaan Tunku Abdul Rahman Putra, Kulai
 
(The Star) KULAIJAYA: Police are investigating a school principal who allegedly used racist remarks against non-Malay students during a Merdeka celebration at the school here recently.
Kulaijaya deputy OCPD Asst Supt Mohd Kamil said police had received 12 reports against the principal since Saturday and that the case was being investigated under Section 504 of the Penal Code.
Over 50 parents and students had lodged the reports against the principal, who allegedly described the non-Malays as “penumpang” (passengers) in the country during her speech at the start of the celebration on Aug 12.
“I was shocked that my principal had used such a word against non-Malay students in our school.
“This is not the first time that she had made racist comments against Chinese and Indian students in our school,” said 17-year-old student Brevia Pan.
She added that the principal, who joined the school early this year, would only target Chinese and Indian students.
“During the Merdeka celebration, she had told non-Malay students to go study in a Chinese school or go back to China,” she told reporters in a press conference organised by Senai assemblyman Ong Kow Meng.
Another student, Ashvini Thi-na­karan, 17, said many Malay students were influenced by the principal’s remarks and made similar comments and called them names.
“Before she came to my school, all the students got along well,” she said. Her father R. Thinakaran, 47, said this was a serious matter and that principals should not behave like this.
“This principal has caused racial disharmony at the school,” he said, adding that if no action was taken, he would take his daughter out of the school.
Ong called for stern action against the principal, adding that such school heads and educators would affect the minds of students.

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 Remember what I said before about our national schools? Please read my education column.

//

Vasugi Supramaniam and Richard Loo Wai Hoong
Jul 23, 10
4:13pm

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Malaysia is probably the only country which retrain graduates. Instead of addressing the root of the problem which is of course the poor quality of students that are being enrolled to universities as well as the poor quality of our universities, our “boleh land” government has decided to spend more of our tax payer’s money for this kind of idiotic programmes!

Programmes like this has been going on for the past few years. I have come across a few of them as my patients. I remember a so-called graduate of biochemistry who initially got a job at Pizza Hut as assistant manager, gave up the job just to enroll herself in this programme. When I asked her why, the answer is simple : “tak sukalah kerja kat pizza hut tu, kena berdiri and jalan aje. dekat program ini, kita diajar banyak benda macam Inglish, communication skills dan sebagainya. Lagi pun kita akan di bayar rm500 sebulan dan di beri makan/minum dan penginapan free! Nanti kita akan dihantar buat attachment dekat company. Masa buat attachment, kerajaan bayar allowance RM 1000/bulan selama 6 bulan” !!! WTH

This is the main problem. Our graduates are incompetent first of all. They are not interested in the course that they have just completed in the university. Our university has a very peculiar way of giving university places for the students. Many students do not get the field that they have applied for! The UPU decides for them and many parents especially the Malays will just take whatever the university offers whether the son/daughter likes it or not, unlike the non-Malays who will sacrifice everything to send their child for the course that the child likes. Coming back to the lady above, she is now working as a teacher teaching Kemahiran Hidup and Bahasa Malaysia! When I asked her about her graduation in Biochemistry, answer: “saya tak sukalah buat kerja-kerja makmal ini” So apapasal you buat kursus ini? answer ” Saya pun tak tahu, dia orang bagi, saya ambil la! Now you know why our education system is screwed!

If you look below, UiTM(the only racist university in the world) is going to open another 12 campus and targeting to produce 200 000 graduates in 5 years!!! Do they really have any proper planning? Where are these people going to get their jobs!  Oh forgot, they will be retrained by your money! And they will also be paid by you for free! BTW, are you considered unemployed if you don’t get a job in 3 months!!!! It all depends how hard you work to get a job!

Government launches new scheme for unemployed graduates

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