I spoke to some GPs recently and I can say that most are worried with what is happening to the medical field in this country and how their income is going down gradually. The drop in income for GPs is unavoidable, as with the income of specialists in private hospitals. Many specialists in private hospitals are not earning as much as how their seniors were earning 5-10 years ago. The same goes to the GPs.

Many newly opened GP clinics in major towns are struggling to survive. I just heard a GP who opened a new clinic near my hospital for the last 8 months. Till today, he does not even see more then 10 patients a day. His rental for the clinic is RM 3000/month! And don’t forget the maintenance cost for the clinic. I know many GPs who have closed shop. Some have ventured into unethical practices and complementary medicine as I have written here. I know some who have become health product agents. I had a patient who attended a close door discussion on a health product that was conducted by a doctor. The doctor even claims that the product can cure immune related diseases like SLE etc. I just saw a patient today (exacerbation of bronchial asthma) who told me that the GP refuse to refer him to a private hospital despite having employer insurance. It is a group practice clinic and it seems the doctor said that his boss do not allow referral to a private hospital. Only referral to government hospital is allowed!! And this is not the first time I have heard this. Many GPs would rather refer to the government hospital or a private hospital further away. If they refer to the nearby private hospital, the patient may not come back to them!! That is the idea. It has nothing to do with the quality of care! They rather keep the patient then loosing them to a nearby private hospital.

Why are GPs struggling? It is competition. They not only need to compete with their own colleagues in the same area but also with Klinik Kesihatans, District Hospitals, Klinik 1Malaysia, Pharmacies, Traditional Medicine Practitioners, Labs and Private Hospitals. Whenever a Klinik Kesihatan or Klinik 1Malaysia opens nearby their clinic, their income drops further, some as much as 10-20%.

This is a comment from a GP in one of the Primary Care Group at Facebook:

Quote from MPCN Group at Facebook:

 “My view is that whether solo or group practice GP, the business is not as good as 10-20 years ago. With more 1M clinics (with MOs), Klinik Desa being upgraded to full scale Klinik Kesihatan (with FMS) and extended hours of Klinik Kesihatan till 10pm, I can only foresee more and more GP’s find it hard to survive.

 Relying on panels like ING, PMCare, Compumed etc is not a truly long term solution too, as these MCO/TPA will keep cut throat the GPs. And we can see in previous posts in other section, some lamented that new GPs are willing to take only RM5 as consultation fees! Appalling!! 

 Most of my GP’s are venturing into either aesthtic practice or some “alternatives” (eg. PRP, Live Blood Analysis, Ozone treatment etc) in order to make more money! Some even start becoming MLM (Amway or Usana) agents to coax patients into buying some of those products! Sad.

 Patients with freedom in seeing specialists in our country also contributes to the “demise” of GPs. A little nose bleed, they go to ENT; a little bloody diarrhea, they go to Gastro; Headache, they see Neurologist; and sprain ankle, they head straight to an orthopedic surgeon. And how many times nowadays, parents bring in their children to see GPs? Most if not all, are at the nearby Paediatrician clinic, even with trivial URTI or for any form of vaccinations.

 Seeing cough and cold, and issuing MCs will be the norm for GPs nowadays. Hypertension patients are half taken away by the cardiologists, and DM patients, the endocrinologists.

 BP lab, Pathlab etc will be giving out free annual vouchers for doing blood tests, and they hire in house doctors to give consultation and result interpretation.

 Our friendly neighbourhood pharmacists will be selling drugs like nobody’s business. Some without prescription, but just need to write down your name, phone no and address in the ruled line exercise book, and that’s it. You will get whatever antibiotics you want over the counter.

 So what’s left for GPs? I reallydunno”

The above statement basically sums up what is happening to the GPs nowadays. GPs were once a highly respected profession. Even when I was small, my father use to take me to see a GP for simple cough, fever and flu. These GPs were considered equivalent to a specialist. In fact, a family rather trusts the GP then a specialist in a government hospital. Those days are gone!

To add salt to the wound, I am sorry to say that more nightmares are coming for the GPs. Budget 2013 will be delivered this Friday 28/09/2012. There may be further shocks in this budget, which will reduce GPs income even further. With the overflow of doctors in government sector, it is only going to get worst. Our Minister’s statement here and here is a clear indication of what is coming (attached below). There will be another 175 1Malaysia clinics throughout the country. Previously GPs were still not very much worried about the 1Malaysia clinics as only Medical Assistants (MA) manned it. Unfortunately, the situation is changing. With some Klinik Kesihatans having more doctors then the number of rooms, doctors are being sent to these 1Malaysia clinics.  It has already started in states like Selangor, N.Sembilan and Malacca.

Soon, as mentioned in the newspaper article, these 1Malaysia clinics will start antenatal and child health care services.  These clinics are open till 10pm daily! Doctors at Klinik Kesihatans on the other hand are now being asked to work on 2 shifts in order to open the clinics till 10pm every night. This has started as a pilot project in some Klinik Kesihatan as I have mentioned here. It was also mentioned in the newspaper article as “Shorter queues and extended hours at rural public clinics”.

Many GPs survived those days because the government clinics close at 5pm and only the hospital emergency services were open. The “Q” were extremely long in these emergency departments as they entertain emergency cases first. So, the GPs were able to get the “after office hours” market as the patients had no choice if they want faster treatment. Now, that advantage is going or gone!

If you walk into any GP clinic nowadays, you need atleast RM 50. Compare this to RM 1 in Klinik 1Mlaaysia and Klinik Kesihatan? Free for senior citizens! You may end up getting the same medicine from both sides as GPs are also surviving on generic medications to cut cost and to make higher profit.

In another 2-3 years, probably by 2014, the 1Care system will be implemented. This will appoint GPs as one of the primary care providers to the public. I have mentioned about this over here and here. There is a high possibility that dispensing rights of GPs will be taken away and given to community pharmacist. The pharmacist association has been pushing for this for a very long time. As most GPs make money from medications, this change will further reduce their income and they have to survive on consultation fee alone which is regulated by law (PHFS Act).

As you can see by now, life is going to be tough for GPs in another few years time. The days of good money and life are gone. You may still be able to earn a decent income for a decent living just like any other profession but don’t expect to make tons of money! And for this, you have to work from 9am till 10pm daily for 7 days a week and 30 days a month. That’s the reason why many doctors rather join a franchise GP practice rather then opening a solo clinic nowadays. Some GPs have even agreed for a RM 5 consultation fee with insurance and panels to survive. That’s how desperate these doctors have become. It is a matter of survival! The same goes to specialist as well.

My advise for younger doctors whose intention is to open their own clinic is to think carefully. It would be better to open a clinic in rural and semirural areas where people still have high regards for doctors. Find a place where there are no nearby government clinics. However, you can’t charge high rates in these places but you may have better load of patients with lower cost of living.

With the upcoming glut, many doctors who could not get a government job after housemanship may end up opening a clinic to survive. This will only make the situation worst. They may even accept RM1 for consultation from panels and insurance companies. The good old days are gone……………… 40 000 graduates are unemployed according to the government which I think is still underestimated. Will the doctors join the list soon? Only time will tell.

Happy listening to Budget 2013, an election budget for sure with a lot of goodies and good news to the public and civil servants.

Liow: Health Ministry to focus on people-friendly measures in Budget

By YUEN MEIKENG

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This news appeared in the Star 2 days ago: http://thestar.com.my/news/story.asp?file=/2012/4/17/nation/11116137&sec=nation. A MOU was signed to allow some private and public university lecturers to run specialist services in district hospitals. Few people asked for my opinion on this issue and whether it is a prelude for something else that is coming. I would say that there are pros and cons to this arrangement. One of the main reason why many do not want to join the private or public universities is because majority would not be able to do clinical practise. Even though all these medical schools are attached to a MOH hospital, the politics that goes inside these hospital prevents the academics from running any service for the hospital. I had written about this in March 2007 in Berita MMA https://pagalavan.com/my-mma-articles/march-2007academicians-vs-service-providers-clash-of-the-titans/. Allowing these specialist to run services in district hospitals will allow them to keep the clinical skills intact and at the same time teach the students.

However, we must understand that majority of the academics in most of our private and some public medical schools are expats. That is the reality. In fact, there is even a joke that some universities can be known as Burmese universities as almost all their lecturers are Burmese. I have seen good ones and bad ones. Some of these academics have not done clinical work for many years. Thus, they may be good in theoretical knowledge but not clinical acumen. Secondly, how many of this district hospitals have enough facilities to run specialist service? For example, do Tapah hospital have ultrasound facilities, CT scans, operating theatres etc? The OT is mainly for minor cases and not for major cases. Most of these hospitals do not even have enough A class medications. Even LSCS cannot be done in their OT.  Most of the hospitals mentioned below are in this category. So, having a specialist in this hospital may not add any benefit. It may be useful for Internal medicine services but not surgical services. I am also not sure whether MOH is paying for these services, as previously they don’t.

The government prevented medical schools from building their own teaching hospitals since the late 1990s, after HUKM. Unfortunately, this rule was removed when our PM launched Perdana University!! Now, every medical school is racing ahead to set up their own teaching hospital. UCSI is setting up in PD, IMU is buying over Pantai Ampang, Melaka Manipal is setting up Manipal Hospital and I heard even Allianz Medical college is building a private hospital too!! So, here comes another madness after 36 medical schools. It is a way for the private uni to make more money. Frankly speaking, private hospital are not suitable to be made a teaching hospital at this moment. How many private hospitals have all the specialities and manage complicated and chronic cases? WE do not have a National healthcare scheme yet to subsidise patients in private hospitals. Almost 80-90% of the patients in private hospitals now are insurance paid. The cost is just too high for any cash paying patients. Most of these patients wants privacy and personalised care by a consultant. Any new private hospitals will take 5-7 years to be fully occupied by patients. It does not mean that when these hospitals open, patients will be rushing in like a shopping complex! There will not be enough pool of patients for training purposes.

Private hospitals do not hire medical officers or housemen. The only medical officers they hire is for the emergency department. Consultants are NOT employed or paid a salary by these hospitals. Will this scenario change? There are still few questions that are unanswered .  Are these hospitals only meant for their lecturers ? Will the specialist be paid a fixed salary by the university unlike the normal private hospitals? Will this private hospitals start to hire MOs and HOs? Economically, it is not viable. That’s the reason why Monash decided to put their plan on hold. Private hospitals will take at least 5-7 years to start to make profit for the investment made. Thus, it is very unlikely they can employ MOs and HOs as financially they will not be able to cope. Furthermore, under the Medical Act, housemanship can only be done in public hospitals. And, will the consultants/lecturers have enough time to teach the students when they are busy with their patients in the ward/clinic?

I was informed that some private hospitals which belongs to big corporate giants are proposing to use their hospitals for postgraduate training. Well, it may be useful for certain subspeciality training in big private hospitals but not for basic speciality training. Again, there will be a lot of issues to settle. Will MOH pay the trainees to be trained in these hospitals? How much will MOH pay to these hospitals to run this “training” scheme? How much will the consultants be paid by MOH or will MOH pay the hospitals only? Will the consultant really train these trainees or merely use them as their free coolie?

Whatever it is , I smell something fishy in all this. For sure, there will be a lot of money involved and changing hands, from right pocket to left pocket! The standard of healthcare will definitely go down the drain due to poor training etc. I wonder whether there will come a time where the rakyat will lose faith in our doctors and go elsewhere for medical treatment? Our politicians are already doing it! Will we become like the Indonesians who rush to Malaysia and Singapore to seek treatment??? Only time will tell……………….

Varsity lecturers to help out at 22 hospitals

By ROSHIDI ABU SAMAH  roshidi@thestar.com.my

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Yesterday (18/03/2012), the Malaysian Medical Association Johor Branch had its AGM for 2012. It was a special occasion as the President of MMA and the SCHOMOS Chairperson were present to have a dialogue session with all the members. It was a fruitful meeting and many issues concerning the medical fraternity were discussed. We also got to know the latest happening that will change the future of medical profession in this country.

1)      Housemanship

 The declining standards of medical education and oversupply of doctors were discussed. It is indeed true that the number of housemen is reaching an unimaginable level and MOH is very much aware of this. To cover this up, MOH has come up with the shift duty system and to allocate more district hospitals for training. Most hospital’s housemanship post is fully occupied. The ratio of housemen to specialist supposed to be 5: 1. Unfortunately, the way MOH calculates this figure is rather odd as they include all specialists in the hospital including radiologists, pathologist, ophthalmologist, ENT surgeons etc where housemen are never placed. So, in reality there are not enough trainers for all the housemen who are currently in the system.

The oversupply of doctors is a harsh reality which is going to happen anytime soon. MMA has discussed this issue with MOH but unfortunately MOH puts the blame on MOHE. The moratorium is just eyewash. It is very clear that it is all about money and the only people who can stop this rot will be the general public and not MMA. Whenever MMA brings up this issue to MOH or MOHE, they are accused of being selfish and avoiding competition! Thus, it is very clear that they want to flood the market with doctors and no one is going to guarantee you a job.

The maximum period to complete your housemanship is 3 years. Anyone who does not complete the housemanship in 3 years will be automatically terminated.  Any houseman who is caught doing “locum” will be automatically terminated.

It is indeed true that MMC may soon remove the 4 years compulsory service under pressure. It is no more a rumour as I have mentioned before. It basically means that after 2 years of housemanship which is given on contract basis, there is no guarantee that you will get a job. You will have to apply to get a job in civil service or open a clinic (with license to kill). You can also forget about postgraduate education if you do not get a job in public sector.

2)      Postgraduate education

It is also true that you are only eligible to apply for Master’s programme on 5^th year of service (2+3 years). The number of Master’s post is gradually being increased due to political pressure. It is way too many compared to what the universities can really handle. The quality of Master’s graduates is slowly dropping and many consultants in hospitals have voiced out their concern. We are now seeing Master’s graduates who can’t do simple surgeries. Fresh Master’s graduates are teaching Master’s students in the universities!

Those who quit Master’s programme or who failed 4 times (meaning disqualified) will still need to serve their bond with the government and repay the JPA scholarship.

3)      Insurance companies

One of the GPs brought up the issue about insurance companies cutting the consultation fees and threatening doctors. It seems that many of these insurance companies and MCOs are requesting doctors to reduce their fee if their contract is going to be renewed. If you refuse they will find another GP who is willing. The situation has reached a critical stage to the extent that some newly opened GP clinics are willing to be paid only RM5 per consultation!! How desperate the situation has made of some doctors!

With the removal of compulsory service, many of these unemployed doctors will end up opening a clinic to survive. These doctors would probably even accept RM1 per consultation! Someone in this blog commented about competition some time ago, so here you are………..

It basically means that doctor’s income will gradually reduce and many may just earn enough to survive. It is also unavoidable that the dispensing rights of doctors will eventually be removed.

The 1Care system is still in planning stages and nothing has been finalised. So, we just have to wait and see.

4)      Liberalisation of Health Sector

In Budget 2012, our PM has announced the liberalisation of many subsectors which includes health sector. The MMA has voiced out its concern regarding this matter as proper monitoring mechanism is not in place yet http://www.themalaysianinsider.com/litee/malaysia/article/mma-putrajaya-gambling-with-nations-health-by-liberalising-medical-sector/. Unfortunately, it is unavoidable once again. Since February 2012, the government has allowed private hospital of 100% foreign equity to be set up in Malaysia. They are also allowed to hire foreign consultants as long as their degree is recognised by MMC/NSR. By September 2012, foreign specialist/doctors will be able to set up their clinics in Malaysia!!

Unfortunately, the amended Medical Act 1971 is yet to be tabled in Parliament. Thus, the National Specialist Register (NSR) is not compulsory at this point in time. So, where is the monitoring system to make sure that these “so-called” specialists are indeed what they claim to be? Someone can set up a “proctologist” clinic beside yours and earn a decent living! Even now, there are some private hospitals which are hiring “so-called” specialist “trained” in some other country without NSR registration. Private hospitals are profit driven and what they are interested is only money and not quality. With the poor monitoring system, these doctors can easily get away with whatever they are doing and the rakyat will eventually be the victim.

Over the last 24 months since I started blogging I have been constantly saying that the future is bleak for doctors. Guaranteed job, good money and life are the reasons why many choose medicine. That is the fact! Forget about helping people, curing the sick etc which is actually the minority. Whatever said, at the end of the day, it is a profession to earn a living. Unfortunately, many people believe that just because they spend RM 500 000 to RM 1 million to do medicine, the return of investment is high!! It is a total misconception that the public is totally unaware.  Our society is just obsessed in getting their children to become a doctor for glamour and social status. That must change!

Secondly, doctors are so disunited that the government can just do what they want. The only organisation that we have is MMA but unfortunately how many of you guys who are reading this are even members of MMA? How many of you are even interested to fight for the betterment of future doctors? I have done my part and still contributing to the betterment of doctors in this country. I created this blog to educate the public/future doctors as I realised that many are not aware the mess that they are getting into. MMA received a lot of bad publicity recently but it is still the only organisation to fight for doctors.

The future is indeed bleak……………………….

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