Back from the Future: From First World to Third World!
It has been more than 18 months since I last wrote an article in Berita MMA (March 2007 to be exact!). It has also been quite an interesting 18 months in my life as well as for the country with a lot of fascinating events taking place. I have been away “overseas” since March 2007 till September 2008 to complete my subspecialty training. I said “overseas” as it is only 1km away from my hometown, Johor Bahru. Being in Singapore (Singapore General Hospital) really opened my eyes to how much backward we are in term of “knowledge based economy”, mentality, healthcare as well as attracting best brains based on merit.
First let us see what happened in Malaysia since I last wrote in Berita MMA.
Government Salary and Allowance Revision
The 15% increment of salary for government doctors as well as the rest of the government servants really brought some temporary cheers. I said “temporary” because, soon after that, the cost of living jumped and made the increase looked like peanuts. However it must be said that it was the best increment after 2002 of 10%, not sure how long it’s going to take for the next increment to happen! Soon after that the housing allowance for U44 was increased to RM400 from RM250 and the critical allowance was increased from RM500 to RM750 effective January 2008. Recently an increase of specialist allowance was announced in Budget 2009 but the quantum still remains a mystery.
The automatic promotion of UD41 to UD44 upon completion of Housemanship was something that SCHOMOS actively pursued with Ministry of Health in 2006 when I was part of the national SCHOMOS Exco. I still remember the proposal paper that I personally wrote on behalf of SCHOMOS to be submitted to the Health Minister, Dato’ Dr Chua Soi Lek, after the national level SCHOMOS workshop in Putrajaya (January 2006). The introduction of RM80 per hour for doctors working overtime in A&E and polyclinics is another milestone in the MOH, even though this has caused a lot of unhappiness among the hospital based doctors. SCHOMOS need to discuss this further with MOH. However, not all have been that exciting for doctors or future doctors in government service.
Ministry of Health, Housemanship and Subspecialty
The scandal involving our previous Health Minister, I must say has some impact on the running of the Ministry. Dato’ Dr Chua Soi Lek has been a very attentive Minister when it comes to the issues of government doctors. Being a doctor, he did make a lot of changes even though we did not see it coming as fast as we wanted it to be. The extension of housemanship to two years did cause a lot of dissatisfaction to future doctors. To add further insult to this, the duration of time before you can get into subspecialty fellowship programme upon completion of postgraduate degree has been extended by a year. This means that you have to complete two years of housemanship, one year of service, four years of Masters, six months of gazettment, one year of service and three years of subspecialty before you can call yourself a subspecialist!!. A total of 11½ years!!!!. When other countries are trying to shorten the duration to subspecialty, our experts are trying to prolong it! This has caused a lot of dissatisfaction to our junior specialist and they are beginning to leave to our neighbouring country for a faster training and recognition.
Politics
The 8 March 2008 “political tsunami” that swept the country has also changed the situation in the country to a new defining moment in the history of this country. I hope it is for the better!
MMA
What about MMA? I closely followed the development of internal scandals of MMA. The “hoo-ha” about the deregistration of MMA and the problems that came up regarding the election of “President-Elect” really frustrated a lot of people who began to look at MMA just like another self serving political party. I did not attend the last two AGM but I gather that the problems were “resolved” successfully in the last AGM. I just hope another new scandal would not appear soon. The change of guards in the MMA House would hopefully bring a “New Dawn” in MMA history. It is becoming increasingly difficult to convince anyone to join MMA anymore! Unless and until MMA rebrands itself and reach out to the grassroots, MMA may undergo the same fate as some of the political parties in this country may undergo in near future!
Many of our grassroots suggestion that we brought up few years ago still remains a suggestion. Singapore Medical Association (SMA) has a one page simple application form and we have four pages with proposer etc. etc. Their HO membership fee is only SGD53.80 with staggered increase with a max of SGD214 after seven years of service. Please don’t convert as their salary is also double of ours! E.g. their MO earns about SGD5000-6000/month. I do not know whether MMA has started giving the welcome pack which SMA definitely has.
Now, just take a look at Singapore. We cannot deny that Singapore being a small country without a single drop of natural resource has progressed far ahead of us to have one of the highest per capita income in the world and the second most competitive country in the world. Being in Singapore for 18 months taught me why and how they have developed as such and why we will never be able to compete with them.
K-economy
Singapore is obsessed with human resource and “knowledge based economy (k-economy)”. They will invest to get the best brains from around the world to develop their country based on merit. Their favorite targets are Malaysians who are readily frustrated! Almost 50% of their doctors in Singapore are Malaysians or were Malaysian. Many of them are senior consultants and over the last two years, many more Malaysians joined them as Registrars, medical officers and even house officers (after UM and UKM were recognised). Do you wonder why many Malaysians did not return to Malaysia after the new immigration laws in UK? Because they are all in Singapore! During my stay there I saw many Malaysian doctors from UK joining their hospitals as medical officers and registrars. The new “backward” ruling in our country regarding the housemanship and subspecialty has further pushed more and more doctors to pursue their training in Singapore. I must say that their training in various medical fields are more structured and well organised with up to date treatment and management. Every houseman, medical officer and registrars are supervised in every aspect of their management, shortening their learning curve. As a registrar you are always supervised by an allocated consultant. There is no such thing as “not available” in Singapore. If they don’t have it, they will get it! If they don’t know, they will find it!
Working Environment, Planning and Staff Attitude
The working environment in Singapore is far more comfortable than any hospitals in Malaysia. They really take care of their assets: doctors and medical staffs. Their planning starts from bottom up rather than top bottom principle. If you need anything to set up a new unit, just ask and you will get it! Further to this I also realise that the attitude of consultants over there is different. They are very approachable, well mannered and anyone can call them at any time. There is hardly any bullying and there is no such thing as “I am the consultant, you listen to me, I am always right” kind of attitude.
One of the reasons why I feel this arrogance is curtailed is because of their Head of Department rotation system. In Singapore, a Head of Department only holds the post for a maximum of 6 years (2 × three year contract), after which they must pass it on to the next most senior person. During the time of holding the HOD post, they must still continue their clinics and ward service as usual. Their clinics are personalised clinics and as such you should not be asking any other doctors to run your clinic unless in an emergency situation. This I think is a very good strategy and I would suggest such a system to be implemented in Malaysia. This will definitely prevent any wrong doing by the HOD which frequently occurs here when they feel that they are “untouchables” once they acquire the HOD post, which they can keep even after retirement! The “I am the Boss” phenomenon does not occur as you know three years down the line you are not the boss anymore!
CME and Specialist Training
Singaporeans doctors also keep up to date with the latest therapies as their academic events goes hand in hand with their clinical service. In fact, it is compulsory for each department to conduct CME activities for a certain number of hours per-month for their medical officers, registrars etc. If not, the MOH will reduce their budget allocation to that particular department!
Their specialist training programme is well structured and I must admire them for that. After one year of housemanship, they can enroll themselves in “Basic Specialist Training (BST)” programme. The BST programme runs for three years and the MO will have to undergo rotation in every medical discipline. They can pursue their MRCP during this time but even if they pass the MRCP, they are still considered as MO till they complete their BST. After completing their BST, submission of log book and attending an interview, they will proceed to “Advanced Specialist Training (AST)” programme. AST is a subspecialist training programme which takes three years and the doctor will be promoted as registrar during AST. After three years of AST and completing the exit exam, they will be promoted to Associate Consultant of the particular subspecialist field. All in all it will only take seven years to become a subspecialist generally! Subsequently they will be promoted to Consultant in three years, on the dot! Now you see why our doctors are leaving to Singapore? 11½ vs 7 years with a well structured, well supervised training programme! And please don’t forget the better salary, perks and promotional prospects!
Healthcare
As for their Healthcare scheme, Dr Harvinder Singh has written in Berita MMA last year. Even though patients have to pay a subsidised rate for all service and treatment, there are many avenues for them to settle the bill including Medisave, Medifund etc. etc. There has not been a single instance where patients have been denied any form of treatment just because they cannot afford it. Imagine getting CT scan and MRI within 24 hours for inpatients! No wonder Singapore has the second most ageing population in the world. Furthermore, their obsession with human capital rather than physical structures has put them way forward in terms of development. Singapore General Hospital has a total of almost 30-40 radiologist (includes senior consultant, consultant and associate consultants, EXCLUDING registrars and MOs) covering various radiology subspecialty in a 1,500 bedded hospital. Can we match that?
Well, back in Malaysia, I feel like going back to ground zero. I have to go back to the same old system of waiting for everything. We may have excellent “fungating” buildings/hospitals but empty inside. Patients are not receiving the best healthcare services despite having best accessibility. We should have been better than any other South-East Asian countries after being the second biggest economy in 1960s. I am sad to see where we are now. The feeling of coming from a first world to a third world should not have happened.
Just hope that it does not get any worst……………………..
Pagalavan's Avatar 
Dear Dr. Pagalavan,
thank you for your prompt reply and reference to this article.
-according to the singapore training system, once i have pass MRCP in malaysia, apply and being accepted into singapore system, where does that land me? at the beginning of the BST, meaning i still have roughly 6 years to obtain my subspecialty, or i’m in AST, or i’m in neither, and is just basically working to wait for offer?
– i read somewhere on your blog that the singaporean system has changed again. is that true? or is my question above still relevant?
– there is no choice but for me to complete 5 years compulsory service in malaysia before switching to singapore with MRCP result because otherwise, i cannot practice medicine in malaysia right?
my interest is the same as yours Dr., which is general medicine but in malaysia we do not have a family medicine specialist, and due to pursue of better prospect, i guess i have to pick a subspecialty after all.
looking forward to hearing from you. thank you.
1) You will joint as a MO and depending on the availability of post , you can get into the AST training usually in about a year. The less popular field will be easier to get in. You don’t need to do BST but of course, preference will be given for those who have completed BST.
2) I heard that singapore is changing the system to residency system like US. Not sure whether they have started !
3) Compulsory service is 4 years, including 2 years HO. By the time you finish MRCP, you would have completed your 4 years, so no worries. You can still practise in Malaysia even if you did not complete your compulsory service depending on your seniority and case by case basis when you return to the country.
I just got info from my singapore colleague that all hospitals in Singapore have started the residency programme. Immediately after housemanship, you can go on to do subspeciality! MRCP is still recognised and thus you can straight away get into the subspeciality training , depending on availability of post. The full training will be recognised in USA and you can become a fellow of the american colleges.
Wow Dr. Pagalavan~!
this is incredible news! and your information is always so up to date and needless to say, exciting!
– i am not familiar with residency programme. meaning it’s two years HO in singapore, and then proceed to be trained as a specialist of choice for 3 years? no MRCP will be necessary? in short, you can be a specialist after 5 years graduation from university? if this is the case, meaning i should consider taking the entrance exam to work in singapore as soon as i graduate because my uni is obviously not recognized by singapore. i bet the singapore entrance exam is much easier than MRCP?
– second choice, complete 4 years of service and get my MRCP, and apply to get into singapore, worse case scenario, get my specialist training in a year. this is obviously much longer than the route above.
– after i obtain my specialist cert, i can even practise in USA? unbelievable…
i’m not over-eager to cut corner to shorten my time in the process. i want to be a competent doctor and specialist with proper training. but i do not want to waste unnecessary time either, and hence i would like to pick the best and most straight forward route.
your information is very valuable. eagerly awaiting your next reply. thank you so much.
One of the major problem with the American system is that you are very subspecialised. The doctors end up in subspeciality training immediately after internship and they DO NOT have adequate exposure to general medical cases. That’s the reason, they become very investigative in nature and orders a set of investigations whenever they see a patient. THis is well known all over the world. Personally, I prefer the UK system where, general medical and surgical are still considered important. I am not sure why Singapore is moving towards the residency system. I heard there are a lot of resistance from the hospitals on moving towards the residency system.
Frankly, I don’t think our country is ready for such a system. In Malaysia, whatever subspecilist you are, you will still need to manage general medical cases. In fact in private sector, almost 60-80% of the cases that you see will still be general medical cases and the balance will be your subspecialist cases. I will still think that a longer route is better for future prospect.
Dear Dr. Pagalavan,
thank you for your prompt reply. and i understand your concern which makes a lot of sense to me. i guess i should take my steps slowly, get a prestigious MRCP just to prove myself competent, and then start a training in singapore. and hence your final advice would be finishing my MO, get a MRCP and apply for training in singapore right? as long as i hold MRCP, what are the chances of my application for subspecialty training being rejected by singapore?
lastly, you mentioned 4 years training in malaysia as HO/MO, but as far as i know, it’s actually 5 years, 2 HO, and 3 MO. isn’t that so?
thank you so much Dr.
Compulsory service is 4 years: 2 years HO and 2 years MO. You should be able to get a place for training after MRCP. Just need to choose a proper field and hospital as the post depends on the hospital.
hi Dr. Pagalavan,
i have send several thank you notes for you. just wondering if you have received any of it, because i really appreciate all your help. you have no idea how valuable those info is for me.
thank you so much.
hi dr, im a ghanaian studying medicine in one of the universities in russia. but i prefer getting a transfer to a university in ukraine to continue my studies, please doc i need some advice.
Please ask your university.
Hi Dr Pagalavan, I have just finished my MBBS, and now waiting to be posted. My question is, I have read about applying for MRCP, and such. But what about MRCS? Can you give some information about that? Because I would like to pursue a career in surgery, and I would like to get it done as one does for MRCP..
Your reply is much appreciated. Thank you.
Best regards,
Khairul.
MRCS is NOT recognised in Malaysia as a specialist degree. None of the hospital in Malaysia is a recognised training centre for FRCS. BUT you can still sit for MRCS in Malaysia and then either go to Singapore to do FRCS or do local Master’s in Surgery. If you have MRCS , it may be easier to get into Master’s programme and some may evenm exempt you from Part 1 Master’s.