It’s December 2013, time flies! By next month, this blog will be 4 years old. From the time I started this blog in January 2010, the number of views has increased tremendously. Currently, I receive almost 1500 views per day with sometimes reaching close to 4-5000 views/day.

Yesterday, I attended a function which was graced by many government doctors and top civil servants. It was also attended by our MMA president Dato Dr K Tharmaseelan. Interesting facts were revealed, which just made whatever I predicted all these years to become  a reality soon. Over the last few years, the government was trying to improve the income and working condition of the civil service doctors. The salary was increased with time based promotion and shift duty was introduced for housemanship from September 2011.  Whenever something like this is done without proper consultation, setbacks will occur.

The shift duty was introduced not only to reduce the working hours but also to reduce the number of housemen walking around in the ward at any one time. If not, close to 50 housemen will be in each department during office hours. When it was first mooted, I wrote about it over here. As I predicted then, it has happened. Quality of training has deteriorated and patient care has gone down the drain. Many just leave the ward the moment their shift duty finishes without completing their work and promises to the patients. They just don’t bother what happens to the patient till their next shift. They also do not know what is happening to the patients when they come back for their next shift! The situation has caused concerns among the top guys in MOH and thus effective this month, the total working hours for Housemen will be increased from 60 hours with 2 days off to 75 hours with 1 day off !! Will this change anything ? I don’t think so. A better option is to go back to the old system but give them off, based on the total number of hours they have worked. If they have completed the 75 hours for that week, then they should be given the next few days off . This is what practiced in Australia and you can’t run away from your responsibility.

Unemployment of future medical graduates has been written many times in this blog and recently our MMA president voiced it out openly in mainstream newspaper. Public universities have started to cut down their intakes as of this year but private universities have to maintain certain number of students to make profit. Starting from next year, there will ONLY be certain number of intakes into civil service every year. Currently, whenever an application is sent, immediately it is processed and job offer is given within 1-2 months. Starting from next year, the intake dates will be fixed to 2-3 times/year. Whether everyone who applies will get their posting is still a mystery but likely you may need to wait longer. Thus, if you finish your degree in January and the intake is only in July , you need to wait 6 months hoping that enough post is available for all the applicants.

There are also talks at MOH level on giving housemanship on contract basis. It is very likely the time will come for this as the number of post will be limited. The discussion is to offer housemanship on contract basis for 2 years, after which you need to reapply into civil service. How it will be decided on who will receive the job offer is still being determined. Likely an exam plus performance review by HOD will be used. If you do not get a job in civil service, you need to find your own job outside. It also means, you can forget about postgraduate training.

From next year, the 6th posing of housemanship will be done at primary care clinics. I had written about this over here. I do not want to elaborate any further.

The time based promotion has also caused a lot of unhappiness among the senior doctors. When it was introduced in 2010, I wrote this. Whatever I wrote in that article is now becoming a reality. Many senior consultants are still stuck at U54 grade when their previous housemen(who is now a senior MO or junior specialist) are also in the same grade with almost same salary. There is no incentive for any further progress. Thus, why bother doing anything new or challenging when you are going to be paid the same. If you are going to remain in civil service , why even bother doing subspecialty! No new perks or appreciation. Well, didn’t I say that in my article way back in 2010?

Well, enough said in this blog. I will stop here till further information arrives on my table. Sadly, the medical community in Johor lost another great consultant yesterday at a young age. A well-known  Consultant Ophthalmologist and a Head of Department who is from a very well-known family in Johor passed away yesterday after battling with a primary brain tumour. God bless him. RIP. Life is always short……………..

Since my last article on 10/11/2013, I read quite a number of letters in the newspaper regarding the issue of oversupply of doctors in Malaysia and the deteriorating quality of graduates.  There were 2 letters over here and here which was written by lay persons who were deeply concerned about our “doctor’s mill” and “obsession in doing medicine”. Something that I have been screaming about since the last 4 years or longer!

What interest me most was the statement from Datuk Dr Jayaindran who is the Head of Department of Medicine in HKL and a Deputy DG. Even though he decline to admit directly that there will be surplus of doctors, if you read in-between the lines, it is very clear that we are heading in that direction. He admits that the local medical schools are producing about 4000 graduates a year with another 1-2000 returning from overseas (remember, close to 50% of the medical schools in Malaysia have not produced graduates yet). However, he goes on to say that we have about 10 000 posts available? I got no idea from where he got this figure but even if it is true, based on his own calculation of graduates, it should be filled in less than 2 years! He also admits that there will come a time where the job will not be automatic and the graduates will have go through the necessary process and wait in line………….

It is also interesting to note that not only we have the highest number of medical schools per capita population in the world, we have now the best housemen: patient ratio in the world. We have conveniently beaten UK with 800 years of medical education with a ratio of 1: 3 compared to 1: 12 in the UK. Welcome to the true BOLEHLAND!! And now, the MOH will be discussing with MOE to increase the minimum entry qualifications !! So, are we admitting officially that our entry qualifications are low and any tom, dick and harry are becoming doctors? Are we admitting that the quality of students who are doing medicine is low ? No wonder the outputs are generally of low quality as well!

Finally, the madness is now hitting the sky. MOH is coming up with a brilliant plan of sending housemen to polyclinics and district hospitals for “training”, in line with the changing needs of our healthcare system and disease pattern!! Why can’t they just admit that they are running out of post/jobs! Again, we will be the first in the world! Today, our great Health Minister, who is a doctor by training has declared that housemanship training will soon be conducted at polyclinics, likely as early as next year ! As far as I am concerned, this is the most stupidest idea I have ever heard. Housemanship training is not about seeing primary care patients. This is done after completing ward-based horsemanship training. Of course, being a Miniter , he has to toe the line……….. Remember, our PM’s advise to Wathyamoorthy!

Despite admitting that the quality of graduates are going downhill, they seem to be introducing more and more programs which are going to make it worst. Let me tell you an example which I just saw few days ago. An 82 year old lady who is known to have Diabetes and renal impairment came to see me with lethargy, poor oral intake and feeling unwell. She is under a Klinik Kesihatan follow-up with the following medications:

1) Metformin 1g bd

2) Frusemide 40mg od

3) Hydrochlorothiazide 50mg od

4) Spironolactone 25mg od (just added 2 weeks ago for high BP !!)

5) Aspirin 100mg od

I think this is a good MCQ question. What do you think would have happened to this patient ? Obviously, this 82 year old lady is dehydrated with a Creatinine of 330 and Potassium of 6.2 mmol/L !! And this is a doctor who has completed 2 years of housemanship. An 82 year old lady with renal impairment taking all these medications which are contraindicated in renal impairment? I have said many times that doctors can be life savers as well as killers, with a license to kill! The situation is only going to get worst! They can’t even supervise their own MOs but want HOs to undergo training in KKs!  God bless this country……………..

The madness indeed has hit the sky……………..

Read more: Ministry reviewing entry qualifications – General – New Straits Times http://www.nst.com.my/nation/general/ministry-reviewing-entry-qualifications-1.396547#ixzz2kuMUDh1O

More Training Centres Needed To House Newly Graduated Doctors – Dr Subramaniam

Today, many of us would have read the 2 depressing news from the mainstream media. The first was brought to the attention of the public via this blog almost 4 years ago. In fact, I started to write about this issue way back in 2006 in MMA magazine. The MMA president then did not quite agree with me and told me that I am exaggerating. The current MMA president seem to be more vocal and has brought up the issue of “oversupply” of doctors in various mainstream media over the last few months. Somehow, the DG and Minister of Health denies that such a thing will happen at least for another 2-3 years. However, they never denied the fact that we will achieve the ratio of 1: 600 by 2016 and 1: 400 by 2020. With close to 36 medical schools and more than 40 medical programs, it will be sooner than later. The quality of products are becoming atrocious at times. Over the last 2 weeks, I have had at least 4 queries by “medical students” on postgraduate education. These are students in their 4th/5th year of medical educations and yet do not know anything about postgraduate education in medicine. All of them felt that doing Master’s and PhD is like going for another full-time course in a university. I give up!

Another depressing news was about a 3rd year medical students who committed suicide. Based on the newspaper report, the likely cause could be depression as he did not want to continue with his medical education. However, his parents insisted (even though they claim that they had agreed for him to change course, recently!) I will say this again: parents should never force their children to do medicine! Most of the housemen who end up with the psychiatric department belong to this group.

Finally, I received an interesting email from a Malaysian who is currently in Canada. She is a product of IMU twinning program in early 2000. She has given me permission to publish her email over here, in this blog. It looks like the situation in Canada is not better either. Furthermore, she has also commented on the deteriorating quality of medical students who are undergoing twinning program in Canada which has led to some universities closing their twinning arrangements with IMU.

p.s :I forgot to mention – the average graduating medical student in Canada finishes with about CAD$100,000 – CAD$160,000 of debt. This debt collects interest while they toil at their postgraduate studies. So when they finish at last and are making that “average $250,000 salary”, they are usually far behind their peers who have gone on to establish themselves in, say, accountancy or engineering or other such fields. They “lose” those years of saving and asset accumulation AND have debt that they have to pay down. In other words, the physician begins his actual career (as a fully-fledged specialist) with a negative net worth of six figures….”

There are a lot of information about medical education in this blog. As long as there is a demand, businessman will take every opportunity to make money out of our society’s ignorance. I had always opposed the idea of privatisation of medical education. It should never be privatised. Many countries which privatised medical education eventually landed up producing sub par graduates. Businessman will only think about money and would not be bothered about the quality of medical educations. It use to take years to build a medical school but in this “bolehland”, we can start a shop-lot medical school within months! UM which started in 1964, were taking only 180 students by 1992 but we have less than 5 years old medical school taking 200 students ! We are truly a Bolehland!

I came across this interesting article published in New England Journal of Medicine  on 30/10/2013: Are We in a Medical Education Burble Market? . Despite the high medical education cost in US, the income of doctors has been sluggish since the early 2000s. Can the medical schools go on charging high fee when many doctors are finding it difficult to survive in US as I had written before? Many struggle to come out of debt even after years of working and training. The increasing litigation rate has not made their lives any easier. The article is a good read and likely the same situation will happen in Malaysia very soon. When the oversupply hits the country and when many doctors find it difficult to make money and cover their debt, only then people will realise that there is NO money in medicine. Eventually, they will stop sending their children to do medicine and the fee will gradually drop. The bubble will  burst ! In fact, it has already started with many medical schools finding it difficult to get students.

Another interesting article, from the US as well, was about a physician who left her medical practise. The topic was ” Why I left Medicine: A Burnt out Doctor’s decision to quit”. I use to say that there are 2 groups of  doctors out there. One is a group with pure passion in medicine and want to do the best for every patient. Another, is a group which treats medicine like any other job. They just want to come to work on time and leave on time. They don’t care less of what happens to the patients the moment they leave the hospital/clinic. Unfortunately, the dedicated and passionate group of doctors are the one who will get burnt out! That’s the reality. These doctors will spend most of their time in the hospital trying to make sure their patients are doing well and they even think about their patients while they are at home. These will create havoc in their family life and eventually lead to divorce, mental illness and even suicidal tendencies.

At the end of the day, many will realise that it is just another job to make a living. No matter what passion that you have, it will eventually boil down to your family and life. At one point I did almost give up medicine when I had huge debt to settle, a family with 2 kids to feed and without even an own house and furnitures. At that point, passion will be secondary. What matters most will be on how you want to bring up your family without debt. That’s the reason I keep saying that you should not take huge loans to do medicine. It will take a lifetime to settle the debt with car and house loan coming along the way. Unfortunately, many feel that they are going to make tonnes of money after graduating, and that clouds their mind.

Please read the articles below.

HAPPY DEEPAVALI TO EVERYONE…………………..

By Diane Shannon
Guest Contributor

When I introduce myself as a physician who left clinical practice, non-physicians ask me why I left. They’re generally intrigued that someone who sacrificed many years and many dollars for medical training would then change her mind. But physicians, almost universally, never ask me why I left. Instead, they ask me how. They call and email me with logistical questions, wanting to learn the secret of how I managed the transition out of clinical medicine (read “escape”).

Earlier this month I attended a conference on physician well-being at the Massachusetts Medical Society where I heard an alarming statistic: the suicide rate among women physicians is more than two times that of women in the general population.

It may be dramatic and self-serving to frame my career change as a way to avoid suicide, but I can attest that medicine was not conducive to my health. As an internist, working in adult outpatient clinics around Boston, I had trouble leaving my work at work. I’d go for a run and spend the entire 30 minutes wondering if I’d ordered the right diagnostic test. I suffered from chronic early morning wakening, even on my weekends off. I startled easily. I found it impossible to relax. I worried constantly that I’d make a mistake, like ordering the wrong dosage of a medication, or that a system flaw, like an abnormal lab report getting overlooked, would harm a patient. I no longer remembered the joy I’d felt when I first began medical school, and I couldn’t imagine surviving life as a doctor.

I no longer believe it was weakness or selfishness that led me to abandon clinical practice. I believe it was self-preservation. I knew I didn’t have the stamina and single-mindedness to try to provide high-quality, compassionate care within the existing environment. Perhaps, due to temperament or timing, I was less immune than others to the stresses of practicing medicine in a health care system that often seemed blind to humanness, both mine and my patients’.

That’s not to say that I don’t miss practicing medicine. I do. I miss engaging in meaningful interactions and being of service, reassuring an elderly woman that we could make her emphysema easier to endure, bearing witness to a cancer patient’s grace in the face of death, supporting a college student facing an unexpected pregnancy. I miss spending my days in deeply meaningful work. But given my choices at the time, I have no regrets.

I recently interviewed Mark Linzer, M.D., who researches physician burnout, and learned that the underlying causes are fairly predictable. Linzer and his research team found that four factors are associated with higher rates of burnout: time pressure, degree of control regarding work, work pace and level of chaos, and values alignment between the physician and administration. I experienced all four, but I think the greatest source of stress for me was the high level of chaos. I didn’t trust that patients would consistently receive the care they needed. Orders were sometimes incorrect, illegible (in the days before electronic medical records), or overlooked once written. An intravenous catheter left in too long led to widespread infection. Care providers forgot to wash their hands and spread serious infections from one patient to the next. EKGs and x-rays were misread. I’m someone who tends to imagine the worst. In the maelstrom of a chaotic work environment, I was worn down by worry.

Tactics to prevent medical errors have advanced since I practiced medicine. Checklists now remind care providers to replace intravenous catheters. Hand sanitizing gels and handwashing reminders are commonplace in hospitals and clinics now. Electronic ordering systems prevent handwriting errors and signal care providers about drug interactions and duplicate orders. It’s possible that with these improvements my greatest source of stress is now less of an issue, but physician burnout remains a widespread problem.

A 2012 study found that almost half of the practicing physicians surveyed had one or more symptoms of burnout. An online poll in the same year of more than 24,000 physicians found that only 54 percent would choose medicine again as a career, compared with 69 percent in 2011. From personal experience, I know the importance of creating a system in which physicians can fulfill their potential and connect with patients. I believe that until we see physicians as humans, prioritize their well-being, and create systems in which they can provide safe and compassionate care, we cannot expect them to heal others.

Hospital leaders are beginning to understand this equation. At the MMS conference, a panel of hospital executives spoke about the additional pressures on physicians within the current economic climate. I found it encouraging that the hospital leaders saw physician burnout as a serious problem and that many of the changes they were using to combat burnout were relatively simple. At one medical center, leaders attend patient rounds on a regular basis to better understand the physicians’ experience at the frontlines of care. They hold retreats to listen to physician complaints—then follow up on identified issues. Another leader sends thank you notes to physicians each time the hospital receives a complimentary letter from a patient. At another hospital, leaders decided to allow physicians to have more say about their daily schedule at the outpatient clinics. These were not costly interventions, and according to the executives, they seem to be helping.

Some of the solutions to physician burnout may be relatively simple and inexpensive — administration taking the time to understand physicians’ work experience and the barriers they encounter daily. Others are complex and resource-intensive, such as revamping the reimbursement system to measure and reward high quality compassionate care rather than the volume of procedures, tests, and physician visits.

Whether simple or complex, none of the solutions will be easy to execute, especially in the midst of the seismic changes taken place with health reform. But I believe that it’s possible to create a health system that supports physicians in their quest to provide high-quality, safe, compassionate care. I don’t think we can fix the U.S. health care system by expecting superhuman performance from humans under super-sized stress. We will only succeed if we instill safety and compassion for patients and providers in every aspect of care. If I suppress my humanness to survive in an environment that requires such a sacrifice, how will I be able to see yours?

Many groups across the nation are working on ways to infuse more humanity into health care. One example, the Schwartz Center for Compassionate Healthcare, founded by a health care attorney diagnosed with advanced lung cancer at age 40, helps health care organizations set up meetings where care providers can speak openly about the feelings of distress triggered by their daily work. If I’d had a safe place like “Schwartz Center Rounds” to express my emotions — fear, overwhelm, anger, guilt –perhaps I would have developed the resilience I needed to continue practicing medicine.

Given that I recently celebrated my fiftieth birthday and am happily ensconced in a writing career, it is unlikely that I will return to clinical practice. Sometimes this realization saddens me, but I no longer feel that leaving was weak or selfish.

Instead I believe that because I’ve survived in the trenches and now have a bit of perspective, I can help advocate for changes that will allow other physicians to practice medicine in a way that is life-giving to themselves and the patients they are privileged to serve — the way I had hoped to practice when I first donned my white coat.

Diane W. Shannon, M.D., MPH, is a freelance writer who focuses on performance improvement in health care. She lives in Chestnut Hill.

Are We in a Medical Education Bubble Market?

David A. Asch, M.D., M.B.A., Sean Nicholson, Ph.D., and Marko Vujicic, Ph.D.

October 30, 2013DOI: 10.1056/NEJMp1310778

In November 1636, the prices of tulip bulbs in the Dutch market rose rapidly from their normal level to the point where a single bulb might sell for 10 times the annual earnings of a typical worker. Just as quickly, in May 1637, tulip-bulb prices returned to their previous values. The causes of this dramatic rise and fall remain in dispute. The event occurred during the Dutch Golden Age, when stock exchanges, central banking, and many of the fundamental structures that govern contemporary capital markets and the approaches deployed by MBAs today were developed.One modern economic analysis suggests that the precipitous decline in tulip-bulb prices resulted from a February 1637 change in the way that futures contracts were enforced, which immediately reduced the value of those contracts by 97%,1 but this analysis doesn’t explain why the prices had shot up in the first place. Clearly, tulipmania was a bubble market fueled by speculation rather than intrinsic valuation. After all, why would people be willing to pay 10 times the average annual wage for a single tulip bulb unless they were confident that they could sell it to an even greater fool willing to pay even more?

Bubble markets are created when an asset trades for increasingly higher prices as it is bought by people who are hopeful about its future value and then sold to others with even more optimistic views of that value. Recent examples include the U.S. housing bubble, in which home prices rapidly rose until 2007 and then just as rapidly fell, and the dot-com bubble, in which prices of Internet stocks rose until 2000 and then plummeted. Bubbles burst when some new sense of lower intrinsic value appears. The last buyers are stuck with something they paid too much for and can no longer unload. It’s like being caught without a chair when the music stops, but whereas even the losers at musical chairs knew that at some point someone would be left standing, bubble markets are usually recognized only in retrospect — the losers never saw it coming.

Are we in a bubble market in medical education? In medicine, students buy their education from medical schools and residency programs (which pay wages that are lower than the value of the work that residents provide in return). This education is transformed into skills and credentials that are then sold to patients in the form of services. So long as it is believed that patients, or whoever purchases health care on their behalf, will keep paying more and more for physicians’ services, students and trainees should be willing to pay more and more for the education that enables them to sell those services.

A simple measure of this market economy is the ratio of the average debt of a graduating student to the average annual income in the profession on entry into the workforce. There are more precise ways to measure the return on investment in medical education — for example, the net present value of the stream of cash flows out (for education) and in (for services). But that value isn’t very intuitive for most prospective students. In contrast, debt-to-income ratios reflect what students must borrow rather than what they must pay and, given whatever other assets they may have, how much in the hole they have to go. Thus, these ratios may better reflect how students actually feel about buying education.

Figure    1FIGURE 1Ratio

of Debt to Income, According to Medical Specialty. shows these ratios for selected medical specialties over the past 15 years and reveals that the ratio has become less favorable for students overall but particularly unfavorable for students entering family medicine or psychiatry. Although the cost of becoming a doctor is roughly the same whether you go into pediatrics or orthopedics, you earn much more in orthopedics.

The graph is instructive in another way: the debt-to-income ratio reveals the connection between what physicians can charge patients and what schools can charge students. Just as tulip bulbs can be sold at high prices only to people who think they can resell them at still higher prices, schools can sustain their high tuitions only if students can be convinced of higher returns in the form of payments from future patients. So, the amount that schools are able to charge students is inextricably linked to how much we pay doctors now and how much we plan to pay them in the future. Medical students can take on enormous debt only because the costs of that debt can be easily passed along to others down the road.

So are we in a medical education bubble? We would realize we have been in one if a sudden collapse in what patients are willing to pay doctors made it impossible to sell medical education at current prices, causing applications to fall and some medical schools to cut tuition to continue to attract qualified applicants. Figure 1 might be seen as suggesting that we are approaching such a collapse in primary care fields and psychiatry. But that is not likely to be the case. First, at least at the level of undergraduate medical education, schools charge a single price to students whether they go into family medicine or orthopedics. Although it isn’t necessarily clear to students or schools which students will choose what fields, the income of the average doctor can sustain the debt of the average doctor even as the differences among specialties create pressures for primary care and psychiatry.

Second, as high as the debt-to-income ratios may be for primary care and psychiatry, they are even higher for some other fields — notably, veterinary medicine, optometry, pharmacy, and dentistry, as shown in Figure 2FIGURE 2Ratio of Debt to Income, According to Occupation.. For veterinarians, incomes have risen slowly even as student debt has exploded.2 Yet although such company may ease the misery of primary care physicians, it does nothing to solve the underlying problem.

The problem is this: if we aim to reduce the costs of health care, we need to reduce the costs of medical education. We don’t have to believe that the high cost of medical education is what causes increases in health care costs in order to develop this sense of urgency. We just have to recognize that the high costs of medical education are sustainable only if we keep paying doctors a lot of money, and there are strong signs that we can’t or won’t. Only about 20% of health care costs are attributable to physician payments, and many of the current efforts to reduce costs are aimed elsewhere, such as hospital payments, and have only indirect effects on physicians’ earnings. But physicians’ and dentists’ earnings have been sluggish since the early 2000s.3,4 Even if prospects for physicians’ income fall fast, a burst bubble can be averted if schools see it coming before their students do and lower their prices.

The general lesson is that if we want to keep health care costs down and still have access to well-qualified physicians, we also need to keep the cost of creating those physicians down by changing the way that physicians are trained. From college through licensure and credentialing, our annual physician-production costs are high, and they are made higher by the long time we devote to training.5

Although it seems unlikely that we’re in a bubble market for medical education, we may already be in one for veterinary medicine. That bubble will burst when potential students recognize that the costs of training aren’t matched by later returns. Then the optometry bubble may burst, followed by the pharmacy and dentistry bubbles. At the extreme, we will march down the debt-to-income-ratio ladder, through psychiatrists to cardiologists to orthopedists . . . until no one is left but the MBAs.

Over the last 4 years since I started this blog, I had written numerous articles and in formations about medical education, the life of a doctor and the general misconception of public about medicine. Unfortunately, many refused to believe and remained in denial phase. There were many distractors during my early days of this blog , making unnecessary insulting remarks to me. However, many had to swallow their own words when day by day, everything that I wrote in this blog became a reality. For those who followed this blog since January 2010, you will remember what I wrote about degree recognition issues, the marketing gimmicks of medical colleges, the mushrooming of medical colleges, the possible unemployment of future doctors, the declining income of doctors and many more articles that many refuse to believe. The reality is always a bitter truth that need to be swallowed. Slowly, most of these distractors has “disappeared” from this blog.

Today’s article in the Star by Dr Noorul Ameen (see below) would definitely make many people(public) to be surprised. Unfortunately, that is the reality. Declining incomes of doctors is very much a reality which will continue over the years to come. There will come a time where the income of doctors will not be much of a difference than a teacher or any other profession. The difference will be the money that you would have spent to become one and the increasing litigation rate. The number of medico-legal cases are on the rise and there are many lawyers nowadays who are willing to take up cases against doctors. In US, there are firms who promote themselves as experts in suing medical doctors! This website that belongs to a firm explains what is happening in the US and similarly in many other developed countries. It will only create Cover Backside Medicine(CBM) which in turn will increase the cost of healthcare due to unnecessary investigations.

With close to 34 medical colleges and almost 43 medical programs, we have the highest number of medical colleges per-capita population in the world. MMC was forced to come up with a guideline to prevent these colleges to take unqualified students but the criteria introduced is just too low. Yesterday, I had an interesting conversation with a parent whose daughter has been offered a seat in Perdana UNiversity RCSI for just RM 250K for a course which is supposedly RM 800K! It seems that this offer is being given to those Indian students who scored 4flat but could not gain entrance into public university to do medicine. She is currently doing another course in a public university.The deal is being offered via MIC. Even the RM 250K can be obtained via PTPTN loan and education funds of the party. While I appreciate the “help”   given by this university, I just wonder how a course that supposedly cost RM 800K can suddenly become RM 250K. As far as I know, none of these medical courses are recognised overseas. The first few batches were fully sponsored by the government via a special scholarship program specifically for this university (by PM’s department). Surprisingly, even the campus and the hospital has not started construction yet. If I can remember, the first private teaching hospital suppose to be ready by 2014. This could also indicate that the university is finding it difficult to attract students, especially international students.

Coming back to declining incomes of doctors, many doctors nowadays are trying their luck on unethical practices, aesthetic medicine and complimentary medicines. I know many doctors who have started unproven complimentary medical practices, selling supplements and even becoming official promoter for certain direct selling products. They are just trying to survive. The public still believes that doctors are rich and having easy life…………..

BTW, anyone want to make easy money, please read this SMS that I received yesterday:

” Agents wanted to promote Medical, Dental and Pharmacy. Loan PTPTN. Comm : RM 25K. Call 0xxxxxx. www. XXXX.com.my“

This SMS is from the same agency which I wrote in my previous article. From 5K it has become 25K!. It is a business and people are trying to make as much money as possible from our ignorant society…………………

Many things are changing in this world. The same goes to the field of medicine. It use to be a so-called glamorous job where no one will question whatever you say. Whatever you tell the patients is considered gospel truth and patients will just swallow it. However, times are changing and doctors are finding it difficult to deal with patients. Patients are becoming more demanding and do not hesitate to question you. Internet is both a gift and a curse. Patients come to you after spending some time “google-ing” their symptoms and ask you various questions which you are not prepared for. I have had patients who walk into my room with a diagnosis in their mind and they just want me to confirm it! It does irritate me but I will always tell them that I will decide what need to be done.  But then , there will always be an anxiety at the back of your mind whether you are missing something and  the patient might be right. I am still able to control this anxiety but I am seeing many consultants/doctors out there who practise CBM ( Cover Backside Medicine). They order all sorts of unnecessary investigations just to make sure they do not miss something. This was what happened in US when the litigation rate started to rise which subsequently pushed the healthcare cost up the roof. Likely , the same will happen over here , both in private and public hospitals.  Mind you, government hospitals are also seeing increasing number of medico-legal cases.

The article below was written in the Malaysian Insider today.  I decided to publish it over here as the article do bring up certain issues that are important. I had highlighted some of the sentences for easier reference. In fact, I had written many times in this blog regarding unethical practices and “Cover Backside Medicine” practices in private sector. That’s why I use to say that never judge a book by its cover. Most naive and ethical doctors do not earn much but the unethical doctors may be laughing to the banks. This is partly because, patients tend to believe a doctor who tells them what they want to hear. A doctor who removes an asymptomatic gallstone is good where as a doctor who says nothing need to be done is useless. I believe that patients are partly to be blamed for this.

Coming back to the article below, I personally do not like some of the words used in this article like ” useless doctor” and ” bastard”! This sentence ” “You wonder why we should pay these useless doctors so much when we can find reliable answers online!” is rather annoying. Internet do not really give you reliable answers. I have had many patients who ended up getting anxiety and panic attacks after reading informations in the net. Today, interestingly I even had a patient who diagnosed herself as “bipolar disorder” after reading from the internet!!

But one thing that this article proofs is that patients are becoming more educated, demanding and would not hesitate to take actions against doctors. Gone are the good old days where patients swallow what you say, forgive and forget. The situation is changing rapidly and life is not going to be easy for future doctors. With the deteriorating quality of doctors being produced, the situation is only going to get worst. Many patients are already aware of this scenario of oversupply and under trained doctors. Many of them do go to a few doctors for second opinions.

The rest I will let the readers to read the article below……………….

The sickness of our private healthcare services

OCTOBER 09, 2013

Lim Ka Ea is a traveller who sees travel as the answer to all the world’s woes. Writing is a grand love. Ka Ea has had NGO and legal experience.

“If I keep this oath faithfully, may I enjoy my life and practise my art, respected by all humanity and in all times; but if I swerve from it or violate it, may the reverse be my life.”
– The Hippocratic Oath

Mary was entering her mid-thirties when it finally dawned on her that she is reproductively challenged. The thought of her own infertility did play in her mind when she was much younger but her suspicion was only confirmed recently when she was diagnosed for polycystic ovarian syndrome (POS). The strange thing was, the diagnosis did not come from her fertility doctor, who had then been too eager to start her and her husband on the notoriously expensive and invasive in vitro treatment, without first examining their health.

The diagnosis for POS had come up through her own initiative. Once she and her husband decided that they would try to conceive through artificial insemination, Mary thought it would be prudent to go through a full medical check-up, “just to make sure my body is ready for the baby, you know. We’ve read that in vitro is very stressful and we want to make sure that we’ve tried everything possible to make sure that the conditions are conducive,” she said.

When her blood work came back, her thyroid function tests were elevated. Later, it was her endocrinologist who told her that in addition to hypothyroidism, she might be suffering from POS too. He told her that the sudden and continuous weight gain, increased cholesterol level, development of fatty liver, irregular menstruation, and acne are some of the symptoms of POS.

Mary had initially thought that these symptoms were attributed to her bad eating habits and sedentary lifestyle but it now explains why these unflattering conditions remain unchanged even after her vigorous attempts to eat and exercise better.

“The funny thing is, no one told me about it. The GP (General Practitioner) at the hospital where I did the full medical check-up did not alert me to anything after he examined my test results. All he did was to make me feel bad about my weight and asked me to take another test in three months’ time to see whether there are any changes to my thyroid functions. All this while, I had been wondering why I’ve been battling bad skin and weight gain. If only I had known earlier, I would have been less depressed and feeling hopeless all the time,” Mary said.

“You have most of the POS symptoms. Go home and do a search online. Read up and learn as much as possible about POS and then go see a gynaecologist to seek treatment. You need to solve all this hormonal issue first before you even try to get pregnant. There are other options before you start considering in vitro. Let’s get you fixed up first, ok?”

That was the most honest and reassuring conversation Mary have had with a doctor so far.

After reading up on hypothyroidism and POS on the Internet, Mary discovered that the chances of having a problematic pregnancy would have been high if she had become pregnant either through natural or artificial means. She confessed that much to her disappointment and great horror, she felt that the renowned fertility specialist she saw at a highly recommended infertility clinic in Kuala Lumpur should have informed her of this vital piece of information.

Mary and her husband initially reasoned that the specialist would have alerted them to her condition if only he had bothered to look at their medical records, which they had brought along with them during their first consultation, having thought pre-emptively that the doctor would have asked for it.

“It was going to cost us about seventeen thousand ringgit for the whole procedure and that doesn’t even cover the cost of a second treatment if the first one doesn’t work. With hypothyroidism and POS, the chances of having a miscarriage would have been great.

“Can you imagine how devastating it would have been if we hadn’t known?” Mary asked and added dejectedly, “The thing is, the doctor didn’t even bother looking at our medical records, you know. They just wanted to make money out of us.”

Mary said that on hindsight now, she is not even sure whether the doctor would have warned them of the potential complications if he had known of her conditions. Mary insisted that her endocrinologist is the minority.

“There are definitely good doctors out there, but they are extremely rare,” she said.  She revealed that she no longer trusts the medical service and would turn to her trusted online sites for all her medical diagnosis and query.

“You wonder why we should pay these useless doctors so much when we can find reliable answers online!” She laughed scornfully.

Mary is not alone when it comes to being at the receiving end of bad medical services and not trusting our medical practitioners. It would appear that more and more private hospitals are abandoning the Hippocratic Oath for personal gain.

A medical practitioner revealed that the price of medicine at a private hospital costs a lot more than an external pharmacy. He often advises his patients to buy their medicine from external pharmacies because it makes no sense for them to pay “cut-throat” prices for the same medicine. However, when Kelly tried to do precisely that, the doctor treating her apparently did not take it too well.

“Instead of giving me a prescription for six months as he had recommended, the bastard only prescribed me a month’s worth of medication. In other words, he was ‘forcing’ me to go back to him for a follow-up prescription and that would have meant paying him ninety ringgit for just a bloody piece of paper. Can you imagine that?!”

The Department of Pharmaceutical Services at the Ministry of Health informed that there is currently no law to control the prices of medication at private hospitals. However, it is encouraging when the Head of the Medicine Pricing Unit wrote, “As a patient, you have the right to obtain a prescription from your doctor to buy your medicine from any pharmacy even though it displeases the doctor. I believe that empowered patients can change the current bad habits practised by medical professions so that we can all guarantee affordable medication for the people.”

Vikram, another unhappy patient, shared the experience he had with his doctor when he was undergoing treatment for Hepatitis C. He said that he was mortified when the nurse asked about his treatment in front of other patients while he was waiting for his doctor in a clinic. He understood that the nurse probably asked out of customary politeness but he did not appreciate the fact that in the course of her doing so, other people had learned about his medical condition.

He said that patient information management is lacking in many healthcare facilities and was shocked that this clinic is part of a hospital that has received an accreditation from the Malaysian Society for Quality in Health (MSQH), the national accrediting body for healthcare facilities and services.

“On top of that, my doctor failed to inform me of all the side effects of the antiviral medication I was taking. There was no counselling or support for me and my spouse. The repercussions of the medication was so great that I felt as if the treatment had ruined an important part of our lives. 

“For each visit, I paid ninety ringgit for a five-minute consultation where the doctor did practically nothing. Thankfully I had a good insurance coverage because the medication cost an arm and a leg. To be honest, I wish I had not undergone this treatment if only I had known of the repercussions. I wasn’t informed properly,” Vikram said regretfully.

As of June this year, 75 percent of public hospitals have received the MSQH accreditation while only 25 percent of private hospitals have. At the international level, only eight hospitals have received the Joint Commission International (JCI)’s accreditation.

The JCI is created by the Joint Commission on Accreditation of Healthcare Organisations, a US government agency, aimed to improve the safety and quality of care in the international community through the provision of education and advisory services, and international accreditation and certification.

The assessment criteria used by the MSQH is quite similar to the one used by the JCI, except the latter provides additional components such as patient and family education, staff qualifications and education, medication management and use, and the assessment and care of patients; elements which seem to be sorely lacking in our own private healthcare services.

Previously, the government has made several attempts to make it mandatory for all public and private hospitals to obtain MSQH accreditation but these attempts have been put on hold thus far. Although having some sort of national or international accreditation by a recognised and credible agency does boost public confidence, alongside minimising and mitigating clinical and safety related risks, these accreditations do not take into account public rating. The application submission for accreditation is done by the hospital in question and the assessment is then carried out by a panel of surveyors appointed by the accreditation agency.

There is no consideration for public opinion on how the hospital has fared.

“As a patient, I would like us to have some sort of a scorecard for all the hospital in Malaysia. Something simple for a start and it can be done by civil society, someone independent and done from the patient’s perspectives.

“What we need is someone who will disguise as a patient to test out the hospitals. So you have this person who goes to several hospitals and says he’s got liver problem, for instance, and then he assesses how the hospitals handle him based on selected key criteria. The problem has to be the same though, so you can compare apple for apple,” Vikram suggested thoughtfully.

Kelly said the hospital’s ability to deal with complaints is something left to be desired.

“No point. I’ve written to a hospital before to express my dissatisfaction over their service. I haven’t received any response from them. This was last year. It’s like as if the hospital doesn’t really care if you’re unhappy with them. They have patients lined up anyway. So why should they care?”

Sumitra, who is married to a doctor, revealed that medical practitioners often tend to close an eye when their colleagues commit a medical error. This culture is deeply rooted on the notion of solidarity akin to “I have your back now so that when I need you, you’ll have mine.” 

This makes it virtually impossible to have a doctor testifies against the other, even when a grave error occurs at the expense of a patient’s life.

Perhaps what Malaysia needs is a patients association such as the one in the United Kingdom. The UK’s Patients Association provides a platform for the people to rate their National Health Service (NHS). The association also runs educational campaigns such as the Speaking Up Complaints Project which encourages patients to speak up against poor medical services and the NHS to improve the way it deals with patients’ complaints. The NHS is ranked as one of the top 20 best healthcare services in the world by the World Health Organisation.

Not all is lost. Malaysia seems to be doing remarkably well in the area of medical tourism. A private hospital in Kuala Lumpur is recently recognised by the Medical Travel Quality Alliance as one of the world’s top ten best hospitals for medical tourists. By taking advantage of the weaker Malaysian currency, foreigners from the Middle East, Europe and Japan are flocking to Malaysia to enjoy better medical treatment.

It would have cost the local patients an arm and a leg to receive treatment in these hospitals but Mary said, “If the service is compatible with the amount I pay for, why not? The problem with the private hospitals here is that I’m not even getting the value for my money.”

While our private hospitals continue to nurse tourists with top notch care, in order to stay competitive alongside South Korea, Thailand and Turkey, have they forgot about our own illnesses along the way? – October 9, 2013.

* This is the personal opinion of the writer or publication and does not necessarily represent the views of The Malaysian Insider.