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One of my loyal follower sent me this 2 articles below which appeared in The Sun (http://www.thesundaily.my/news/167606, http://www.thesundaily.my/news/175519). I have said this many times that medicine is different. You are dealing with life and it does involve a lot of stress. That’s the reason why I started this blog to educate the people of what medicine is all about! Don’t just jump into doing medicine just for money and glamour.

Being a doctor is not about working office hours and going back on time like many other jobs. You are dealing with life and you have to make sure that you do whatever necessary for the patients before you leave. Of course I don’t agree working long hours like 36 hours continuously but even if you work shift hours, you still need to finish your job!! Life’s are at stake! I am rather amused with the first author below because at one point he is talking about long working hours and on another note, he is talking about excessive work load. Who said that when you become a doctor, you workload is not heavy? Even if you are doing shift system, the number of patients that you are going to take care will still be the same! And finally, he is saying that there will be a paycut!! I mean, I don’t know what this author wants? I guess he wants a comfortable, office hour work for his sister with a lot of money. Then, don’t become a doctor, that is my answer.

I think the reply by the specialist below sums up what is actually happening in our hospitals currently. I have said it along the way in my blog. If you think being a housemen is stressful, wait till you become a specialist especially in private hospitals. You are the housemen, medical officer and the consultant for the patients. You work 24 hours a day, 7 days a week. You can be called at anytime of the day.And you will sued for any mistake that you make. No one cares whether you are tired or not! So, don’t think only as a housemen, you are overworked!!!

The day you choose medicine as your career, that’s the day you have committed to life long learning, hard work, stressful life and poor social life. So, if you are NOT into it, then find another job!

Overworked housemen

Posted on 5 October 2011 – 10:09pm
Last updated on 6 October 2011 – 09:57pm

THE term houseman refers to an advanced student or graduate in medicine gaining supervised practical experience. In Malaysia, it is compulsory for doctors to undergo housemanship for two years after completing a medical degree.

During housemanship, they are rotated between six departments – emergency, medical, paediatric, general surgery, orthopaedic, and obstetrics and gynaecology – spending four months in each.

My sister is a houseman in a government hospital in Selangor. For the past eight months, I have been surprised to notice her working hours. There is no maximum number of hours a houseman can work.

This has led to a situation where my sister is often overworked and has hardly seen daylight since she embarked on this respected career. She had always wanted to become a doctor, but eight months into her housemanship, she seems to have snapped. Such conditions may result in wrong decision-making and management, and poor performance.

The work load is too heavy and the hours too long. When she is on call, she sometimes has to work for up to 36 hours straight. Unfortunately, housemanship is taking its toll on many young doctors. After completing a gruelling course, they get to face endless working hours.

Previous Health Ministry director-general Tan Sri Dr Ismail Merican had revealed that many medical graduates were unable to cope with housemanship.

My sister informs me that a shift hours concept has now been introduced in housemanship as a measure to address the problem of too many new doctors and of overwork. I’m not sure that this system will work, but I really hope it does.

The only drawback of this system is that you are not entitled to “on call” allowance.

Currently, with housemen required to do 10 “on-calls” a month, this adds another RM1,000-RM1,200 to their monthly salary. So indirectly, shift hours means a pay cut.

Furthermore, there is also sometimes an element of bullying and high-handedness in the way some senior medical officers and consultants treat their junior house officers. They become Little Napoleons and are dictatorial. They say they went through the same regimen which made them good doctors.

So it is decided that the current crop of newbies needs to go through the same process.

Housemen are often screamed at by specialists. This is bad work ethics and I find it to be uncivilised as research has shown that the result of such an attitude would result in less effective staff.

Finally, I hope the ministry is aware of this matter. May the relevant authority ensure that these public service doctors are happy and capable of providing the best service to the nation.

F.A.
Alam Impian

Young doctors mollycoddled

Posted on 12 October 2011 – 08:53pm
Last updated on 12 October 2011 – 10:00pm

I REFER to “Overworked housemen” (Letters, Oct 5) and other grouses that increasingly make their way into our media by Generation Y housemen. As a specialist in a government hospital in Selangor, I feel that instead of silence that may be misconstrued as guilt, there is a need to reply.

We are now at a crossroads in our health system. The high standards that were maintained through the years have fallen by the wayside. This is especially evident from the constant complaints of the younger generation, although the system and the government are bending over backwards to accommodate them. The reasons:

— An overload of new housemen/doctors – 500 a year in 1998 and 7,500 in 2011, with the number estimated to rise to 10,000 in coming years.

— Too many medical schools in the country – 42 at the last count, with some having very low standards. Indonesia with a population of about 300 million has half the number. How did these colleges come to be recognised?

— Too many medical schools recognised overseas, with the standards, especially of Russian ones, being extremely low.

— So we are now inundated with housemen to train, wherein 60% are of very low standard – meaning not even fit to pass the finals in a medical school exam, let alone to treat patients.

— We, the specialists, are forced to retrain and even reteach these incompetents.

— There are only so many times you can give advice to a person who doesn’t listen – sometimes when a patient’s life is at stake, voices have to be raised! Don’t you agree?

— Increasingly, our politicians get involved when some VIP’s son or daughter who can’t cope, just wants to float through. Many specialists have been given letters of warning, when all they were doing was enforcing appropriate disciplinary action in respect of housemen who had gone AWOL.

— The number of litigation cases against the Health Ministry due to housemen is at an all-time high.

— The shift system was opposed by all senior faculty in the ministry, vis a vis all senior specialists, but it was forced on us. Who is going to monitor all these housemen under the shift system – the specialists?

— When these housemen become medical officers and specialists, are they also going to go on shift?

— We have better things to do than mollycoddle a tsunami of sub-standard doctors. If we are not careful, there will be a great exodus of specialists from the public health system in the next few years.

All you see in government hospital nowadays are the poor and the illegals – everyone else has an insurance card! So to the powers that be, wake up and smell the coffee.

S.A.
via email

Malaysian Medical Association in collaboration with Columbia Asia Hospital Nusajaya and Hospital Sultan Ismail will be organising the Johor Rheumatology Update course at Grand Paragon Hotel, Johor Bahru on 23/10/2011. I am the organising chairman for the above course which is being held for the first time in JB, open to all doctors free of charge. Below, is the programme outline:

08.40 a.m.     Opening speech by MMA Chairman:                   

                        Dr. Kamarudin Ahmad

08.45 a.m.     Introduction by Organizing Chairman

                        Dr. Pagalavan Letchumanan

09.00 a.m.     Making a Diagnosis in Rheumatology : Simplified

                        Dr. Pagalavan Letchumanan

09.45 a.m.     Systemic Lupus Erythematosus : Diagnosis and Treatment

                        Dr. Loh Yet Lin

10.30 a.m.     Tea Break

11.00 a.m.     Rheumatoid Arthritis: The era of Biologics?

                       Dr. Pagalavan Letchumanan

11.45 a.m.     Seronegative Spondyloarthropathy:  The Masala

                        Dr. Loh Yet Lin

12.30 p.m.    Lunch

01.15 p.m.    A Global Epidemic: The Double “O”

                        Dr. Yoga Raj

02.00 p.m.    Treating an Ancient Disease: Gout

                        Dr. Pagalavan Letchumanan

02.45 p.m.    SLE and Pregnancy: What to look out for?

                        Dr. Rajesh Mahendran

03.30 p.m.    Tea Break & The End

World Arthritis Day is on 12/10/2011 and the Arthritis Foundation of Malaysia(AFM) usually organises public forums to educate the public in creating awareness of various musculoskeletal diseases in Malaysia. For the first time in Johor, on behalf of AFM, I will be organising a public forum this coming Sunday 16/10/2011 in my hospital , Columbia Asia Hospital Nusajaya.

We chose 2 very common arthritic problems that the general public faces: Gout and Osteoarthritis. See below for more info on this forum. Admission is free and all those who are staying in JB are welcomed.

Didn’t I say , it is coming. It is official that the compulsory service for Pharmacist will be reduced from 4 years to 2 years ( including housemanship). This was announced today by MOH. If I am not mistaken, the compulsory service for pharmacist was introduced in 2004 due to shortage of pharmacist in the government sector. In just 6 years, they have reduced it back. It was reported in Bernama that 90% of the post in government sector has been filled!! I know pharmacist are now functioning as dispensers in many government hospitals and some klinik kesihatans have 2 pharmacist!

So, the government is now allowing them to resign earlier to enter private market. Another knee jerk reaction for poor planning! Unfortunately the private market is not that great either. Most private hospitals only need 1-2 pharmacist to run the show. Same goes to the retail outlets. So where are these pharmacist going to go? Is this the prelude to stopping dispensing rights to GPs? Once there are a lot of jobless pharmacist out there, the government may just stop allowing doctors to dispense medications and insist on GP clinics to hire pharmacist. Well, doctors are next in line……….. I am already hearing rumours of compulsory service being scraped for doctors.

 http://www.bernama.com.my/bernama/v5/newsindex.php?id=618149

Pharmacists’ three-year stint with Govt reduced to one

KUALA LUMPUR: The requirement for pharmacists to serve a mandatory three years with government hospitals after they graduate has been reduced to a year.

Health Minister Datuk Seri Liow Tiong Lai said the cabinet had approved the decision in early September. It will take effect immediately.

However, he said, the one-year training before the compulsory service would still be maintained.

I am a UK graduate and I’ve been working in Malaysia for almost a year. On my first day, I called my MO by her first name (respectfully) to ask her a question, and she did not answer, so I asked again, and she said to me ‘I would like to be addressed as Dr xxx’. For someone who has been calling all doctors, even my consultants in medical school by their first name, how lame that is, I thought. But I’m used to that now. Just because I am addressing them by their title doesn’t mean that I respect them all of them, especially ones who are obviously empty tins. If I disagree with something, I will say it out.

In Malaysia there is this thing that HO should round early in the morning first, then the MO will round again (which we are suppose to follow and write), then again with the reg and the specialist. I have never encountered anything like this where I studied. There is just so much repetition here. What is the problem with everyone just arriving at the same time and then we do ONE single round together? Are consultants too mighty high to be asking questions or examining patients? Yes, the juniors should know and present the cases, but so should the specialists and the consultants. Here, we come at 6:00-6:30am in the morning to see all the patients, then there will be another 2 or 3 rounds with people more senior than us so we can ‘update’ them patient condition so that they are able to add on their own management plan. Most of the specialist/consultant would just stand at the bedside listen to the juniors present, bombard lots of question, dictate some plans then move on, without even saying a word or looking at the patient. Then when the intimidating boss-like figure is finished, the patient would rush to ask me what had he just muttered before I had to rush off to tail ward round. In the UK, junior doctors come half an hour earlier than the consultant to get the investigations results ready and find out if anything happened overnight/over the weekend, then wait for the consultant to turn up to start the round. If it is a non-consultant round, everyone would get on with the round as a team. There is no such thing as HO to see the patients before the reg. There, the registrars, SHO and HO help each other out so they finish their work as quickly as possible. Isn’t that a much more efficient use of everybody’s time? Once, my nice MO was helping me with a particularly difficult IV line, and another MO asked him ‘why are you doing HO’s work?’ You see the attitude? Don’t get me started on the TDS round. Yes, they do rounds three times a day here (in most specialties), sometimes x 3 due to the hierarchical arrangement as I have mentioned above.

The worst part is having to play the servant for MO/reg/specialist/consultants. In my hospital, HOs have to regularly to go the record department to trace files for the reg’s case presentation/ write up. Last week, my friend had to go to my specialist’s car to fetch a stack of photo frames to her office. In departmental census, the HOs does all the data collection (trawling through the case records) not knowing the end results whilst the boss gets to present and publish. We call patient up to inform op date, cancelled op, rearrange op so often I thought we sounded like a professional telephone operator. You can’t blame me for cursing under my breath whilst performing these stupid errants.

In Malaysia, HOs are unappreciated slaves. Everyone, senior and junior figures in the medical profession, should rethink the way we are doing things here. You may say the practice has stood the test of time but is it really worth wasting so many hours for sometimes so unproductive as three morning ward rounds in a day just because of hierarchy? Is it fair to treat HO as your servant doing your secretarial job? Are MO/Reg/Specialist incapable of occasionally helping your new HO make some referrals or write a prescription or ask for a CT scan, or God forbids, take blood? Are we not in the same boat to make patient better? I foresee that it will take another 10-20 years for us to change the culture, if it ever will. The seniors always have their ‘back in those days’ or ‘you have to learn’ excuses

The above comment was posted in my blog by a houseman. I must say that he was right on certain issues that are ingrained into our system. It is a culture here that you must address a senior by the title and not by his/her name. I know that in western countries, you can call a consultant by his/her name but in Malaysia, you will be considered as disrespectful. It is part of the Asian culture and you just to accept it. It will take many more years to come before it chances. It is the same for all Dato’s and Tan Sri’s. When I refuse to address them as Dato so and so when they come to see me as a patient, they will look at me differently but I do not give a damn. It is not a God-given title for me to address them by the title. At least if you are a Professor or something, I will address them as such. Same goes to the community who are so enthusiastic to make their children a doctor by hook or crook just to get the title “Dr” infront of their names.

Let’s come to the ward round system in Malaysian MOH hospitals. The system that the HO is talking about has been around for many years, even when I was a houseman. In fact, even I use to ask the same questions when I was a houseman. It is really a time-wasting situation. That’s the reason when I became a specialist; I made sure that I am in the ward by 8am every morning unless I am stuck in a meeting or jam. I usually walk into the ward around 8am and wait for the houseman to finish taking blood by 8.15am. By 8.15am I will start my rounds and the houseman must join the rounds by then. It is mandatory for them to finish taking blood by then. My idea is always to finish the rounds by 10-11am so that the houseman and medical officers will have all the time to do what that has been ordered.

Then, when I went to a hospital in Klang Valley to do my subspeciality training, I entered the ward at 7.50am and noticed that I was the only one around!! I asked the nurse where the housemen and MOs are; and they smiled at me. It seems the HO comes at 8am, MO comes at 8.30am and the specialist only comes at 9.30am!! WTH!! Sometimes the specialist comes only after the MO/HO has completed the rounds and starts all over again. Of course, the specialist who does a consultant round has all the right to start the round again BUT I always felt that it is counterproductive. By the time they finish the round will be around 12-1pm and you are just left with another 4 hours to settle everything else! Sorry to say but most of the current specialists in government hospitals are in this category. Majority of the good ones have left the service not due to money but due to frustration with the system. No matter what you do, the system will always frustrate you. As someone said: either you join them or leave!

Now, housemen doing office boy’s job? Well, no matter what you become or what job that you do, you always have to start from the bottom, unless you are self-employed. It is common for all profession. Even fresh law graduates have to work as an office boy when they do chambering. There is no such thing as easy way to learn. You have to go through tough times and even be a slave to become a better person in the future. That’s why you are known as government “servants” ! But of course, I think it is atrocious for the specialist to ask the housemen to do the data collection and tracing of notes for something that the consultant is going to publish. If they do so, then the houseman’s name should be included as one of the author. When I was a houseman, the Head of O&G department challenged me to do a study on maternal weight gain during pregnancy for the 3 different races in the hospital.  I took up the challenge and completed the study just before I completed my O&G posting, which was my last posting as a houseman. On my last day, I submitted the report to him and he was shocked. He never expected me to do it. The data supposed to be presented at the state scientific meeting but I was transferred before that.

I know that not everyone will be interested in academic life but the houseman should take the opportunity to get involved in the study and learn something. I am sure most specialist or consultants will be happy to welcome you into the group. Having said that, I must admit that most of the good specialists and consultants are not in MOH hospitals anymore. That is the sad part! And also, please remember that no one appreciates you in government service. You will always remain unappreciated. Your job is to serve the community, paid by the government/tax payers. Before 1994, there was no such thing as “oncall” allowance and then we were offered RM20 for every call! pathetic.

A 68 year old man was seen in an emergency department of a hospital for chest discomfort. By the time he reached the hospital, he was asymptomatic with no evidence of any ischaemic changes on ECG. However, he was noted to have a glucometer reading of 20 mmol/L. He is a known diabetic on medications. Thus, he was admitted. Before admission, a  branulla/venofix was inserted to his left wrist.

He was admitted to the medical ward and discharged 3 days later. He presented to me yesterday ( 10 days later) with this:

 According to the patient, the swelling started immediately after he was admitted but no one bothered to rectify the problem. In fact, before he was discharged, he spiked a fever but he was discharged the same day after removing the branulla. NO antibiotics were given.

 He is now having florid cellulitis with pus collection/discharge and ultrasound showed an abscess collection. Despite 2 courses of antibiotics by GP, he did not get better.

The case above is just to illustrate how a simple procedure like this can lead to complications. Since I was a houseman I was trained to look at the branulla site during every round. When I did my housemanship, my consultant was a Haematology trainee and most of her patients were on chemotherapy ( 1 cubicle in the ward was allocated for chemo patients). I was taking care of her patients for almost 3 months as she refused to let me change ward! I had to beg her to let me go to another ward for the last month of my medical posting.

Since haematolgist are very particular about infection, I was trained to look out for any possible hospital acquired infection in all the patients. Since then, I have this habit of looking at the branulla in all my patients. In fact, the nurse in charge will get a earful if she fails to recognise phlebitis and I had always made sure my housemen are also trained to look at it as well.

Unfortunately, many of the younger doctors/nurses nowadays does not seem to be bothered with this. The above complication is what you get when you do not identify early phlebitis and remove the branulla immediately. If the branulla has been removed on the day of the swelling, he would not have developed this abscess. In fact, even antibiotics may not be necessary.

So, I hope the younger doctors will learn why they wanted to become a doctor in the first place: to comfort always, to treat sometimes and to do NO harm. It is your duty to make sure the patient walks out of the hospital better than how he came into the hospital. I use to tell my housemen and medical officers that if a patients walks into the hospital, he should not be going out on a wheelchair or 6ft underground!

For the case above, I am beginning to wonder whether he has MRSA infection as he did not respond to 2 courses of antibiotics by GP!

I came across this blog today: http://jimbocyberdoc.wordpress.com/2011/09/09/disowned/. An interesting and short write-up about the current situation of the glut and the problems with shift duties. The situation is only going to get worst. I just completed writing an article for MMA magazine about the situation of oversupply of doctors and poor quality of medical schools which will be published by next month.

I have said this before that if the shift duties are not done properly, it will make the situation worst than before. I like the last sentence written by this blogger “So, if you are sick, come to the hospital at your own risk – you shall be DISOWNED!”  The shift duty may actually deteriorate the continuity of care of the patients. We can already see a lot of half-baked houseofficers who are not interested in taking care of the patients and this shift duties will only give them more chances to take their own sweat time to do their work so that they can dump it to the next person. Please read the comments on this blog above for the said article and you will realise that these problems have already started.

I was also informed by various sources that soon, you will need to apply for a medical officers(MO) post after your housemanship! It seems that the government may only provide post for housemanship on a 2 year contract basis after which you need to apply for a job! Compulsory service will be scraped! So, you’re going to see a lot of jobless doctors running around as I have predicted before. And some said, it will not happen……………..! of course, JPA and all other sponsored students including local public uni students will be given priority. The rest can say sayonara! Being in Malaysia, you can forget about a transparent selection process.

Disowned

Sep9 by Jimbo
Quantcast

Much has been written about the oversupply of new doctors, like this well written article by a concerned medical student: Too many doctors, too few hospitals.

I said in jest to a group of medical students yesterday while taking them for bedside teaching: “If I close my eyes and walk, I’d likely walk into 10 house officers and if I throw a rock, I’d hit 5 of them!”

Actually, at the rate we are going, there won’t be any bedside space left for teaching – right now the hospital where I am working in serves as a teaching hospital to medical students from 1 private university, nursing students from at least 3-4 private and government-owned nursing colleges and physiotherapy students from similar number of institutions. When I walked into the ward in the mornings, I get a feeling that I am walking into a Jusco sale.

The reason I jested with my students was because I was trying to impress upon them the need to “shine and rise above the rest”, because despite the sudden rise of number of house officers, the number of training centres have more or less remained stagnant, likewise with the number of specialists/consultants to train them and similarly with the number of postgraduate places available; and this does not bode well for the nation.

We will (or already have) produce a generation of incompetent doctors who will be a danger to society.

When I came back from Melbourne 2 months ago, I discovered that I had 4 house officers assigned to the 2 cubicles that I usually perform my rounds. These 2 cubicles have 16 beds, giving an impressive ratio of one doctor to 4 patients! Since the beds were not often fully occupied, the ratio was much higher in most instances. There is a medical officer overseeing these 4 house officers and then there is me…so the doctor:patient ratio was indeed very impressive.

At least on paper it was.

I don’t want to go into details but suffice to say, I’d rather have 1 house officer who thinks and analyzes than many who merely act as scribes, penning down every word spoken by the medical officer or by me or what I would term as “palliative doctors” – prescribing Panadol for fever or Benadryl for cough, without much thought on why a patient has fever or cough to begin with!

And to add to the woe, these house officers are rotated between cubicles or wards every TWO weeks making it very difficult for me to train them. By the time I see something positive in them, they would have vanished to the next ward or cubicle!

Frankly I’d rather that house officers stay in a single ward or cubicles for a prolonged period of time instead of being moved around. Like they say, “a rolling stone gathers no moss”; likewise a junior doctor being constantly moved gains no knowledge or skills.

And then last week, the department started the shift system for house officers – basically now, medical house officers work in 2 shifts per day. I am not too clear about the way it works but I believe those who work 3 night shifts would be given the 4th day off being starting the day shift. It’s the ‘knee jerk’ reaction from the powers-that-be as a short term solution to the oversupply of young doctors.

Again on paper it looks good. Shorter working hours for young doctors (no one gives a hoot to the long working hours of more senior doctors), the massive amount of money saved because technically since these doctors are no longer “on call”, they are not paid call claims, and it clears the congestion in the wards.

All very good indeed.It’s a win-win situation, they tell us.

I tell you this is NOT a win-win situation. Now, house officers change places faster than you can say “dysdiadochokinesis”!

The BIGGEST LOSER in this whole fiasco, ironically, are the very ones the health care system was set up in the first place: THE PATIENTS.

Now patients had to content with seeing different doctors every day in the wards, each doctor not knowing the management plan for the patient because with all the shifting and moving, no one will take ownership of the patients!

So, if you are sick, come to the hospital at your own risk – you shall be DISOWNED!

 

I received the following link from a commentor in my blog : http://chronicle.com/article/Corruption-in-Russian-Medical/128200/. I have attached the article for easy reading, below. Even, before this article was published in July 2011, I have already heard about this corruption issues. Generally, most incompetent doctors are somehow graduates from Russian medical schools or Indonesia. Probably Egypt may join the team soon as we are beginning to see their graduates. Of course it is a generalisation as I have seen good students from Russia and Indonesia as well( a minority, I must say). What the article has said below is indeed true.

I had spoken to some housemen from Russia who do not even know how to take a history and examine a patient. In fact, some do not even know many of the medical terms. What they told me was very shocking indeed. It seems most of the international students are placed in the international wing ( I do not want to mention which uni is this). The lecturers hardly come to teach and the students are just left alone to learn by themselves. After 5 years, they are all passed to go back to their respective countries! It is a way for the college to make money and they are not bothered about the quality, same as to what is happening in Malaysia currently. Some will pay to pass their exams! In fact, most of these medical colleges do not even bother what is your entry qualifications. They just take whoever , based on whether you can pay or not! Money talks!

Well, having said that, will Malaysian medical schools end up the same as Russian medical schools? Most likely. We can already see it happening. Almost all medical schools in Malaysia seem to be having a 100% passing rate, especially the private medical colleges. It is an indirect form of corruption. What you need is just money and some basic entry qualifications to get a medical degree. I am still hearing of students with poor SPM/A level results being guaranteed a medical seat by our private medical colleges, despite MMC coming up with a guideline of entry qualifications!! Can MMC really monitor all these hanky panky things that are going around? I doubt so.

Medical education should never be commercialised. That’s the reason in many developed countries, all medical colleges are government-funded with strict entry qualifications.

Now, anyone can become a doctor…………………. as long as you have the money………………….

Corruption in Russian Medical Schools Triggers Uproar

By Anna Nemtsova

Moscow

An exposé in the Russian edition of Esquire has roiled education and health officials here by detailing the corruption at six medical schools. The magazine in April published nine short articles by medical students describing the various ways they can pay professors in exchange for passing tests.

It is not exactly breaking news that bribery exists at Russian universities. According to a May poll of 17,500 people by the Public Opinion Foundation, an independent group in Russia, respondents identified higher education as the most corrupt sector of public life, with traffic cops coming in second. But the news that future doctors, dentists, and surgeons often buy grades instead of actually learning the material triggered an immediate uproar.

Perhaps no institution has been embarrassed more than the I.M. Sechenov First Moscow State Medical University, one of Russia’s best-known medical schools. In Esquire and in discussions with The Chronicle, students described an environment where bribery runs rampant. It is so common at the university, known as First Medical, that students aren’t surprised to see a peer casually hand a professor of histology a thick wad of 1,000-ruble bills.

Vladimir, a third-year student who asked that only his first name be used, given the sensitive nature of the topic, told The Chronicle that before exams, his mother helps him pay $200 to $450 in under-the-table payments to faculty members. In exchange, professors help students “survive the brain-crashing number of tests and exams,” he said.

After the Esquire article appeared, First Medical received a letter from the Ministry of Health that ordered university administrators to meet with the ministry. “Our rector and the rector of three other Moscow medical universities were invited to the Ministry of Health last week to discuss ways of fighting corruption,” First Medical’s deputy rector, Igor N. Denisov, said. He did not specify any concrete proposals put forward at the meeting to curb bribery.

One thing the medical schools did not do is deny the corruption. Mr. Denisov said he and the university’s rector, Petr V. Globychko, have been actively trying to fight the tradition of paying bribes. They have asked students to inform the administration when it happens. During the last two years, two professors resigned after being confronted with accusations of taking bribes, Mr. Denisov said. “We let professors with a reputation for taking bribes know that they are not welcomed at our campus, so they prefer to quit voluntarily,” he said.

‘An Epidemic of Ignorance’

But relying on students to come forward may be a faulty strategy.

During his first year of studies, anatomy seemed absolutely incomprehensible, Vladimir said. His fellow student, Anna, said pharmacology “is threatening to drive me crazy.” For both, the problem of passing difficult courses was easy to solve: The medical students paid $400 for a good grade or $500 for an excellent grade at the anatomy department. Last year some professors in the department switched from U.S. dollar to Euro rates, the students said. “Corruption is like an epidemic of ignorance,” Anna said. “As a result of it, our poor skills will be dangerous for our future patients’ health, of course.”

The degree to which the students openly discuss giving bribes—and their willingness to acknowledge their lack of learning—does concern the university’s administrators. “If I were there to witness a professor taking cash from a student, I would have fallen though the ground from shame,” Mr. Denisov said in an interview at his office.

Mr. Denisov said the core issue was low salaries for professors: 50,000 rubbles ($1,800) is an average monthly salary for a professor at First Medical, which enrolls 13,000 to 14,000 students a year. “That is not enough for those supporting their families,” Mr. Denisov said. He also blames parents for spoiling their children “by stuffing their pockets with cash for bribes,” and schools for poorly educating students, who he compared to Raskolnikov, the Dostoevsky character ready to commit a crime without expecting to be punished.

Most mornings, Mr. Denisov arrives by his modest Suzuki at the university parking lot where students park their Infinity or Bentley luxury cars; some even have drivers waiting in the car until the end of lectures. “I do not understand what else but empty thirst for prestige inspires parents to pay so much money for their students to go to First Medical,” the deputy rector said. “A surgery room is not going to be fun if they fear making a mistake, blood, pain, or emotional stress.”

Corrupt Students Become Corrupt Doctors

Not every student can learn all required information, the deputy rector said with a sigh. First Medical has tried to screen applicants for those who may be unable to handle the difficult course load, but some students say they paid bribes to get into the school.

For those with poor learning skills, the university invented a system of extra private classes. To get a credit, a student has to take about 10 private lessons in a subject and pay the professor for those sessions. Instead of curbing bribes, the system quickly led to corrupt practices. To pass the anatomy exam last year, Misha, another student who prefers anonymity, and eight of his second-year classmates had to take extra classes from their professor. Officially, classes cost about 1,000 rubles, but the professor charged students 2,500 rubles, or $89 per class. “She did not give us any knowledge, just asked us questions for about half an hour, then opened the pocket on her white medical gown, so we could slip in our 50-euro or 1,000-ruble bills,” Misha said. He said he was disappointed that the university management did not fire the professor after Misha and his friends reported her to the university management.

Mr. Denisov said that it is the responsibility of the federal security service to prosecute corrupt professors. The service “has its office on our campus—it is their job to check the evidence of crime,” he said. The leader of the nongovernmental National Anti-Corruption Committee and a member of President Dmitry Medvedev’s Human Rights Council, Kirill Kabanov, said the seeds of cheating and abusing rules are planted in Russian students’ mind by the time they reach universities; as a result, “corruption in medical service is literally killing Russia.” Corrupt medical students grow into corrupt doctors. “The health and social-development ministry has been repeatedly involved in scandals where hundreds of millions of dollars disappear from government purchases each year,” Mr. Kabanov said.

Russia’s Ministry of Health says it does not have data on the extent to which corruption is hurting the nation’s health service, but it says it is trying to fix the problem. Sofiya Maliavina, an aide to the minister of health, said the government is pushing medical schools to provide more practical training to students. What’s more, in February the ministry invested 1 million rubbles ($35,624) to establish a telephone hot line to report corruption in the state medical system. The ministry reports receiving an average of 50 calls a day.

THis is an interesting write-up from Asia Sentinel. Day by day, it looks like our current PM is becoming like our previous PM. Too much rhetoric but nothing much has moved. Too much flip-flops and changing policies. Whatever so-called economic policy transformation that he had promised before seem to be reversing due to pressures within UMNO and certain Malay right groups!! PM and DPM saying 2 opposite things ? Did you realise that? And today’s news: 43% of MRT work bills will be given to Bumi contractors! I can assure you many UMNOputras will be queuing up in front of his office to get this projects! Some how, I feel the MRT project is going to be riddled with problems and delays. Let’s see whether what I say will come true in 5-10 years time! And why the hell they need to demolish all the heritage buildings in China town/Petaling Street for underground tunneling? Is it a way to take over and sell off the prime land from the people who has been staying and working there for centuries?

Enjoy the article below:

There are strong institutional reasons for the lagging performance against its regional neighbors

In the 70 years since World War II ended, East Asian economies, including Malaysia, appear to have largely got performance right. Malaysia was also one of 13 countries identified by the Commission on Growth and Development in its 2008 Growth Report to have recorded average growth of more than 7 percent per year for 25 years or more. Malaysia achieved this spectacular performance from 1967 to 1997.

However, since the Asian Financial Crisis of 1997 and1998, Malaysia’s economic performance when compared to previous decades has been lackluster and most macroeconomic indicators are trending downwards. This was confirmed by Prime Minister Najib Tun Razak himself in the publication on March 30, 2010 of the New Economic Model – Part 1. This was a very brave move but a necessary one by the premier as he acknowledged publicly the failures of Malaysia’s current economic model in order to demonstrate urgency for reforms.

The New Economic Model identifies domestic factors such as weak investor confidence, capability constraints (weak human capital, entrepreneurial base and innovative capacity) , productivity ceilings and institutional degradation and external factors such as a sluggish global economy caused by the global financial crisis of 2008-2009 and the rise of neighbors in the region in contributing to the declining growth trajectory.

If we were to revisit the determinants of growth and agree that proper institutions form the overall structure that determines long-term sustainable growth, then the logical response is to reform Malaysia’s institutional set-up, as it must be the deepest determinant of what is hindering economic growth.

This view is further strengthened as Malaysia’s other deep determinants, geography and trade, are favorable. The country has abundant natural resources, is shielded from natural hazards and is well-located strategically both geopolitically and economically. Malaysia has also benefitted tremendously from being an open economy, especially in the merchandise sector.

The New Economic Model also reports that regional challenges from China, India and Vietnam, etc. are a cause for Malaysia’s declining economic performance. What has changed about these countries? They have all undertaken institutional reforms: China since 1978, India since 1992 and Vietnam since 1986. They are reaping the benefits while Malaysia has stalled in its institutional reforms since the 1990s, regressed in some ways and is suffering from the consequences.

The above points stress the importance of institutional reforms in Malaysia, something that Najib has ironically neglected in his signature policies – 1Malaysia, Government Transformation Programme and Economic Transformation Programme.

According to the Growth Commission report, “…fast sustained growth is not a miracle; it is attainable for developing countries with the ‘right mix of ingredients.’ Countries need leaders who are committed to achieving growth and who can take advantage of opportunities from the global economy. They also need to know about the levels of incentives and public investments that are necessary for private investment to take off and ensure the long-term diversification of the economy and its integration in the global economy…”

Michael Spence, the Chairman of the Growth Commission, elaborated on his extensive experience working with developing countries on growth issues in his latest book by emphasizing two important characteristics for developing countries to ensure long term sustainable growth – the role of political leadership and democratic norms. He suggests four characteristics for governments that are necessary requirements to underpin long term growth:

  1. The government takes economic performance and growth seriously.
  2. The governing group has values that cause it to try to act in the interest of the vast majority of the people (as opposed to themselves or some subgroup, however defined)
  3. The government is competent and effective and selects a viable sustained-growth strategy that includes openness to the global economy, high levels of investment, and a strong future orientation.
  4. Economic freedom is present and is supported by the legal system and regulatory policy

Manifestations of Malay/Muslim Supremacy

Malaysia is classified as a non-democratic state by all international indexes measuring quality of democracy. This is also affirmed in academic circles. During the boom years, Malaysians accepted this tradeoff – restricted freedom for economic growth. Since 1997/98, this has changed as expected. The government has not delivered on growth, therefore the natural demand for reforms and by extension freedom.

There is consensus that Malaysia needs extensive economic, political and social reforms. This is all the more evident IF we agree that institutions are key to long term growth. Also, IF we agree with Spence, these reforms must come from a government with the four characteristics identified above.

Astute observers of Malaysia know the reasons why the present administration and the ones before were unable to make fundamental reforms. This has much to do with the ideology of Malay/Muslim Supremacy as defined by the United Malays National Organization (UMNO) and accepted by large swaths of Malaysians, Muslims and non-Muslims alike.

From the literature we can infer that the ideology of Malay/Muslim supremacy has provided the perverse incentives that have manifested themselves in many ways. The more critical ones are:

  • Institutional degradation: The deterioration in the quality of Malaysia’s institutions, particularly during former Prime Minister Mahathir Mohamad’s years, such as the lack of independence between the branches of government; the politicization of the civil service, producing a culture of risk aversion and a lack of creativity; and the expansion of the non-transparent Government Linked Corporations (GLCs):
  • Crony capitalism: Affirmative action in the name of Malays has become a smokescreen for crony capitalism. Affirmative action is the instrument for rampant elite-based (from all races, not only Malays) corruption. High levels of income inequality in Malaysia in general but more so within the Malay community prove this.
  • Race based affirmative action: Race-based affirmative action in itself is recognized as one of the important reasons for Malaysia’s declining economic performance. Malaysia’s focus on the ex-post equalization of outcomes across ethnicities rather than ensuring effective ex-ante equalization of access to opportunities has had important direct efficiency implications, affecting growth by distorting incentives and thereby the competitive process.
  • Excessive centralization: An interesting institutional feature is the lack of decentralization in the country, which is nominally a Federation and the top-down approach in public policymaking. This is a key disconnect in the reform rhetoric in the ETP and GTP. To strengthen public service delivery, local communities need to be empowered. Fiscal relationships between federal-state-local also demonstrates institutional failure.
  • Feedback mechanisms: Related to Malaysia’s top-down approaches is an almost complete disregard for monitoring and evaluation. As a result there is little feedback from outcomes into policy design. The obsession with centralizing policy-making is also evident in lack of information sharing both within government and with the public.

The need to remove UMNO to create a new “people based ideology”

In relation to competency, the quality of the human capital base in Malaysia is suspect. This is due to the quality of education from preschool through tertiary and on-the-job training. It is linked with ethnicity issues and is exacerbated by the outflow of high-skill individuals and affected by the inflow of low-skill labor.

There are not only problems on the supply side of the market for skills, but also on the demand side, where firms may not be competitive enough to offer higher wages. The market for skills itself is also problematic in that the price mechanism does not work adequately and this is where wage-setting issues play a role.

A bigger and more important challenge than competency is the question of internal competition. This is quite distinct from external competitiveness, on which front Malaysia has scored relatively well in the merchandise sector given its stage of development and the nature of its manufacturing processes which are still dominated by competitiveness identified by low cost rather than high value.

Internal competition refers to the allocation of certain factors including labor, capital, land and product markets. Internal competition works well when there is good governance, openness and transparency. It relates to the need for deregulation, liberalization and competition policies especially in key areas such as government procurement and the activities of GLCs in the domestic economy.

All of these are also needed to produce effective competition for good ideas and good policies as well as competition in the political arena. This of course challenges the basic idea of meritocracy and affirmative action in Malaysia.

To reform these will ostensibly mean changing Malaysia’s embedded incentives and institutions. This definitely means undoing the manifestations of Malay/Muslim supremacy.

Can UMNO implement these reforms?

My hypothesis is that the present leadership in Malaysia within the Barisan Nasional framework is incapable of institutionalizing reforms as the present leadership does not meet the criteria set out by Spence for a simple reason – its ideology. This ideology that overrides and at the same time influences all other norms, rules, conventions, habits and values is the ideology of Malay/Muslim Supremacy.

As the Prime Minister of Malaysia always comes from UMNO it will be impossible for him or her to undo the cornerstone ideology of his/her political party and its adherents in the Barisan Nasional, which includes Malays and non-Malays.

The logic above is discussed extensively in the political science literature. To summarize, the Malay/Muslim ideology provides psychological and material benefits to its adherents. This makes it a potent force for groups that rely on this ideology. However, since it is deeply embedded, it is also extremely difficult to counter when needed. Malaysia’s present institutional equilibrium is a reflection of the strength of the adherents of Malay/Muslim supremacy, known by its Malay-language slogan Ketuanan Melayu.

There are many examples to illustrate Malay/Muslim supremacy but the one that is cited most often as holding back Malaysia’s economic reforms is affirmative action, the most comprehensive in the world. It has by inference been touted as the one of the key reasons for Malaysia’s declining economic performance although causality has not been explicitly demonstrated.

Supporters of affirmative action argue that Article 153 of the Federal Constitution provides the Bumiputeras the right to this extensive affirmative action. However this is factually incorrect.

Article 153 of the Malaysian Federal Constitution states that:

153. (1) It shall be the responsibility of the Yang di-Pertuan Agong to safeguard the special position of the Malays and natives of any of the States of Sabah and Sarawak and the legitimate interests of other communities in accordance with the provisions of this Article.

(2) Notwithstanding anything in this Constitution, but subject to the provisions of Article 40 and of this Article, the Yang di-Pertuan Agong shall exercise his functions under this Constitutions and federal law in such manner as may be necessary to safeguard the special position of the Malays and natives of any of the States of Sabah and Sarawak and to ensure the reservation for Malays and natives of any of the States of Sabah and Sarawak of such proportion as he may deem reasonable of positions in the public service (other than the public service of a State) and of scholarships, exhibitions and other similar educational or training privileges or special facilities given or accorded by the Federal Government and, when any permit or license for the operation of any trade or business is required by federal law, then, subject to the provisions of that law and this Article, of such permits and licenses.

In more simple words, the Federal Constitution limits affirmative action to placement in the civil service at the Federal level, scholarships and permits and licences for Bumiputras and only if necessary and in a reasonable manner by the Prime Minister who advises the Yang diPertuan Agung.

Does the Prime Minister have the power to revoke or reform affirmative action policies?

Yes, he does. Malaysia is a constitutional monarchy where the monarch reigns but do not rule. Article 153 is subject to Article 40 and Article 40 states that the Yang diPertuan Agung must act on the advice of the Cabinet.

40. (1) In the exercise of his functions under this Constitution or federal law the Yang di-Pertuan Agong shall act in accordance with the advice of the Cabinet or of a Minister acting under the general authority of the Cabinet, except as otherwise provided by this Constitution; but shall be entitled, at his request, to any information concerning the government of the Federation which is available to the Cabinet.

The decision to continue or reform affirmative action policies and the attendant institutions in Malaysia lies solely at the prerogative of the Prime Minister along with his colleagues in Cabinet as stated in Article 40.

With power centralized in the Executive (Cabinet), and with the Prime Minister already having six Ministers of 31 from the Prime Minister’s Department in the Cabinet, and with the Prime Minister himself holding two portfolios (Prime Minister and Finance Minister I), and legitimised by the Constitution (Article 40), the Prime Minister should on all counts, be able to implement these reforms without much difficulty.

Yet he has been unable to do so for the simple reason that the Federal Constitution may be the law of the land but it is clearly not the supreme power/ideology in Malaysia. The supreme power/ideology is the primacy of Malays/Muslims as defined by UMNO. Hence the Prime Minister may have de jure power to reform, but he does not have de facto power. This power resides among the Malays and non-Malays who support Malay/Muslim supremacy and the current institutional set-up.

Until and unless this supreme ideology of Malay/Muslim supremacy is removed, Malaysian politicians will be constrained in making the necessary institutional reforms to move Malaysia towards long term sustainable growth.

(Greg Lopez is a PhD candidate at the Crawford School of Economics and Government, Australian National University. A longer scholarly version of this appeared on The New Mandala.)

The last time when I wrote the Part 3 of this topic, some of the commentators were saying that I am only talking about the problems/mismanagement of the government sector and not much about the problems in the private sector. Well, I had written about the problems caused by General Practitioners and soon I will be writing about private hospitals in more detail. The issue that I am trying to bring up is not whether a proper diagnosis is made or not. Most of the time, if the attitude of the doctors, especially the frontliners are good, simple diagnosis like what I had mentioned before would not have been missed. It all boils down to attitude. If you become a doctor just to get a paid job and not with the interest of the patients at heart, then you might as well leave the job! In this part, probably my last part, I will expose few more simple but dangerous errors that was made by the frontline doctors.

A 36-year-old lady had abruptio placenta and an emergency LSCS was done in a government hospital. Unfortunately she lost the baby (IUD). She was discharged 3 days later. 3 days after discharge, she presented with fever, diarrhoea and lower abdominal pain. She was brought to the A&E department of the same hospital 2 days later. The doctor in the A&E department just asked her a few questions and discharged her with some medications ( treated as a simple AGE). The doctor did not even touch the patient!! The next day she went back to her GP who referred her to me. On arrival she was toxic looking, febrile with tender guarded lower abdomen. She was immediately referred to our O&G consultant who diagnosed her to have huge rectus sheath hematoma, infected. She recovered well with antibiotics and conservative management.

A 20-year-old Vietnamese lady was admitted to a general hospital with LIF pain of 2 days duration. She was admitted the night before to the Gynae ward but discharged the next morning! It seems only a medical officer saw the patient the next morning and discharged her with TCA 6 weeks while she was still in pain. She was immediately brought to our hospital. An ultrasound showed huge left Ovarian cyst which was already leaking. An urgent laparoscopic surgery was done.

A 30-year-old lady was referred by GP to a government hospital’s gynae clinic to rule out ectopic pregnancy. She had LIF pain with positive UPT. The patient waited at the clinic from morning to about 2pm before seeing a doctor. She was not sure who saw her but she was told that it is all fine and asked to come back in 6 weeks. She went back to her GP who referred her to my hospital. Ultrasound by our Consultant showed a left ectopic pregnancy which was already leaking.  A similar case happened few months ago where the patient collapsed at home just the day after she was seen in gynae clinic to rule out ectopic. An urgent laporotomy done at the same hospital for ruptured ectopic pregnancy!

In my Part 2 and 3 , I had mentioned that one of the problems in government hospitals is the lack of proper supervision from good senior consultants. These situations seem to be getting worst day by day. This coupled with poor attitude of the junior doctors is only making the situation worst. If you look at the 3 cases above, even a good medical student knows that something is not right with these patients. Come on, a patient who just had LSCS 3 days ago comes to you with fever, diarrhoea and lower abdo pain? I am sure even a medical student should be able to think of the causes even before you put your hand on the patient. The 2nd and 3rd case above also demonstrates that some doctors are not taking their job seriously. They seem not to be interested in their patients and just wants to keep their load down or shall I say ” don’t want more workload and headache”!

As a doctor, we should always be very suspicious of anything that a patient complains. I use to tell my Monash students before that we should work like a police officer who is investigating a crime. A detail history and a good physical examination will give you a diagnosis almost 80% of the time. A high index of suspicion is needed to make any serious diagnosis.  If not, you are of no difference compared to a medical assistant or nurse!!