It has been 3 months since I wrote my Part 2 of this topic where I discussed about the public healthcare system of this country. Now, I will move to the private healthcare system.

One of the first component of the private healthcare system of this country are the General Practitioners or simply known as GPs. The private hospitals started to appear in the 1980s. Thus, I will divide this topic into 2 parts: GPs and private hospitals.

General Practitioners (GPs)

In Malaysia, anyone can become a GP after completing 4 years of compulsory service with the government. GPs were the first private healthcare service providers in this country. They were highly respected by the community as almost equivalent to a specialist. In 1970s and even 1980s, specialists in various disciplines were a rare species in our healthcare system and thus the community considers GPs as their family specialist. In fact GPs did a wonderful job in providing simple primary care services to the general public as they were open till at least 10pm daily and there were not many government polyclinics then. When I was small, I still remember my father bringing me to see a GP for simple upper respiratory tract infections. Consultation and medications will just come to about RM7-10, which is quite a big amount those days!

It was quite a profitable business for doctors to become a GP then. Whatever people say about being a GP, it is still a business to earn money and a living. Almost all GPs in 1970s up to 1990s were doing very well and were earning quite a big sum of money. There were no regulations to monitor them except for professional conduct which was monitored by Malaysian Medical Council. They were also allowed to store and dispense medications without a pharmacist and trained nurses. This situation is still the same up to today. However, when more and more doctors started to open clinics in a town, competition began to set in and this has changed the scenario of GPs currently.

The competitions for GPs are not just from their fellow GPs and private hospitals but also from the government polyclinics and recently, the 1Malaysia clinics. At one point of time many doctors were leaving the civil service to start their clinic immediately after completing their 4 years compulsory service but the situation is slowing down gradually. Why is it so? Firstly, the government has come up with the Private Healthcare and Facilities Act 1998 which was implemented from 2006. This act makes sure that every private facility is built based on certain requirements, like the size of the door, toilet, consultation room etc etc. Before you can even start the clinic, you need to submit the floor plan to MOH for approval. You can only start your renovation after they had given the approval. After completing your renovation, the ministry’s unit(UKAPS) will come down to inspect your clinic to make sure that you comply with the act. Any non-compliance is punishable under the law. Only then you will be given the permit to start your practise.

Secondly, the income of many GPs is gradually dropping due to severe competitions. I know of some GPs who had closed down their clinic and doing locums instead, both privately and in government clinics. Some GPs are only earning a net profit of less than 10K per month. Remember, an income like this by working from 9am till 10pm daily is pathetic to say the least. There are many factors that will decide on whether you will be successful or not. Your location of the clinic is one of the factors. Many town areas are quite saturated. The best option will still be rural and semirural areas. Most successful GPs are from these areas as well as in housing areas which are far from government polyclinics/private hospitals. Your communication and clinical skills is the next factor.

Unfortunately, due to severe competition, some black sheep’s began to appear in this system. Many of these GPs were just interested in making money and nothing more. They refuse to upgrade their knowledge and manage their patients accordingly. In Malaysia, unlike other countries, you can renew your Annual Practising License (APC) without needing any CME points. In many other countries, you need a certain minimal number of CME points before your APC is renewed. Even Dr Mahathir and Dr Chua Soi Lek can still get their APC despite not practising as a doctor for so many years. As long as you are a doctor, you will get your APC!

 I had seen many GPs mismanage common medical conditions like asthma, diabetes and hypertension. Even when they know that they can’t do anything much, no referral is made to a specialist in either public or private sector. This is because they do not want to lose the patient to another physician and thus reducing their income. I had seen patient who are diabetics for many years but not a single blood test was done for renal function, fasting blood sugar, HBA1c etc etc. Only glucometer readings are done. Many will turn out to have renal impairment. Many at times, even a diagnosis of hypertension and diabetes is not properly made. I had seen many patients presenting with hypoglycemia with treatment started by GPs and turn out to be non-diabetics. I still see obese diabetic patients being started on sulphanylureas when the standard guideline says that Metformin should the first line treatment. These are bread and butter diseases that should be managed properly by GPs but not so in this country due to poor continuous medical education and the non-existence of compulsory CME points for renewal of license. I know GPs who are selling medications including sleeping tablets over the counter, asthmatics still being managed with tablets and daily steroids etc etc.

Many years ago, I did locum in a GP clinic. For every patient, irrespective what is the complaint, 3 medications must be given including 1 antibiotic!! Even if the patient complain of headache or bodyache! If you don’t do it, the staffs in the clinic has been ordered to add the medications! How unethical! This was one of the reasons why I never did locum after that! I had only done a total of less than 30 GP locum sessions in my entire medical practise so far. It is becoming increasingly difficult to see GPs who really cares for a patient.

Future Direction

When the national health care financing system is introduced in the future, GPs will be forced to do postgraduate degree in family medicine like in many other developed countries. As you may be aware that in many other countries, you can’t become a GP without a postgraduate degree or proper training. Being a GP itself is a specialist.

Soon, GPs will also lose the right to dispense medications. This is already in the pipeline with full support from the Malaysian Pharmacist Association. Only MMA is still fighting against it to safeguard the lifeline of many GPs. Selling medications really brings a lot of profit for these GPs.

MOH is encouraging GPs and soon to be GPs to do Diploma in Family Medicine for a start. Academy of Family Physicians of Malaysia has started this programme since 2009 and the first batch has graduated. It is an online course. They can go on to do FRACGP for another 2 years after that.

I got nothing against GPs but many black sheep are destroying the reputation and status that these doctors had once upon a time. Once respected doctors are now going down the drain. Many, finding it difficult to survive. That’s the reason why you don’t see many new clinics opening recently or doctors leaving civil service to open GP clinics……………… Frankly speaking, government polyclinics have better facilities to manage chronic diseases then GPs but the doctors got not much time to spend with the patients and there are no proper supervision of junior doctors.

Next: Private Hospitals……………..

Dr Andy Teh, Principal of Teh & Associates, presented his paper on physician resource planning at the National Conference on Redefining & Reforming Medical Education, held at the Putra World Trade Centre, Kuala Lumpur, on 21 July 2011.

The following is an excerpt of Dr Teh’s paper entitled:

“Eradicating incompetent medical graduates, leveraging oversupply of housemen, avoiding substandard doctors and nurses:- Renegotiating and laying the foundation for national healthcare reform.”

The Problem: An Oversupply of Doctors in Malaysia

More than 6,000 fresh medical graduates enter the Malaysian health workforce annually; about 4,000 from local medical schools and the rest from overseas institutions. This is a remarkably large number for a country with a population of about 28.5 million. In recent years, the alarmingly high rate at which fresh graduates have entered the workforce has caused concern in several quarters (see a list of blogs at the end of this article) because:

• The number of internship positions approved by the Malaysian Medical Council exceeds the capacity for appropriate supervision and training. In other words, there is an insufficient number of qualified senior physicians to oversee the training of housemen (interns)
• Inadequate supervision of housemen, leading to:
  • Potentially compromised patient care at the 63 training hospitals approved for houseman training
  • Failure to meet the training objectives of housemen, which has negative effects on the health system both in the short- and long-term

An often cited reason for the rapid escalation in physician production is a shortage of doctors in the country’s public sector and target population-to-doctor ratios of 600:1 by 2015 and 400:1 by 2020.

The government has not put forward any other argument that explains the methods used to forecast the country’s requirement for physicians.

Moratorium

Despite the government’s adamance that there is no surplus of doctors in the public sector, it imposed a five-year moratorium on medical programs in December 2010. However, the moratorium does not restrict the number of students that existing medical schools can accept—this seems to defeat the purpose of the moratorium.

Issues

There are several problems with the current approach to physician workforce planning:

1. Lack of strategic planning. Health workforce planning should be strategic, i.e. take a long-term view, say, 25 years (as opposed to a 10-year view) and rolling. The use of short-term targets often yield unsatisfactory results, especially when coupled with quick fixes (as appears to be the case).
2. Inadequate consideration of factors that influence workforce effectiveness other than physician density. Density, as measured by a population-to-physician ratio is merely one of the determinants of workforce effectiveness. The other main factors that influence effectiveness are: skill mix, distribution, and quality. In other words, a health workforce with the desired population-to-doctor ratio may still fail to deliver the best possible outcomes. Further, if the mix of health workers (doctors, nurses, pharmacists, and other allied health staff) is not optimal, production of health services might be inefficient, i.e. a greater number of health services at the same quality could be achieved for the same cost or the same number of health services at the same quality could be achieved at a lower cost. The relative excess of health workers, especially doctors, in the urban areas and their relative deficit in rural areas are masked by an aggregate population-to-doctor ratio. In fact, the maldistribution of physicians may be exacerbated with the massive influx of doctors. The overall quality of fresh medical graduates may also be compromised due to lack of supervisory capacity during their two years of housemanship/internship.
3. Mismatch between the supply of housemen and postgraduate medical education capacity. The critical shortage of qualified senior physicians to oversee the internship of housemen is a serious issue.

A Possible Solution

Any strategy to address the current issues requires a tailored and collaborative approach. Indeed, the World Health Organization (WHO) states that:

A blueprint approach will not work, as effective workforce strategies must be matched to a country’s unique history and situation. Most workforce problems are deeply embedded in changing contexts, and they cannot be easily resolved. These problems can be emotionally charged because of status issues and politically loaded because of divergent interests. That is why workforce solutions require stakeholders to be engaged in both problem diagnosis and problem solving.¹

Projecting Future Requirement for Medical Personnel

In addition to density, skill mix, distribution, and quality, other factors should be considered when projecting the future requirement for physicians, including:

• Demographic trends
• Effects of economic development
• Affordability of healthcare services
• Demand for healthcare services
• Regional and international comparisons
• Recommended standards, e.g. WHO, World Bank
• Past trends
• Expert opinion

Working Group

Due to the disparate interests and considerable number of issues at hand, we propose a Working Group, responsible for high-level planning as well as executive oversight, be set up. This Group would consist of at least the following parties:

• Policy makers and health planners from MOH, Ministry of Higher Education, Malaysian Medical Council and National Accreditation Board
• Representatives from the medical schools
• Representatives from the public and private healthcare sector, e.g. Association of Private Hospitals of Malaysia

The implementation of national plans will require sufficient political will.

We suggested several ideas that may form part of the overall strategy to address the issues mentioned above. These may be classified into two major categories:

• Tactics that improve the quality of postgraduate medical and nursing training
• Tactics that control the number of fresh graduates entering the local workforce

Tactics that improve the quality of postgraduate medical and nursing training

According to WHO, “(s)trategies to improve the performance of the health workforce must initially focus on existing staff because of the time lag in training new health workers.”

In brief, we suggested tactics to:

• Build education capacity
• Harness the value of supervision
• Leverage opportunities for “non-clinical” education, for example, in the areas of public health, clinical research, risk management, and also training methods that address the new paradigms of care, e.g. from acute tertiary hospital care to home-based and team-driven care.

Tactics that control the number of fresh graduates entering the local workforce

• Continuous reevaluation of future requirement for health workers.
• Controlling the number of Malaysians being admitted and graduating from medical schools. This can be achieved through:
  • Creation of a body to oversee the quality of medical education, the functions of which may be similar to the Council on Medical Education in the United States.
  • Introduction of standards to improve the quality of medical education, e.g. requiring a basic university degree before acceptance into a professional degree program (as in some parts of the word), establishing minimum expectations in a medical curriculum, and a minimum number of full-time medical faculty.² Following the Flexner Report² which advocated these changes (and more) in similar circumstances to the present in Malaysia, a large proportion of medical schools in the United States merged or closed, and the average physician quality improved significantly.
  • A standardized examination for all newly graduated medical practitioners entering the workforce.
  • Review of requirements for admission and graduation.
  • Review of school recruitment practices.
• Manage student and parent expectations.

Conclusion

The issues related to the oversupply of physicians in recent years can only be overcome by an approach that is more responsive to the health needs of the population, and that incorporates planning with a longer-term focus, appropriate planning methods, data-based decision-making, better coordination among the various stakeholders, and a shared intent to improve the safety and quality of patient care.

References

1. World Health Organization. 2006. World Health Report 2006: Working together for health. World Health Organization. Retrieved July 7, 2011 from: http://www.who.int/whr/2006/en/.
2. Flexner A. Medical education in the United States and Canada: a report to the Carnegie Foundation for the Advancement of Teaching. New York: Carnegie Foundation for the Advancement of Teaching, 1910.

Commentary About the Oversupply of Doctors

• A doctor too many!
• Bernama—Health Minister: No Surplus Of Doctors In Public Sector By 2015 (Read the commentary below the newspaper article.)
• Houseman Glut : Why should we be surprised?
• For Future Doctors: Housemanship Glut

In my 2^nd part, I wrote about the rot that begins from the top. Well, that is the reality. Lack of supervision and guidance from GOOD consultants are lacking and this has deteriorated the entire civil service. In fact it is reaching a very dangerous level and the patients are suffering on a daily basis. These coupled with attitude problems among the junior doctors is only making the situation worst.

Over the past few weeks, I have been very busy in my hospital. I had blogged about it few days ago with few complicated and rare cases being admitted to my ward. One of the commentator asked why these complicated cases are going to private hospitals rather than government hospitals. First of all, a patient who goes to whichever hospital do not know how complicated their disease is until the doctor diagnoses the condition. I am not talking about collapsed patients who need CPR etc. All ambulance calls are taken to the nearest government hospitals and thus most of these cases are seen in government hospitals. The rest just goes to whichever hospital nearby when they are ill. Unfortunately, our frontline doctors are becoming very complacent, coupled with poor training that they get during housemanship, diseases are being missed!

A 25-year-old patient goes to a GH emergency department after being unwell for 1 week. He was having fever, nausea, vomiting and abdominal pain. He saw a GP for 2-3 times and then the GP referred him to the hospital as he was unable to eat at all and appeared dehydrated. He was observed in the A&E observation ward for 2 hours with a drip and was discharged when the Full Blood Count was normal. The next day he came to see me. From the history and by just looking at him, I knew what was the diagnosis:  Hepatitis! He was jaundiced and the liver was palpable 6cm below costal margin, tender as well. His liver was so nicely palpable that even a medical student should be able to feel. It seems that the doctor in the A&E department did not even examine this patient and just told him that it is not Dengue!!

A patient who is a known diabetic, well controlled, presented with 3 weeks history of fever, nausea, vomiting and upper abdominal pain. She was seen 2 weeks prior at a district hospital and admitted for 2 days. She was discharged with no diagnosis while the patient was still having the pain. When she came to see me, she appeared septic with tender, guarded RT hypochondriac region. A diagnosis of cholecystitis was made and confirmed by USG abdomen. In fact, she also had a stone at cystic duct with mild pancreatitis. She was transferred to the GH for further management of empyema of the gallbladder (her gallbladder was clearly palpable). Again, according to the patient, the doctor did not even examine/feel her abdomen during her 2 days stay in the district hospital!

The case of Malaria that I mentioned in my earlier posting was also seen by 2-3 GPs and twice at a government clinic before coming to see me. That’s the reason why the patient refuses to go back to GH despite not having any insurance.

A 31-year-old primigravida at 34 weeks of gestation presented with acute onset of palpitation and chest discomfort. ECG showed sinus tachycardia of about 120/min with S1Q3T3 changes. SpO2 was 94-96% under RA. She was admitted and observed. Since she was unable to afford any further investigations, a d-dimer was sent and came back 3 days later as raised. Her sister is known to have some coagulation disorder and was on heparin during all her pregnancies. She is unsure of the diagnosis of her sister. We transferred her to the nearby GH as a possible case of minor Pulmonary Embolism for further investigations. When she arrived at the GH “bilik saringan” (this was about 5 -6 days after the incident of palpitation), some of the doctors (housemen and even junior MOs) were laughing at her. It seems that she does not look like a patient with Pulmonary Embolism! Since our O&G consultant has already spoken to the registrar on-call, she was admitted to the ward. She was kept for 3 days in the ward and nothing much was done except a repeat D-Dimer and ABG. Since the repeat d-dimer was negative and ABG was normal, she was told that it is unlikely Pulmonary embolism and no further investigations were done! She was also referred to the cardiology MO who just ask 1 question to the patient “is it you who they suspect PE?” When the patient said “Yes”, the MO just took the folder and went to the table and her diagnosis: “ No Pulmonary Embolism”.

This case clearly illustrates the type of doctors we have nowadays. It is the attitude that stinks! All this happened without anyone knowing that the patient is actually a senior staff nurse at a private hospital in KL. She was horrified with the attitude of the doctors especially the cardiology MO who did not even asks her the history of what actually happened.  D-dimer can be raised in pregnancy but the very fact that the repeat test 6 days later was normal indicates that the first episode may as well be a minor pulmonary embolism. This coupled with the history of her sister makes the diagnosis of Pulmonary embolism a possibility and a high index of suspicion is important. Unfortunately, even the blood test for thrombophilia screen was not sent. The patient took AOR discharge and came back to our hospital despite not having any money.

A 45-year-old lady presented to a GH emergency department with acute onset of inability to talk. She was crying while she entered their emergency department. She was observed in the observation room and some blood test was done. After about an hour, she was discharged with a diagnosis of  ? depression. She was brought to see me the same day and she was crying whenever I ask her any question but she is able to understand what I am trying to say. She can reply by writing or with some slurred speech. This is a clear case of Expressive Dysphasia, likely secondary to a stroke. She is crying because she could not talk/respond to anyone! An MRI showed infarct at Broca’s area. She was also noted to have Hypertension and Diabetes. I just saw her almost 2 months after the incident and she is now able to talk and explained what actually happened at the GH’s emergency department. The attitude of the doctors in the emergency department that she mentioned really makes me feel sad.

To be continued…………….

The statement “Housemen need to practise their specialties at district level as there is a lack of specialists in district hospitals,” he said after witnessing the signing of three Memoranda of Agreement between the ministry and Universiti Tunku Abdul Rahman (Utar) here, yesterday.” really made my day!!

If what the reporter has written is the truth, then I am speechless, in thinking what type of Health Minister this country has! Since when housemen became specialist and can provide specialist services in district hospitals? We already have some below par medical officers mismanaging patients in these hospitals without supervision and now we are going to let Housemen to manage this patients? As I said earlier, our current DG is just a puppet to the politicians. Our previous DG had better guts to say NO but was thrown out! I will let the email below to say the rest:

Hi Doc,

 The muppets at MOH have done it again! (see linked article above) How do they solve the glut of HOs? Simply create more HO jobs! MOH have just accredited 22 district hospitals to complement the 41 hospitals where housemanship can already be done. The problem is, these 22 district hospitals do not have enough specialists! Where are they going to get them from? You can hire 500 from Pakistan/Bangladesh/Egypt but there are no facilities at these hospitals for specialist services (e.g. theatres, beds, radiological equipment, etc).

 Liow Tiong Lai justifies it like this: “Housemen need to practise (sic) their specialties at district level as there is a lack of specialists in district hospitals”. IS HE MAD? How can they ‘practice their specialties’ when there are no specialists to supervise these house officers? Are the MOs going to supervise them? It will be a case of the blind leading the blind.

 I am seriously at a loss for words. There is no doubt that many district hospitals in Malaysia should be upgraded to allow specialists to practice there. But this cannot practically happen overnight. Bed spaces and operating theatres do not magically manifest themselves. It takes months to years to plan service upgrades. Once all that is in place, especially the specialists themselves, then HOs can work there. Problem is, the govt has already shot themselves in the foot by allowing all these med schools to mushroom and also sponsoring hundreds of students to med schools overseas (1,000 to Egypt alone each year).

 One more thing: LTL mentioned that the current capacity is 6500 housemen, increasing to nearly 10,000 with these district hospitals. Personally, I don’t believe that number because it probably includes departments with 60-100 house officers when there should be only 20-30. Even if we accept his figure, the number of house officers per year is conservatively projected to be 6,000-7,000 by 2014, which means we will need 12,000-14,000 houseman places. Good luck.

 p.s. Feel free to post my rant on your blog

63 hospitals to train housemen

By QISHIN TARIQ
qishin.tariq@thestar.com.my

 

KAJANG: A total of 63 hospitals are now available to universities as a training ground for medical students, said Health Minister Datuk Seri Liow Tiong Lai.

The ministry has added 22 district government hospitals to complement the 41 hospitals currently hosting housemen undergoing practical training.

Liow said the 63 hospitals would be able to host nearly 10,000 housemen, up from the current capacity of 6,500 housemen.

“The chosen hospitals will be able to give better service with the addition of more staff and in return provide facilities to train medical students.

 Good practice: Utar nursing lecturer Liew Siew Fun giving a briefing to Liow along with others during his visit in Kajang yesterday.

“Housemen need to practise their specialties at district level as there is a lack of specialists in district hospitals,” he said after witnessing the signing of three Memoranda of Agreement between the ministry and Universiti Tunku Abdul Rahman (Utar) here, yesterday.

The agreements would allow Utar degree students in nursing, physiotherapy, biomedical science, biochemistry and microbiology to be placed at one of 13 government hospitals or eight health clinics.

Meanwhile, Liow said the Traditional and Complementary Medicine (TCM) Bill would not be postponed any further as all the relevant parties, including TCM associations and practitioners, had been consulted.

He said once the bill was passed, the industry would be registered under a council and regulated, just like doctors.

“Practitioners can be held liable if they do not give proper treatment to their patients,” said Liow, adding that the Act would also cut down on fly-by-night TCM practitioners.

Ayurvedic, homeopathic and traditional Malay medicine practitioners would also be regulated under the Act.

Liow said the Act would not only regulate and enforce the industry but also allow the ministry to officially fund research for evidence-based TCM treatment.

Just when everyone is talking about the 5 year moratorium of medical colleges, here comes another advertisement in the Star:

Royal College of Medicine Perak has a long history. It started off as Sheffield University in 1998, the first branch campus of a foreign university. Unfortunately it failed due to financial reasons as well as the fact that Sheffield was unable to receive GMC accreditation. It was then taken over by the Perak state government and used UM’s curriculum and offered UM degree. Subsequently it was taken over by UniKL. As I have said earlier, the 5 year moratorium is of no use as the existing medical colleges will continue to expand and recruit more students. This advert just proves what I had said. By having another collaboration, the university can increase their student intake, which means that they will have 2 sets of students, one following the local UM degree and another using the twinning programme with Salem university!!

The below article also appeared in Star on the same day:

Second degree in medicine
By ALYCIA LIM
educate@thestar.com.my
STUDENTS who have completed their first degree in the science field can soon pursue a a graduate degree in medicine with Perdana University Graduate School of Medicine (Pugsom), which will open its doors for the first intake of students in September.

Adopting the full model of the Johns Hopkins University School of Medicine (Johns Hopkins) in Maryland, the United States (US), the institution will be using the “Genes to Society” curriculum, which encourages students to explore the biological properties of a patient’s health within a larger integrated system of social, cultural, psychological and environmental variables for its four-year doctor of medicine (MD) degree.

At an information session on the institution recently, Pugsom dean and chief executive officer Prof Dr Charles Wiener explained, “The benefits of going into medicine after the first degree is that students would have a greater sense of altruism, and they would be more prepared for the course.

“Because of their maturity and academic preparation, the curriculum can also be more demanding, and allows for more research to be done.”

Prof Wiener says that the university would only have an intake of about 100 students a year to ensure the quality of graduates.

He added that the graduate school, which would be the first in Malaysia to offer a US structured medical education, was a separate entity of its own.

“While we are working very closely as partners with Johns Hopkins, Pugsom is a Malaysian university, not a branch campus,” he said.
However, he said, half of the initial teaching staff at the institution would come from Johns Hopkins.

Despite its campus size of 130 acres (52.6ha), the institution would only have an intake of about 100 students a year to ensure the quality of graduates.

“If we have to, I think 125 students per intake is about as high as we go, because beyond that you cannot treat every student as an individual,” Prof Wiener said.

He added that anyone with a first degree in a science-related field could apply.

However, as a baseline, applicants are required to sit for the US Medical College Admission Test (MCAT).

“At the moment, we are quite flexible with the applications because we understand that this system is new in Malaysia.”

He added that the applicant’s background also played a big role in terms of gaining admission to the institution.

“We are not looking for someone who has all the A’s but has no experience and cannot relate to people. This is because as a doctor, you would be working with people all the time,” he said.

The institution’s main campus and teaching hospital are scheduled for completion in 2014.

In the meantime, students will be placed at the interim campus in Serdang.

The students will be doing their medical placements in 2013 in five hospitals allocated by the Health Ministry; namely Putrajaya Hospital, Tuanku Ja’afar Hospital (Seremban), Bentong Hospital (Pahang), Likas Women and Children’s Hospital and Beaufort Hospital, both in Sabah.

The Johns Hopkins University has campuses in China, Singapore and Italy. This is the first foray for the School of Medicine outside the US.

During her visit to Malaysia last year, US Secretary of State Hillary Clinton and Deputy Prime Minister Tan Sri Muhyiddin Yassin witnessed the signing of collaboration, affiliation and licensing agreements between the Academic Medical Centre Sdn Bhd, Johns Hopkins University and Johns Hopkins Medicine International.

It is interesting to note that the dean himself has officially announced that Perdana University is NOT a branch campus but merely a collaboration!! So, why is this university offering a local, non-recognised degree for RM 1 million? I must say that John Hopkins’ is NOT stupid. It is our PM who is making a fool out of himself!

Have anyone wondered where the money to support this university is going to come from? The tax payers! Just see the advert below which was just released by JPA:

PROGRAM PENAJAAN PELAJAR PERUBATAN KE UNIVERSITI PERDANA

” Saudara/ saudari adalah calon yang telah di senarai pendekkan oleh pihak Jabatan Perkhidmatan Awam (JPA) untuk mengikuti Program Penajaan Pelajar Perubatan JPA Ke Universiti Perdana bagi program Universiti Perdana (UP) – Perdana University Graduate School of Medicine (PUGSOM) / Universiti Perdana (UP) – Royal College of Surgeons in Ireland (RCSI) bermula semester pengajian September 2011. Program UP-PUGSOM adalah bagi calon lepasan Ijazah Sarjana Muda Sains. Manakala program UP-RCSI adalah bagi calon lepasan STPM/ Matrikulasi/ Asasi/ A-Level /AUSMAT/ IB.

Sehubungan itu, sekiranya saudari berminat, saudara / saudari adalah dipohon untuk melayari laman sesawang http://www.perdanauniversity.edu.my/ bagi tujuan permohonan kemasukan ke Universiti Perdana terlebih dahulu sebelum memohon penajaan Biasiswa Kerajaan (JPA). Manakala bagi permohonan penajaan Biasiswa Kerajaan (JPA), saudara / saudari boleh melayari laman sesawang http://esilav2.jpa.gov.my/ untuk mengetahui garis panduan, syarat-syarat dan kriteria permohonan bagi Program Penajaan Pelajar Perubatan JPA Ke Universiti Perdana. Permohonan Biasiswa Kerajaan (JPA) adalah bermula dari 27 Jun 2011 sehingga 4 Julai 2011.

Ingin diingatkan bahawa hanya calon-calon yang layak dan memenuhi syarat-syarat serta kriteria permohonan sahaja akan dipertimbangkan untuk mendapat tajaan Biasiswa Kerajaan (JPA). Pertanyaan mengenai program tajaan boleh dibuat dengan menghubungi talian 03-8885 3704 (10 talian) pada setiap hari bekerja mulai jam 8:00 pagi hingga 5:00 petang atau e-mel di alamat lspamc@jpa.gov.my bermula 27 Jun 2011.”

Sekian, terima kasih

Hazwan Nizam Bin Fadil
Penolong Pengarah
Unit Penawaran Latihan Sebelum Perkhidmatan
Bahagian Pembangunan Modal Insan
Jabatan Perkhidmatan Awam Malaysia

Basically, JPA or should I say, our PM’s department has come up with special scholarships for any students who are accepted to Perdana University!! So, what private initiative is our government talking about. It is still our tax payers money being pumped in via a different pathway! Remember, it is RM 1 million for 1 student and for a degree which is not even recognised anywhere!!
God bless this country. Will it end up like Royal College of Medicine Perak? Time will tell.

Today was a bad day for me. I must say it was the weirdest day with few complicated/rare cases being admitted under my care. The day started off with a 15-year-old boy with Juvenile Idiopathic Arthritis , followed by an interesting case of PUO. A 55-year-old gentleman with 2 weeks history of intermittent fever(every 2 days) associated with chills and rigors. A very classical picture of something tropical: Malaria! Yes, the malarial screen was positive for Plasmodium Falciparum. Many feel that malaria has disappeared from our radar but no so. I just heard that a patient died in JB hospital a few days ago due to Malaria. A disease that we are still fighting for centuries. The worst part: I heard Quinine is running low in stock in government hospitals and the distributor is also out of stock. There are some newer drugs that are being used to treat Malaria like artesunate, artemether etc but it is still not widely used nor available.

Then came an interesting patient who took some chinese medicine for Gout and developed rashes after about 1 month (delayed hypersensitivity reaction). The rash was typical of photodermatitis:  maculopapular rash with blister that appeared only on sun exposed area of face, neck, forearm and lower leg. I am very sure the chinese medicine contained Allopurinol, the commonest drug to cause allergic reaction including Steven Johnson’s syndrome.

While I was seeing these patients, came a case of Thyroid Crisis to our ER. 25-year-old lady who had defaulted anti-thyroid medications for 2 years presented with high-grade fever, agitation, restlessness, palpitation and shortness of breath. Her HR was 150/min with ECG showing sinus tachycardia. Her T4 level was > 100, beyond what our machine can measure. She was resuscitated and transferred to GH as they are unable to sustain the cost of ICU management.

At the same time, came another patient who had a simple fall at home and subsequently noted to have mild left-sided weakness. No loss of consciousness was noted. GCS was full with a power of 4+/5 over the left side and he was admitted as a case of stroke from ER. A CT scan later showed a RT subdural haemorrhage(2.4cm thick)  with cerebral edema and slight midline shift of 0.4cm. I had to transfer him to GH neurosurgical unit for evacuation.

These cases really kept me busy today. I must say that since I joined private sector, I have seen many interesting and weird cases. Just last month I had 2 young patients( 28 and 31 years old) with severe hypertension (BP around 260/160!). One turn out to be bilateral renal artery stenosis and the other Conn’s syndrome!

Just last week I had a patient with advanced Systemic sclerosis with atonic dilated esophagus throughout the entire length. She was unable to swallow even fluid. I referred to my Gastroenterolgy friend who did the OGDS and found food particles in her throat! A barium swallow done at another centre showed the contrast entering/aspirated into the lung! We actually got a bronchogram!

 What a day…………………….

Lately, I am hearing and coming across many issues that really make me feel that our healthcare system is going down the drain. Yesterday I publish the first Part of this topic, taken from an MO’s blog. The attitudes of current doctors is simply so glaring for anyone to miss. In fact almost every day I am hearing news from my ex-hospital regarding the house-officer’s situation and how many patients have succumbed due to poor basic knowledge of the frontline doctors. The entire system seems to be collapsing day by day.

 I have talked enough about the mushrooming of medical schools over the last few years. In fact, I first wrote about these and the quality of doctors produced way back in 2006 when I wrote an article in MMA magazine. Many said that I was over exaggerating. The same people who told me that, agrees with me now. Many of these medical schools were only interested in making money and not bothered about the quality. They just dump the quality issue to Ministry of Health. Unfortunately, MOH can’t do much. Once you are a HO, you have already been accepted as a civil servant and any action need to follow proper procedure under the General Order (GO). It will take years before any action is taken to any civil servant unless it is a criminal charge. I remember one of my ex-Pengarah of a hospital told me that he wrote tonnes of report about a missing Attendant, but after 4 years, his name is still on the employee list, of course his pay was stopped. I also had a Cardiologist who left almost 6 years ago but his name is still in the list because he has not officially resigned. Thus, if you follow the procedure, they have to take disciplinary action before terminating him!! WTH! The entire system is just too much of bureaucracy and procedures.

 When I was active in SCHOMOS from 2002 till 2006, we use to bring up the issue of retaining senior specialist in Ministry of Health. One of the main reasons is to train junior doctors in service. Without experienced senior consultants and specialist, what guidance do the junior doctors get? Unfortunately, MOH and JPA were not interested. As for JPA, doctors are just another bunch of government servants who do not need any special attention. Thus, slowly all the senior specialists just left the system not only because of poor pay/promotion but also due to frustration with the system. Many felt that they could not do the best for the patients due to various limitations and poor support from the government in developing certain field. Political influence and bureaucracy is another factor.

 This left the system with poor guidance from “good” senior consultants. It is sad to see that most of the remaining senior consultants and heads of departments are also known as “world travellers”. Most of the time they are either not around or going for conferences all over the world sponsored by pharma companies. I know one HOD who stays at home most of the time and only comes for ward-rounds about 1-2 times/month and receive JUSA C salary. I heard she got JUSA B recently! The best part, she is also the head of a subspeciality training committee! In MOH, once you become the head of a department, you will remain so forever and no one can touch you. In fact, even after you retire, you can be reappointed as HOD under contract basis. About 3 years ago, I did suggest that HOD post should be rotated every 3 years like in Singapore in my MMA article after returning from Singapore General Hospital. I heard that our ex-DG did issue a circular for HOD rotation but unfortunately there were tremendous amount of objections from the current HODs, for obvious reasons I presume!

 In 2006, after much discussion and countless number of paperwork’s by SCHOMOS with JPA and MOH, finally locum was legalised. We should thank our ex-Minister of Health Dato Seri Dr. Chua Soi Lek and our ex-DG for making this a reality. Unfortunately, it is clearly being abused and misused currently. The locum should be after office hours and weekends when you are not on-call. However, we have consultants and HODs doing locum in private hospitals during office hours and leave the wards to the junior doctors. I know of one HOD from East Malaysia doing locum almost on a weekly basis in 2 different hospitals in West Malaysia!! Not sure whether he even does anything in his so-called resident hospital. There are even some consultants who does locum outside during office hours and send their patients to the government hospital for certain procedures and even to collect medications. So, the patient sees this particular consultant in a private hospital and gets all the procedures and medications from the government hospital. The consultant gets the fee!

These HODs and senior consultants in government hospitals are misusing the system to the maximum. Of course, not all of them. I know some who are really dedicated and work hard but they are becoming a minority species now. Those who misuse the system know that the hospital will still run and there are junior specialist, medical officers and houseofficres to take care of the patients. This is why there seem to be a lot of mismanagement/misdiagnosis happening in these hospitals nowadays. No proper guidance from senior consultants!  And what can you do about it? Nothing! Everyone covers everyone. The Pengarahs of the hospitals are not bothered as they don’t want paperwork. The juniors will not complaint as their SKT marks depends on the HOD. The good junior specialist will also get frustrated with the department and eventually leave the service! And so it goes into a vicious cycle of mediocrity…………………….

Next: The rot from the top to the bottom……………………

I found this interesting article from a fan of mine’s blog, Dr Simon: http://simonsim.wordpress.com/2011/05/27/houseman-stress/#comments. I find it rather amusing and at the same time don’t know whether I should cry. Infact I had mentioned all these in my blog before. Please read the case examples below. Soon, I will write more issues about the standards of our doctors and the future direction that our public healthcare is taking.

Houseman Stress..??

27 May

I did not realise that MMC has come up with a minimum criteria and qualifications for entry into medical schools last month. I came across the criteria over here

Well, even though it is commendable but I wonder how are they going to monitor this for the 33 medical schools in Malaysia and hundreds overseas. In many countries, it is compulsory for the medical schools to give the details of their student’s entry qualifications to their respective medical council. We are just too late but better late than never!

One of the main reason why the government came up with “No Objection Certificate(NOC)” many years ago was because the Ministry of Education realised that there were many unqualified students being accepted into medical schools in countries like India, Russia and Indonesia. But now we know that the NOC is a big joke! I have seen many with poor SPM results being given the NOC, usually done by the agents. Some even falsify their SPM results to cheat the Ministry.

I noticed that under this circular by MMC, it is stated that the students need to fulfill both the SPM and the Pre-U qualifications criteria in order to be accepted into medical schools ( the word ” IN ADDITION” is highlighted”). Foundation in science courses are still being recognised even though I feel that a lot of hanky-panky things are happening in these colleges with no proper standardisation. I feel that MMC should have just limited their Pre-U courses to a few internationally recognised courses. What about MARA sending their students to Egypt without the need for Pre-U courses? Will MMC take any action or practise double standards as usual?

I wonder how are they going to monitor almost 4000 students who will be recruited by these medical colleges annually. If NOC can be faked, what more in this case! But this will definitely put a lot of stress to the medical schools.