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Here goes another flip-flop!! As usual our government who is famous for flip-flopping policies had done it again. After so much hype on this Medical Qualification Exams(MQE), finally the government has decided that it is not a popular idea after all, to get votes!! Why is cabinet making a decision on this? IT should be MMC!! MMC should be a free body to monitor the standards of doctors practising in this country. In most countries, their medical councils are independent bodies and they are NOT influenced by any politicians. Politics should never be brought into the education system. Politicians are only interested in taking care of their seats and thus any unpopular policies will not be considered. Furthermore, most of their children are studying overseas anyway and they usually seek treatment from overseas or private hospitals. Go to hell with the rakyat who will be getting the treatment from many underqualified doctors that are being produced/trained nowadays.

Somehow, right from the beginning I had a gut feeling that the government will not implement this. This is because they are still sending thousands of students under MARA, JPA, JAKIM and Majlis Agama Islam sponsorship to various countries in the world. What will happen if these students fail the MQE exams? It will reflect badly on the government and the amount of money spent will obviously go to waste. Thus, the easiest way will be to abandon the common MQE. I heard that this was one of the reason why our ex-DG was unceremoniously dismissed early this year. Our current DG is a YES man unlike our ex-DG who is a “quality” man.

BUT wait a minute, is there are catch here. Our great health minister says that they must still complete their Housemanship? Hmmmmm, I mean, everyone knows this right! Either our Minister is talking nonsense as usual OR it means that there is no guarantee that you will get a housemanship post in the first place! So, if you don’t get a post for housemanship, you can’t get a job or work as a doctor. Of course, JPA and other government sponsored students(including local university grads) will be given priority. What happens to the rest? When that time comes, either they will introduce a common exam to get a job or the rest can simply say SAYONARA……………………..

Common exam plan axed, but medical graduates still need to complete housemanship

By ALYCIA LIM
educate@thestar.com.my

Over the last few months I received a couple of info and concerns regarding Occupational Health specialist training. Previously, in order for you to become a Occuptional Health Specialist, you need to do the 4 year Master in Public Health ( Occupational Medicine) in UM, UKM or USM. However, I was informed that beginning last year or 2009 intake, this programme has been removed and another programme known as DrPh ( Doctor of Public Health) has been introduced. This is a 3 year programme where you need to publish at least 2 papers in international journals to graduate. Before entering this programme, you need to do 1 year of Master’s in Public Health. If you do not complete DrPh, you will not be known as Public Health Specialist and not eligible to receive specialist allowance.

Previously, there use to be Master’s in Public Health:  MPH ( occupational Medicine), MPH ( epidemiology) MPH ( Hospital Management) etc etc but all these has been removed and everyone will just be known as Public Health Specialist with DrPh. I find this rather backwards in planning. Most of these Public Health Specialist will just end up doing administrative work in Ministry of Health as they will be lumped together. How will MOH decide who will function as Occupational Health specialist and who will function as epidemiologist? I am not sure what actually happened and why did they make these changes. Who are the people involved in the discussion and was everyone consulted? Oops, forgot, we are in Malaysia.

NIOSH do offer courses to become Occupational Health Doctors but NOT a specialist. Many GPs and Medical Officers are doing this 1 week course and calling themselves Occupational Health Doctor!! The government does not seem to be paying much attention to the importance of Occupational Health Specialist. Probably, that’s the reason why we are seeing so many industrial accidents in our country. In most industrialised countries, occupational health specialist plays an important role in preventing any accidents. The laws are also very strict in occupational safety. As usual in bolehland, something major has to happen before the politicians start to act. Probably they are not bothered as most of our factory workers are foreigners from 3rd world countries!  Talking about developed and high income nation by 2020? Poooodah…………………

Below, I have attached the 2 emails that I had received over the last 2 months concerning the frustration that has occurred among the budding Occupational Health Specialists:

Email 1:

THANKS for taking time to blog.
Ur experience and sharing are both invaluable and interesting.
I am interested to take up Occupational Medicine as part of the specialized field under Public Health. However, the feedback I got from seniors are very shocking.
For the benefits of other students and readers.. I shall share this:

1) There is no more route to become Occupational Physician in Malaysia besides the OHD course by NIOSH as the MPH(Occ Health) has been removed and replaced by DrPH.
Our most established Uni Malaya is no exception.
DrPH is a license to be a PUBLIC HEALTH Specialist NOT a Occupational Physician.

2) Since MOH has upgraded MPH (OH) to DrPH…the standard is totally different from those days. It is NO LONGER attachment at work site….factory, DOSH, SOCSO….etc…
but GUESS WHAT???  Need to do Public Health Research work in the span of 3 years including publishing papers in International Journals. Uni Malaya is pushing the candidates to the max….even the supervisors are helpless having to meet the KPI. Quite a number of candidates are unable to get approval from their supervisors for research grant given that the failure to publish the papers by the DrPH candidate would further reduce their subsequent research grant of the lecturers.

3) Was told that only 3 local uni have Occupational Health Unit: UM, UKM, USM. However, regardless which Uni you go, DrPH will NOT qualify you as Occ Health Physician.
OHD offered by NIOSH remains the ONLY way to be a Occupational Health Doctor in Malaysia. It is a short course preferred by GP looking for panels from Multinational companies…. 

4) Whether this field can progress in Malaysia is another issue. Many if NOT all companies in Malaysia engage Occ Health service merely to adhere to the law…not so much to safeguard the safety and health of the employees.

5) It is high time to rebrand public health services beyond health promotion and health education. Who is going to advocate that? Besides CDC, Epid, Outbreak control…..can public health doctors do more? Besides Needlestick injury…can Unit Keselamatan Pekerjaan do something more…?
Whether it is in clinical or public health….it really takes someone to make a CHANGE to the old system in order to serve the public better…

THANK YOU !

Comment 2:

Hi Dr P,
Firstly I am really happy and ‘lucky’ to come across your web page. It is really informative and rich in substance. Thank you so much Dr P.
I am currently pursuing my doctorate in public health (by default) in one of our local unis. I wish to stress at this point that my area of interest was and will always be Occupational Medicine. Unfortunately our country doesn’t recognize this field as a sub-specialty nor occupational physicians in the clinical aspect. Most of them end up in some state/district health office as public health doctors confined to administrative duties. To make matters worse certificate courses being conferred by NIOSH (9 day courses!!) to GP’s have subsequently resulted in ‘questionable’ credibility of occupational health doctors out in the field. Initially there was a MPH(occupational Health)-4 yr programme offered by UM and USM, unfortunately now they have so called ‘upgraded’ it to a doctorate programme in general public health. Most of us were aghast with the MOH’s abrupt overnight decision to transform the MPH(OH) into a Public Health Doctorate programme. End of the day we get conferred a Public Health Specialist status which sounds good on paper but prospect of becoming credible a OH physician becomes hampered. I am keeping my options open in Australia and New Zealand on practicing OH in their setup. If you have any info on my taking another accredited OH degree or practicing OH in another country who may really appreciate my services pls be free to let me know.

Thank so much Dr P

Ex-paulian- DR B 

Hmmm, I wonder how?  This appeared like the first statement from our new DG since he took the office and I find it rather amusing. Year in and year out, there are thousands of Master’s applicants who are rejected. This year, I was informed that the number of seats for local Master’s programme will be increased to 800, all disciplines included. BUT at the same time, the number of graduates is increasing exponentially. In fact, he has rightfully said that the number of new doctors will be 4500 this year and will continue to increase as 50% of our 33 medical schools have yet to produce their graduates. So, what is 800 compared to 5-6 000 doctors finishing housemanship soon. I also heard that they are planning to increase the number to 1000 seats by 2015. At the same time, would this increase in the number of Master’s post maintain the quality? We can already see the quality of Master’s graduates declining over the last few years due to lack of proper supervision by senior academics.  We have Master of Surgery graduates who can’t operate! I just had a bad experience with a surgeon who could not even do a simple herniorraphy( complicated by bladder injury, recurrent hernia in 1 week etc) and diagnose breast cancer.

Getting into Master’s programme is also becoming very much dependant on who you know rather than merit. If you have strong cables, your chances are better. And don’t forget the quota system, not only based on race but also based on certain allocation for certain universities under the lecturer training scheme. Unfortunately, as I had said earlier, the only option for anyone who wants to become a surgeon is via the Master’s programme. As for Internal Medicine, pediatrics and O&G, you still have MRCP, MRCPCH and MRCOG to fall back upon. FRACGP is another option for those who wants to do Family Medicine.

Post graduate education is going to become very competitive soon and I can assure you that many people is going to be frustrated and rejected. This is when they will curse themselves for becoming a doctor. DG’s statements does not make sense because it is not that the doctors DO NOT want to become specialist. It is the availability of post and the standards need to be maintained. We can’t make any tom, dick and harry as a specialist by just giving them a cert. I just hope that the government will not make Master’s programme  as a specialist mill just like our 33 medical colleges!

Young docs urged to specialise

 So, here you are! I remember quite some time ago that I did mention about this issue in my blog. I remember saying that what Najib had promised 1 year ago that all top scorers will be given JPA scholarship remain to be seen.  And now he is saying that he never promised that all will get scholarship to do degree courses and overseas courses. Personally I know that it will never happen as there is always a quota system to follow, no matter what 1Malaysia crap that Najib talks about. Of course most of the complains seem to be coming from the non-bumiputeras compared to bumiputeras. This is simply because most of the bumiputeras who do well are in MARA colleges and boarding schools and will almost always receive either JPA or MARA sponsorship. I also feel that JPA and MARA should stop giving scholarship to SPM leavers. Everyone should do STPM, Matriculation or A-Levels before even applying for scholarship. Only after these Pre-U courses, a student should be assessed for scholarship. I had seen many who did well in SPM but flopped in STPM/A Levels. In fact, looking at our standards of SPM exams now, I doubt the quality of the As!

On another note, I still feel that JPA and MARA should stop sending students to overseas. The government seems to be promoting Malaysia as an education hub etc etc and talking about world-class education but at the same time sending all our top students to overseas universities. Does this make any sense? Only in boleh land! Most countries DO NOT send their top students overseas. They keep them in local universities and make their local universities world-class.

PM: Govt did not promise overseas scholarships to all top students

KUALA LUMPUR: While the Government promises scholarships for all top students, not everyone will be sent overseas, said Prime Minister Datuk Seri Najib Tun Razak.He said the Government was committed to giving Public Service Department (PSD) scholarships to SPM students with results of 8A+ and better.“We didn’t promise that everyone will get overseas scholarships. This is what the public did not understand,” he told reporters here yesterday.Najib said students given scholarships for diploma and matriculation courses were still eligible for degree-level scholarships.“We will guarantee to sponsor students with a degree scholarship. Some people misunderstand that the sponsorship will stop at the diploma level and not be extended further,” he said, adding that the scholarship issue had been discussed with various groups, including MCA, MIC and Gerakan.http://c.brightcove.com/services/viewer/federated_f9?isVid=1&isUI=1

In a statement, PSD said students were chosen according to criteria approved by the Cabinet in 2009 and agreed to last year.

It said it had received 16,900 applications this year.

It said due to limited places and competition, candidates unsuccessful for overseas scholarships were offered courses in local varsities.

The department said 58.8% of overseas scholarships were granted to Bumiputra students while the rest were for non-Bumiputras.

Najib also said the Government would study the National Economic Council report on the electricity tariff review.

On reports that the increase had already been decided, he said: “We will see first. I cannot say anything.”

Najib said the subsidy rationalisation study was not about reducing subsidies but about reducing its rate of increase.

“The subsidies are increasing from the current RM12bil to some RM20bil. This means we have to find an estimated RM8bil, which is not a small sum,” he added.

I really find this report in The Star today (2nd page) as a big joke and our PM does not seem to know what he is talking about !! Come on, ” the university’s opening would send ripples through the region and be a “phenomenal lure”, adding that it would also attract students from as far as the Middle East and the Indian subcontinent. I mean, really , does he know what he is talking about ?

First of all this is NOT John Hopkins University. It is Perdana University and the degree offered is also from Perdana University with a small caption saying ” in collaboration with John Hopkins University”. Thus, it is NOT an internationally recognised degree. So, how in the hell does this university going to send ripples through the region and be a “phenomenal lure”!! I wonder!

Secondly, it has not even been accredited by the Malaysian Medical Council but the government is willing to send students under JPA scholarship !! WTH!! it is like forcing MMC to accreditate the medical school by hook or crook.

Lastly, I thought this university suppose to be a graduate medical school, meaning that you need a basic degree before enrolling into their medical programme. May I ask how SPM leavers going to enter this medical school with JPA scholarship without having a basic degree? Am I in some dreamland ? Unless you are talking about JPA scholars post basic degree, which is rather unlikely.

I seriously think Najib does not know what he is talking about. Medical schools are different. Untill today, Monash Malaysia is not even recognised in Singapore. I can assure you, Perdana University will also be the same. Having a collaboration with John Hopkins does not change anything. In US, everyone need to sit for an entrance exam irrespective where you graduate from.

Just face it, John Hopkins is here to make money and to benefit their research projects by using patients from Malaysia and the region who are still naive about medical research unlike in US. And our local private medical school under the name of Perdana University is also here to make money. Whose money? tax payers money! I can assure you that most of the students will be JPA or MARA sponsored. Building grandiose buildings does not mean anything without good human resource. Where are they planning to get the academics from, other than pinching from the nearby medical schools!

Please read Page 19 of this Berita MMA(Jan 2011) on an interview with CEO of Perdana University http://www.mma.org.my/LinkClick.aspx?fileticket=Ev5%2bl9i9XNM%3d&tabid=70

PSD students among 100 in first intake for Johns Hopkins

WASHINGTON: The first intake at the Malaysian campus of world-famous teaching and research medical institution Johns Hopkins University will be in September with 100 students.

I was informed today via my blog by a senior houseofficer that shift hours may be introduced for houseofficers as one of the measures to overcome the overcongestion of doctors in wards!! It seems that our new DG has picked certain hospitals to run a pilot project to see whether it will work. The person who gave me this info asked for my comment and thus I thought it is better that I write about it as a fresh blog posting.

Even though I am not totally surprised with this move, there are pros and cons in introducing shift work duties. Whether this system will work, depends on the size of the hospitals and the total number of housemen in each discipline. Usually there will be 3 shifts; am, pm and night shift. In big hospitals such as JB hospital which has 8 medical wards of 30-40 patients each, you will need at least 4 housemen for each am and pm shift followed by 1-2 housemen for night shift. This means a total of 10 housemen/ward with an additional 2-4 housemen to cover for the off day (which is given for the housemen who does 2 continuous night shift). This works out to be 112 housemen per medical department!! Currently, as far as I know, the total number of housemen in JB medical department is about 50. Of course, with the current increasing number of production of doctors, we may reach the magic number of 100 housemen per department within the next few years. For smaller hospitals which has only 2-4 medical wards of about 40 patients each, the number may be adequate to start shift hour work. However, it is not going to be an easy task. We must also understand that not all wards are active and admitting patients all the time. So, it is going to be very difficult to coordinate this shift duties.

Working shift hour means passing over the management of the patient to another housemen every shift. This will definitely cause a lot of problems in the continuity of care of the patient. The responsibility of the housemen will also reduce, making the doctor more complacent. The housemen who is not interested in being a doctor( you are seeing a lot of these nowadays) , may just take his own sweat time to do all his work so that he can pass over the problems to the next housemen who takes over. This will go on and on untill the patient may not get the treatment that he needs. Politics will become the main issue among the housemen. The hard-working ones will continue to suffer and definitely it will be more difficult for the consultants to monitor these housemen as they will keep changing every shift. The medical officers will begin to complain as they will end up doing all the work but they will not be doing shift work. I feel that in order to introduce shift hour duties, the entire team should change, from housemen to medical officer to consultants, like in some countries. Only then a proper shift duties can be introduced without compromising the care of the patient. This is impossible at our hospitals and with our current system. Introducing shift hour work during housemanship will also compromise the training of the housemen. Less working hours with less exposure to emergencies.

Furthermore, working shift hours means you are NOT entitled for “On Call” allowance. Currently, with housemen required to do 10 “on-calls” per month, this adds on another RM 1000-1200 per month to their salary. Indirectly, shift hours means less responsibility, less work and definitely a pay cut. If these system is successfully implemented in all hospitals, which I am sure will happen sooner or later when the glut reaches a umimaginable level, the JPA would not hesitate to stop the “Critical allowance” of RM 750. Another pay cut , a total of RM 2000/month!!

There is also going to be a lot of headache to each department in organising these shift duties, especially those departments which needs housemen in running outpatient clinics. I wish the department heads, best of luck. As usual, the instruction always come from the top without prior consultations with the people on the ground, the typical Malaysian style!!

 So, here you are! As I have been saying over the last 1 year, with 33 medical schools in the country we will achieve a ratio of 1: 600 by 2016 and 1: 400 by 2020. We should also not forget about the foreign medical graduates from various countries in the world. Of course, those students who are going overseas for medical educations from 2012 onwards (if the amended medical act is tabled in Parliament by this July), will have to sit for an entrance exam upon returning home. This will be used as a filtering mechanism. After achieving the target (too fast, too soon) , what’s next?

So, for those who did not believe what I have been saying about jobless doctors, please pay attention. It will become a reality. The number of graduates will increase exponentially from now onwards. Almost half of these medical schools have not produced their graduates yet. Furthermore, most of these medical colleges have not achieved their maximum capacity. For example, Monash is targeting 150 students intake by 2012 compared to 100 now. Newcastle is targeting 180 students compared to 40 students in their first batch (currently in year 3).  So, the existing medical schools will continue to increase their intake , if not they will not be able to make any profit.

The worst is yet to come when all these doctors are going to curse themselves for being a doctor. The postgraduate market is very much limited and the private sector is becoming very saturated. Most GPs are not doing well either. I was told that the latest survey showed that only about 30% of GPs are making net profit of more than 6K/month! So, if you are in for the money, please forget it and choose something else rather than wasting your hard-earned money in doing medicine. Put the money to good use. You will never get back what you had invested, trust me!

The government will not be able to provide job to all graduates by 2016/2017. They may introduce an exam to filter out some students. Or you will be asked to serve rural areas for years and you will never be able to say NO. Some graduates may end up in pharmaceutical companies or as paramedics like what we have seen in countries like Thailand, Vietnam and India.

This 5 years freeze is not going to make any difference. God Bless…………….

Five-year freeze on new medical courses effective immediately

By ALYCIA LIM

For Future Doctors: Malaysian Healthcare System for the Dummies Part 2

 Time flies! I didn’t realise that it has been 2 months since I wrote the first part of this topic on 28/02/2011. Well, I think I had given enough info regarding the public primary healthcare system and it is time to know more about the hospital based public health care system.

 I will divide this topic into 2 parts which consist of district and general hospitals.

Public Hospitals

1)      District Hospitals

Almost every district has a government hospital. Each of this hospital is equipped with 2-7 medical officers, some even as low as 2-3 medical officers, especially in rural areas of Sabah and Sarawak. There are 2 types of district hospitals: with and without specialists.

 In some bigger districts like Segamat and Kluang in Johor or Kuala Pilah in Negeri Sembilan, there will be at least 1 specialist in each basic discipline. These hospitals are also equipped with Operating Theatres to perform minor surgeries. There are also some district hospitals which may function as a general hospital such as Muar/Batu Pahat/Seberang Jaya/Teluk Intan et etc.

 However, most of the smaller District Hospitals are manned by Medical Officers, mostly who had just completed their housemanship. Almost all of these hospitals do have basic diagnostic capabilities such as routine blood investigations, basic X-ray imaging except Ultrasound and facilities to do Forcep and Vacuum delivery. As such, it is presumed that any MO who is posted to these district hospitals should have the competency to diagnose and treat common medical conditions. This is where some major issues arise. There are practically no senior doctors to supervise you or to teach you any procedures, except an MO who is probably at the most 3-4 years senior to you. You may have Visiting Consultants from the nearest general hospital on a monthly basis to run a clinic and to see some non-urgent referrals. Any case that the MO feels cannot be managed in these hospitals, need to be transferred/referred to the nearest general hospital. However, you need to realise that whatever necessary procedures or treatment that need to be done has to be done immediately before transferring the patient as the journey may easily take 1-2 hours in an ambulance!

 There are also certain limitations for doctors who are working in a non-specialist based district hospitals. This is mainly concerning the drugs that a MO can prescribe as I had mentioned in my Part 1 of this topic. Only drugs that are listed as List B and C can be prescribed by an MO. No list A drugs can be prescribed which includes many antibiotics and antihypertensive drugs.

 In smaller district hospitals, only 1 MO is “on-call” each day and during this “call” you need to cover the whole hospital, including the emergency department, wards and labour room. Usually, the medical assistants and nurses will do most of the necessary early management before calling you. In a busy district hospital, it can really be very stressful. Imagine, while you are attending a case in emergency department, the labour room calls you to do a vacuum/forcep delivery? It is basically a one man show during the night and you need to put whatever you had learned as a HO to good use. This is the reason why housemanship is such an important posting in Malaysia as immediately after that you can be thrown to a district hospital to run the show. Remember, you are dealing with lives and can’t afford to make mistakes!

 Some district hospital, especially those in Sabah and Sarawak are situated quite deep into the interior that you need to do certain surgeries including Caesarean sections, acute abdomen surgeries etc. Usually the anaesthesia is given by Medical Assistants’ trained in giving anaesthesia. Thus, it is important for doctors who are going to be posted here to know how to do certain surgeries.

2)      General Hospitals

 Every state has a general hospital. It used to be known as Hospital Besar but over the last 10-15 years, the names were gradually changed reflecting the state’s monarch. Each of this hospital is usually well equipped with all basic specialities. Some of the hospitals also have subspecialties including cardiology, neurosurgery, gastroenterology etc. They are also well equipped with diagnostic laboratories and imaging such as CT scan and even MRI.

 Most of this hospital are overcrowded and congested with patients. Each ward can have between 40-60 patients at any one time. These are also the hospitals that are used to train housemen and postgraduate students. The workload is extremely high and stressfull due to patient load and lack of specialists. The standard of care is definitely not up to any international standards but can’t blame the doctors. Imagine receiving 30-50 new admissions in just 8 hours when you had not even finished the day’s ward round. Of course, this is in reference to general medical wards but the situation may be better in smaller disciplines. The clinics in these hospitals are also another “mad house” or shall I say “fish market”.

 You may find some General hospitals being more relaxing than the other. This depends on the state and the number of big hospitals that are available. For example, in Perak, you have 3 big hospitals with specialist service namely Taiping, Ipoh and Teluk Intan which dilutes the number of patients.  However, when I say more relaxing, don’t assume that you can shake legs and relax! Most of the time, the patient load is almost the same in most general hospitals but the doctor load varies. Some popular hospital may have better number of doctors compared to others. For example, most hospitals in Klang Valley have adequate number of doctors but same can’t be said about Johor Bahru or Sabah. The maldistribution of doctors is a major problem in Ministry of Health where cables and strings are used by certain people to prevent themselves from being transferred out. Thus, you will find many hospitals in Klang Valley being well equipped with doctors so much so, some of them can even go missing in the afternoons. I will discuss more about this in my last part.

 Next………………….. Private health care system