Saturday, May 8, 2010

Why Malaysia Gov Can't Retain His Doctors

Just read this from TheStar online, a doctor who served the country for 2 decades but left the system finally. I totally agree with him though I just serve the country for merely 5 years. Read it after the jump.


Why we left and why we will continue to leave...
Posted by: MS Mohamad

I read an interesting article today about a few prominent figures addressing their concern over the increasing UKM and UM medical graduates who have left the country to continue their medical practice overseas.

After reading the news for 3 times, I called a very close friend, an MD (UKM) graduate to ask his opinion on how the news might have affected him. He has been working in Singapore for more than a decade as a Consultant Surgeon with a certain sub-specialty

"Why be a slave in your own country, when you are a king in another?" He replied.

Indeed, if anybody would want to find a reason why all of us left, either after housemanship, after being a specialist, or even after sub specializing, and now, even prior to doing housemanship, they need not look at our payslip, or the wealth that we have gained overseas, but only to the Medical System that has been rotting in the ignorance and politic-based stupidity that Malaysia has been well-known for (in the medical field).

I have served the system for nearly 2 decades of my career, waiting for it to improve for so long, and only finding myself in despair, quitting with a 24-hour notice and serving abroad. The system is, in my opinion, keeping doctors, since the beginning of their career as House Officers to the end of it, in the lowermost priority. When I was working there, doctors are so ill-treated, while the nurses and the medical assistants are overpowering us.

I still remember the days when I was doing seeing patients and rounds as an MO, while the staff nurses would mind their own business, having breakfast in the pantry, or having gossip chats at their own leisure. My House Officers would then have to do merely all the labour-work, up to the extent of setting intravenous drips, and serving medications. If I am to expect the nurses, my patients would have been dead, or the work would have been too slowly or incompletely done.

When I was a House Officer, I had to run down 4-5 floors just to review a blood investigation of a dying dengue patient. The ward staff would either be nowhere around, or will say that he is busy (busier than the doctor?) or the answer I got at that time:

"Doktor nak cepat, doktor turun sendirilah, gaji doktor lagi banyak dari saya"

Even when I was a Specialist, the staff nurses had to be called again and again just to make sure the management plan for the patient would be done. I was already used to answers from them:

“I’m busy with something else"

“My shift is already over"

...it was routine for me.

The Medical Assistants were worse. They would hide behind their so-called boss, the Head of Medical Assistant. They feel hiding behind him would make them not under our jurisdiction, that we have no power to instruct them in managing the patient, that they have power to manage own their own. I've seen them giving medications not as we prescribed, performing procedures without our knowledge, as if they are the actual "Doctors". They are in their own world, and we have to do their job, taking blood, labelling samples, and even cleaning gadgets from the procedures that we have done.

Oh, but the ministry loves this group. They even let them run a clinic now, instead of upgrading the clinics already run by doctors. The government feels that the MAs are very important and should never be ill-treated by those big bad doctors. One time when I was a District Hospital Medical Officer, I was conducting a delivery of a baby. An MA insisted that I remove my car which was block-parking his car. I answered through the phone that I was busy.

He came to the labor room and yelled "Semua orang pun sibuk jugak, macamlah doktor seorang yang sibuk!”

It is insulting that an MA or a staff nurse claims that they are BUSY, as busy as a doctor? As a Malaysian Doctor, I have even worked for 72 hours straight. I have experienced working until my 6 month old daughter did not recognize me at the end of the week.

Is that how busy they are? I am very sure that they are so busy, that they can only spend 2 hours at the nearby Mamak stall, or can only leave at 5:10 PM instead of 5, or can only have 1 hour of lunch.

The management staffs are worse. I have to beg and plead so that I can get my on-call claims, of RM25 per 48 hours of work. While sitting in an air-conditioned office, they will at their own leisure, process my call claims so that I will receive them by the next decade.

The state health or Hospital Director would just give another inspirational talk (of bollocks) on team effort and beauty of teamwork.

That is how Malaysian doctors are treated in the government sector: without respect, without dignity and without significance. Why?

It is because we are bound by ethics to try our best to save lives, despite how ill-treated we are. We hardly have time to complaint because we are too busy or tired, and we would rather spend the precious time resting or seeing our loved ones. The burden of trying to save lives is on our shoulders alone. No MAs or Staff nurses would shoulder it with us. They have their own bosses: the Sisters, Matrons, or Head of MAs, which job description is to ensure that the big bad doctors will not ask their underlings to do extra work.

This is how the Malaysian Ministry of Health have treated their doctors. I am very sure that in each and every doctor, there is a slowly-burning patience in serving the Malaysian people, which will eventually fade and cause them to surrender to serving a place that treats them better.

A few colleagues who graduated from UK choose to serve there:

"The pay is more, and we get the respect we deserve"

Another works in Brunei:

“Here the staff nurses respect Malaysian doctors, and they are very co-operative" (He ended up marrying one)

A few are consultants in Singapore (working with me):

"Here we are treated well, we spearhead the management, and every else do their work to the best of their capabilities".

A few even enjoys working in Indonesia:

“The work-load is horrible since there are a lot of patients, but we are well respected by every hospital personnel" (They have migrated there for nearly a decade)

I am sure that people will see doctors as power-hungry individuals who want to be the boss in the hospital. Trust me, after having graduated 6-7 years of medical school, earning a DEGREE, and subsequently MASTERS, and SUBSPECIALITY, you would expect a degree of respect and being considered important. We are trying our best to improve patient's quality of life, or making sure he lives another day. Is it too much to ask from the system that we are important?

I find that Malaysia is the only country that is making doctors' lives miserable and treated like rubbish. It was never about the pay in the first place. It is about the treatment we are getting and the false political-based promises. Do you know that the so-called circular about doctors can have the day off after working 24 hours straight released JULY 2009 is not yet implemented? Do you know that the raise of UD 41 to 44 does not involve every doctor in the government service?

We are waiting for improvement. We have waited a long time when we were working in the system. Somewhere along the line we decided to leave and wait outside the system. Until the system changes, we will continue to work overseas, in countries which are appreciative of us. Trust me, Malaysian-graduate doctors are considered highly skilful and competent in neighbouring countries, and the 15 % brain drain is more significant than you think.

We will return when the system prioritize us and gives us the quality of life we deserve.

If it stays the same, Malaysian Hospitals would end up having Staff nurses and Medical Assistants as "Doctors", and we would have to send patients to Indonesia for an appendicectomy.

Hear our voice. We hardly speak, but will usually fade away from conflict (and fly to another place).




Thursday, May 6, 2010

Doctor too many....to be continued by Part 3 & 4

Same author, Dr Hsu, who wrote again regarding "Extraordinary Amount of New Doctors in Malaysia", worth reading.


Part 3

This is the number of house officers as of end of April 2010 in HKL , the biggest hospital in our country:

UnitNumber of housemen in the unit
Orthopaedic Department52
O & G Unit50
Medical Department72
Surgical Department57
Paediatric Department62

Just as an illustration, the orthopedic unit mentioned in the table above has 182 beds. With 52 house officers, it amounts to 1 houseman to slightly more than 3 patients.. A ratio you would not be able to find anywhere else in the world, believe me! Not even in the most advanced country!

Gone were the days when we had only 2 or 3 house officers in a unit. I remember during my time, when I was doing housemanship in Penang GH, I was for 2 weeks the only houseman in the orthopedic unit. Now I heard they too had 60 housemen in the unit (Jan 2010 figure).

Just imagine, if you have 60 house officers following a consultant doing the ward round, how are those at the back going to learn? I do not think there are even enough standing room for all of them. How are they going to examine a textbook case ( a case with classical signs and symptoms), since to do so would have subjected the patient to examinations 60 times– if the patient does not die from his illness, he might die from too much handling from these housemen!!!

The figures I quoted are real figures. I am sure those of you reading now would agree with me that there are now simply too many doctors being produced, and since there are not enough hospitals to place them in, there is no choice but to place them in the same units…

No wonder i received emails after my last posts saying that many house officrs are seen spending most of their time in the canteens, since they just have nowhere to go…

And in no time, these same people will be treating you and me, including the politicians. Perhaps I should warn them here that Healthcare is different from education. In education, if our schools are no good, they can still send their children overseas to study. But when these politicians get a stroke or heart attack, it would be too late for them to fly out to even Singapore to seek treatment. They would be treated by the same local doctors that they help in mass production.

Our healthcare standard is going to deteriorate with this sort of training of our doctors..Just like almost everything else.

I am now in the process of writing a memorandum to be submitted to the Ministry on this problem and I hope my writings can bring some sense to this madness of indiscriminate issuing of licenses to set up medical schools.

Part 4

At the end of 2008, Malaysia has about 23000 doctors, almost half in private sector.

Our Ministry is trying to achieve a ratio of 1:400 as existed in most OECD countries.

In the haste to achieve this number game, they have forgone quality.

It does not mean the more the better. Look at some of the communist countries like Bulgaria. They have a ratio of 1:200 doctor:population ratio. That does not mean that they have a better healthcare than Britain which has a ratio of 1:450. Another example is Kazakhstan which has a ration of 1:280 , as compared to Australia which has a ratio of 1:400. Does that means that Kazakhstan has better healthcare than Australia?

Our officials stress too much on achieving numbers. They stress too much on ‘form’ rather than substance.

If we have well trained doctor which are productive, a ratio of 1:1100, will mean that we are on par with those 1;400 countries with doctors which have low productivity.

Alas, we built 5 star hospitals with lobby bigger than Shangri La, but you dont need 5 star bed to treat diseases. You need clinical acumen , experience, and doctors who communicate with their patients.

As for the question asked by MKO in the last post (A doctor too many 3), it is still ok to get treatment from govt hospital NOW. In 5 to 10 years time, I am not sure. Unless they buck up, and set up a body to oversee the standard of doctors produced, I will not want to get treatment there in 10 years time.

I must stress that I am never against producing doctors. I am not in favour of producing too many INADEQUATELY TRAINED doctors. That would be like producing too many gun-carrying policemen without training them as to when to shoot and when not to shoot.

At the rate we are producing doctors, 4000 a year, we will soon be down to 1:100 ratio.

Let us assume that we have a population of 27 million. Let us assume that the population growth is 3%. So every year, we have an additional 800000 people. Divide 800000 by 400, you get 2000. That means once we achieve a ratio of 1:400, we need only to produce 2000 doctors a year to maintain the ratio found in most advanced country. But we will be producing 4000 local plus 1000 from overseas (India, Indonesia etc..many will be staying put in the place they study like my children). So there will be excess 3000 doctors a year… This will quickly bring our ratio down to perhaps 1:100, and you will find some o the hawkers and taxi drivers with MBBS degree hanging in their stalls or taxis.

Not joking…

And looking at the history of medicine at advanced countries, when their doctor:population ratio decreased, the charges went up, and so was the cost of medical treatment , even when taken into consideration of inflation. This is because those who are competent, will charge higher and do more investigations.

There will come a stage when we have too many doctors, too many lawyers(already happening since some junior lawyers have to pay the senior lawyers to do their chambering), too many nurses, too many hawkers, too many cars, too many motorcycles, too many politicians, too many parties, too many police, too many criminals and too many crooks….. I dread to think of such a day!

As for the suggestion by Stevent in the last post, yes, we can send them overseas to work and gain experience, but which country would take them in if their standard is low? I am sure there is a cutting point where even Singapore would not want to take them in, as is the case now.

So you can still send them, to tag with experience doctors. That would like starting their medical training again and you need to pay overseas doctors money to do that sort of things, and there is really no guarantee these people will come back, once they are competent enough to be able to find a working job overseas.

The whole system is rotten, and all the planners can think of is short term and they are all very short sighted… Ultimately they will suffer too if there is a drop in medical standard. Because health hits everyone equally, it does not mean that if you are wealthy and powerful, you would not get cancer or immune disorders.. Ultimately, like facing the creator, everyone will have to face health problems, and they will then realise that what a monster they have created in their haste to achieve certain figures… Because a healthcare system without good doctors will be like a monster released ..