Surfing In The Sea Of Medicine

Young doctors mollycoddled

2011-10-13T00:40:00.000-07:00

Read this, can't agree more!

http://www.thesundaily.my/node/67897

Young doctors mollycoddled

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

S.A.
via email

Hospital Scenario #3

2010-12-14T03:51:00.000-08:00

An orthopaedic HO referred a case to Internal Medicine MO.
HO: This 75 chinese male was admitted for multiple infected bed sores, need Wound Debridement under General Anesthesia, we want to refer medical for pre-op optimization.
MO: So, what's the underlying medical condition that u want me to optimize?
HO: The patient does not have any co-morbid or no known medical illness.
MO: (already got irritated and started to raise his voice) So, why the patient got bed sore?
HO: Err... not sure, according to family member he has been bed ridden for few years.
MO: Did the patient has any him fracture, stroke, spinal injury?
HO: Err... I m not sure.
MO: So, can u ask further history from the patient or call the family to find out further?
HO: Ok.

1 hour later, HO called the MO back: The family member is here for u take further history, Dcotor.

MO: £$%@&*

Hospital Scenario #2

2010-12-13T04:56:00.001-08:00

An old Lady was admitted for epigastric pain yesterday, provisional diagnosis was treat as gastritis and to rule out acute coronary syndrome. This morning an "innocent" HO did round, happily copy down the investigation results, stated Troponin I 15U and CKMB 22U, and impression was still " Treat as gastritis and to rule out ACS."
The MO: OMG!

Scenario in Hospital *1

2010-12-09T20:38:00.000-08:00

Mecical officer : Off this patient Central venous line.
House officer : Yes, sir.
The house officer took out his scissors, immediately cut the exposed part of the central venous line, leaving the internal line remain in patient's vein and said : I'm done, sir.
Medical officer was shocked and terrified.

睡眠者效應(Sleeper Effect)：當下被拒絕，但其實已經成功了

2010-12-01T06:15:00.000-08:00

A Taiwan article, nice. Remind me that journey of life is very long, no need to rush.

http://mr6.cc/?p=5451&utm_source=feedburner&utm_medium=feed&utm_campaign=Feed:+mr6+(Mr.+6)

昨天看到一則文章，非常有趣，它是提到心理學的一個現象「Sleeper Effect」，中文可翻作「睡眠者效應」。這篇文章在探討，「睡眠者效應」在心理學上已久，但是，它在「行銷」方面教了我們什麼呢？

所謂「睡眠者效應」，來自於二次世界大戰，當時美國對現役軍人播放一些戰爭教育電影，主要想提振美軍的士氣，讓他們很想「參戰」！他們在這些軍人看完電影之後，對他們立刻測驗，結果令電影拍攝者「大失所望」，因為這些美軍竟然完全不被電影所影響，「並沒有」因為看了電影，而產生任何感動或參戰的衝動。檢討原因，應該是因為美軍在看電影之前，就已經先知道這是一部「戰爭教育片」，那是拿來影響他們、教育他們用的，因此美軍在觀賞電影之前，就已經先在心裡建築了一道無形的「心牆」，讓這部電影的訊息「進不來」！

縱使那部電影拍得多麼血腥，多麼震撼，又多麼的令人氣憤，任何正常人一看完都會產生「戰爭」的愚蠢衝動，但是這些美軍因為「心牆」，所以讓這部電影的訊息，竟然進不了他們的內心深處。

有趣的來了。他們對同一批美軍，在幾個月後再做第二批的調查，結果發現，歐不，大家搞錯了，電影並不是沒有進入美軍的內心深處！

它，早就進來了。

第二批的調查顯示，許多美軍開始莫名其妙的產生了強烈的戰鬥的慾望！他們不知道為什麼，但是心理學家認為，應該是幾個月前的電影的效果，他們開始研究，為何這些戰鬥電影的效益，要到幾個月後才會出現？而且，這些美軍還不知道，他們的戰鬥慾望，是因為這些電影所造成的？

他們以為已經「拒絕」了美國政府的「強迫推銷」，但其實，美國政府早就已經成功的鑽入竄入他們的心裡了？

心理學家發現，原來，當下這些美軍對電影製作者（或許是他們的祖國「美國」），有著太深的既定印象「美國就是要催眠我、叫我打仗」，所以不相信電影的震撼畫面，但是，過了幾個月後，電影的震撼畫面的記憶，比對電影製片者的記憶，撐得還要久，以致於最後美軍只記得那些震撼畫面故事，忘了到底是誰給他們那些震撼畫面與故事的，這些電影，終於在幾個月後，達成了他們當初設定的目標！

啊，到底怎麼回事？

為何會產生這麼奇特的「睡眠者效應」呢？

我這邊就引用智庫百科的資料，可以整理成二大原因：

原因一，是因為大家對「人」或「品牌」，比較「記不牢」：「名字」畢竟還是一個比較「抽象」的概念，人的記憶本來就對人或品牌比較不容易記得長長久久。或許這個人很差勁，或者對此公司的印象不佳，但沒關係，只要這個人或這間公司當下給了的那個「畫面」或「故事」有夠震撼，那麼，最後大家終究會先忘了這個人或這個品牌，只記得那個畫面，讓這個畫面的效果，到很久很久以後好好的展現出來。

原因二，當下的「人」或「品牌」效果太大，大到當場不正常扭曲或擴大來掩蓋掉主要的訊息：雖然「人」與「品牌」是記不牢的，但是它們在當下的影響力可能太大，大到在當下「蓋過」了主要的訊息，讓主要的訊息在當下沒辦法發揮出來。這種現象有時候是因為「意義障礙」：所謂的意義障礙，主要是因為人們在接受訊息時，因為那個「人」或「品牌」的短期效果太強烈，讓他心理上產生了巨大的情緒，因而妨礙了他去正常理解前面的這一段訊息而產生的。時間過去後，這些「意義障礙」慢慢不見，這個人終於可以正常的理解、分析一段訊息。

所以，它對於「行銷」的意義為何呢？

我舉個兩個真實的廣告例子的自己的體驗，我看到某廠牌牙膏的廣告，告訴我目前市面上的牙膏，有70%（或類似這個數字）不是在台灣製造的。當時我並沒有因為這個廣告，而買了這個產品，但久久之後到今天，我甚至忘了是哪一家廠商對我作這個廣告的，但今天我在挑選牙膏的時候，那個畫面、那個訊息依然太震撼！以致於我會直接挑選明顯的是「海外原裝進口」的牙膏，寧可付貴一點！換句話說，如果你是一間明顯的是「海外原裝進口」的廠商，那麼你可以透過這一個強烈的訊息，就算在當下沒有太大反應，在幾個月後、甚至幾年後，甚至往後的幾十年，會收到我這個消費者「永遠的不斷回來買單」。

但另一個例子，就是某綠茶廣告的「女友瘦身、男的噴鼻血」的畫面，這個廣告讓近百萬人在YouTube看過，印象非常深刻，也對這位女生手上的那一個牌子的綠茶，產生深刻的印象。但，也由於「睡眠者效應」，在一兩年後，人們一定還記得這位瘦身過後的女性和那個噴鼻血的男生的畫面，但是會忘了她手上握著什麼品牌？加上超商架上一大堆的綠茶品牌，混亂了我們心中的印象，最後大家只會記得這廣告所要產生的訊息「喝綠茶可能能瘦身」，卻忘了是誰要傳達此訊息。這家廠商有可能不小心幫「同業」「一起」打了一場廣告。

另外，該文章在他處有一則留言，內容是某間公司說：「啊哈，難怪有時候去客戶那邊提創意，當下客戶覺得不怎麼樣，結果，過了五個月以後，他們做出來的東西，和我當初講的一模一樣！」這種事情，我們也曾經碰到過，由於我們是網路行銷團隊，當我們去「建議」這個點子時，客戶一定會在心中築起「心牆」，產生排斥，不接受我們的「強迫推銷」，也因此不認為我們精心提出的這個點子有多麼偉大、多麼大創舉？但過了幾個月後，當他們再次有網路行銷需求，回來想想應該做什麼事，這時候他們對當時的「點子」仍有印象，卻忘了是誰提的。在我們看到客戶在幾個月後做出一模一樣的東西之後，現在我們都會每幾個月就回到原客戶那邊問問看，甚再追加一些點子，他們的反應和當初會很不一樣。

所以，大家要記得，有時候我們向他人推銷什麼東西，當下是被「拒絕」的，但其實，我們努力的推銷、努力的將畫面與故事塞到他的耳朵裡，就算當下沒有得到回饋，其實，已經進入了他/她的心裡了。

有趣的是，「睡眠者效應」還不止於「行銷」上面的意義，它還告訴我們人生的道理──

簡而言之，睡眠者效應就是在說兩件事，這兩件事可以在人生中參考：

第一：通常讓決定我們「短期」要做什麼事的，是某個「人」，或某件重大的、充滿情緒化的事件。

第二：但是，決定我們一生長久的幸福、快樂、美滿的，卻是超越人、品牌、情緒等等所有表面物品的「下面」的那些事！

舉個例子來說，今天你的工作可能在一間公司，老闆兇巴巴的，主管天天盯你，當下很火大，真的很想馬上抬起屁股一走了之。你會很不解，為何其他人都還是工作得好端端的？

「睡眠者效應」說，有可能你還沒看到這個工作場合的好處，只看到當下的激動、不爽，只被當下那個「人」給氣得沖昏了頭！其他人或許也曾經激動，但沒有行動，反而慢慢的慢慢的看到「下面的好處」，酒愈陳愈香。我們甚至可以說，「睡眠者效應」為這些待得久的員工構築了保護門檻，幫助他們擋掉新進的、躁進的同事。

另個例子來說，有些人對一些朋友、親戚、甚至自己的長輩無法諒解，有的人對自己父母懷著恨意，電視上見到某藝人或素人說：「永遠無法原諒他/她！」那表示事情才剛剛發生。但，你會發現，許多比較老一點點的藝人/素人卻在電視上侃侃而談，「當年」是多麼恨誰，現在卻已經釋懷，再大的仇恨都可以化為烏有，為什麼？WHY？有可能也是因為「睡眠者效應」。我們以為是時間的關係讓我們「淡忘」，但其實，我們只是忘掉了那個「人」，還記得「事」，由於對「人」不再這麼排斥，我們終於看到了「事」的全貌，可以冷靜的判斷。

其實，「睡眠者效應」在教我們的是，人生是一段很長的過程，如果是平常的決定，那麼明快的訣擇是行動力的展現，愈俐落愈好，但如果是雍關一生的決定，那麼，不一定要在當下產生「激烈」的決定，不然，五年之後、十年之後，當「睡眠者效應」發酵之後，以前重要的變成不重要，以前不重要的慢慢浮現，將後悔莫及！

我們的人生，乃由雜陳的五味所組成的，我們每天的心情乃由好幾種心情交叉混合、輪流搭配出來的，所以，今天的不快樂並不是因為你不快樂，而是因為「快樂不比不快樂多，不快樂比快樂多一點」，到最後，這些讓我們每天痛苦與快樂的「人」，或「品牌」，或「情緒」，總有一天會被遺忘的。

這也告訴我們，就算在辛苦的時刻，仍然努力的把握那一點點的玩樂、一點點的放鬆時刻，儘管只是到樓下抽根煙，也是放鬆；儘管是周末短暫十五分鐘走在無人的街上，也是放鬆。「睡眠者效應」告訴我們，應該用各種方式來盡量延長，人生別毀在當下的感受，真正的氣味要釀久一點才會慢慢出來的。

Doctor too many, Part 5

2010-12-01T06:03:00.001-08:00

Can't agree more, would like to share this article

http://hsudarren.wordpress.com/2010/12/01/a-doctor-too-many-5/

A doctor too many — 5
The problem of too many medical schools being set up in too short a period, which I have raised repeatedly many months ago, is finally being acknowledged by the authority.
On Saturday, Star carried a story on its first page prominently about too many housemen in our hospitals.
Then yesterday, Minister of Health was quoted in the Star, while acknowledging there are too many doctors, as saying that the two ministries (ministry of Health and Ministry of higher education) were working together to ensure a “satisfactory quality” of medical students graduating from abroad”.
I have written in MalaysianInsider about the problem of having too many medical schools, and in May this year, I have written a press statement as well as called a press conference on this issue. It was carried by Sun, as well as Nanyang.
The problem of too many medical schools being set up in too short a time–over the last 10 years, 21 medical schools were set up – inevitably resulted in a shortage of good and experienced medical teachers. It has also resulted in the training facilities unable to grow fast enough to cater for all the medical graduates, resulting in one housemen to 3 or 4 patients ratio, instead of the ideal of 1 to 15 patients.
When there is not enough patients to learn from, the houseman would have very limited hand-on experience to deal with illnesses later on, because after all, medicine is apprenticeship. We learn from looking after patients. The more patients under our care, the more variety of cases we will see, the more experience we gain and the more competent we become.
There are now 3500 housemen being churned out a year. The figure is to hit 4500 soon when all the local medical schools become fully functional. The problem is not with the foreign graduates. The crux of the problem is that we are simply producing too many local doctors without facilities and manpower to adequately train them.
As regards to the standard of foreign graduates, what we have to do is much simpler. Do not simply give recognition to any overseas Medical colleges, especially those from under developed countries. We need to vet them thoroughly before recognition can be considered. There is really nothing wrong with those graduating from UK, US, Canada, AUstralia or NZ. Their medical schools are of world class. Not so with some of the universities of our Big Neighbour down South. Some of the universities have not even been heard of, but they are either producing doctors for us directly or are in partnership with some of our medical schools to provide twinning courses and indirectly producing doctors for us.
Nowadays, it is easy to set up medical schools. You dont even need to have hospitals to back you up. Just pull your string to get a license, and the rest is easy. Set up a pre-clinical school where medical sciences like biochemistry anatomy and physiology are taught and this part is easy and will be like setting up any science colleges. . Once you have a pre-clinical school, the clinical training part can be arranged with some of the unknown universities down south, and there you go, you have a full university churning out doctors. Parents are paying through their nose to put their children in these so-called twinning program. Nevermind the university is unheard of, as long as our Health Ministry recognises it, and as long as the title Dr can be awarded to the graduate.. This is unhealthy.
There cannot be double standard in the vetting of medical colleges overseas, just as we cannot allow any Tom Dick and Harry to set up medical schools locally to make money.
Otherwise, we are going to face with the problem of doctors unable to diagnose simple cases. There is really no point pouring billions into our health system when our doctors in future cannot even treat simple cases correctly or undertake simple procedures competently.
There are already anecdotes of doctors unable to take blood from patients, or of doctors watching movies in cinema during office hours, or doctors loitering in canteens simply because there are too many of them in a ward. These doctors are going to be the very ones that will tend to our healthcare, you and me included. Our lives will be literally be in the hands of these people.
If the situation does not improve, all I can say to you is that ” May God Bless you” the next time you need to see a doctor.
Related readings:
A doctor too many
A doctor too many 2
A doctor too many 3
A doctor too many 4

Life of a Houseman in GH in 2010

2010-11-28T00:26:00.000-08:00

Can't believe it but it's true, there are just too many houseman around who got nothing to do. How are they going to be trained and function as a capable doctor later?

http://thestar.com.my/news/story.asp?file=/2010/11/27/nation/7514254&sec=nation

Saturday November 27, 2010

Time even for a movie during work

PETALING JAYA: Some housemen in a Klang Valley hospital have so little work that they can even catch a movie during their shift, claimed a medical officer, who declined to be named.

“It was because they knew that the medical officers (senior doctors) would just do the work instead,” she said yesterday.

She added that some specialists and heads of department were reluctant to give more work to housemen.

However, the doctor said she received adequate experience when she did her housemanship at the Sultanah Aminah Hospital in Johor.

Another doctor, who had recently completed his housemanship at the same hospital, said his peers in the Klang Valley also said they were not given enough responsibilities.

“Since the beginning of my housemanship and until the time I left two months ago, the housemen in the hospital where I was trained, had sufficient training on the job,” he said.

Houseman glut in Malaysia

2010-11-27T23:34:00.000-08:00

Over supply of Houseman finally get attention from the higher authority, however is condition going to change? Sadly, i don't think so. Here is an article which i would like to share.

http://medicine.com.my/wp/?p=8932

Houseman Glut : Why should we be surprised?

It is no surprise that finally someone has spoken out against the sudden rise in the tide of houseman arrivals. With the production mill at full capacity, Malaysia is seeing a varied quality of graduates arriving at our wards. Every new houseman is so different depending on where they have studied making it almost impossible to tailor make a specific program during their housemanship years. Now with more dubious medical schools being allowed to operate, the quality is sure to drop, resulting in a more strenuous effort in training them during housemanship years.

Building more training hospitals as suggested by our honourable health minister will not solve but in fact aggravate the problem. As it is, our current hospitals are poorly staffed by experienced doctors. With a surge of housemen, more hospitals will only dilute the expertise in each of them.

Malaysia wants to achieve a good doctor patient ratio in the shortest possible duration. Unfortunately many policymakers are unaware of the actual situation on the ground and therefore implementing a quick fix solution by approving more medical schools in Malaysia. There is no foresight to plan for the future careers of these newer doctors as post graduate places are even more limited. Now the current medical officers and specialists are left to retrain many of these new doctors with the barest of resources.

Recent decision to allow foreign medical institutions to set up camp will only result in a potential mass efflux of experienced doctors from our local hospitals and universities. Smaller medical schools can only hope to scramble for the remaining few to fill their academic positions. This will further widen the already gaping difference in competency among our new medical graduates.

Malaysia needs to solidify the existing institutions. They should seek to develop collaboration between local faculties and foreign medical schools, not just allowing them to set up camp here, which can potentially further isolate disadvantaged local faculties.

Why is it that General Medical Council of the United Kingdom refuses to recognise local medical degrees, when their universities are setting up camp in our backyard and populating their academia with local expertise, many of whom are from local universities prior??

The Government should therefore strive to strengthen our local universities by establishing and encouraging collaboration between foreign medical faculties and local ones. In this way, the resources can be solidified and perhaps result in better research ideas and eventual international recognition.

Otherwise, ultimately it is the public that will be the losers with less than competent doctors attending to them.

posted in - Education, - TE Cheah |

Related article in The Star

Time management

2010-08-30T20:18:00.000-07:00

Read one article, very nice. It's a Taiwanese article, very enlightening.

「時間」重要，還是「金錢」重要？

這個老問題常常被許多文章拿出來問，會問出這個問題，最後答案一定是「時間」，但，你真的有碰過任何一個視「時間」比「金錢」還重要的人嗎？所有的促銷活動，有95%是幫人省錢，只有5%幫人省時間（譬如你現在先買，以後可以不必再過來買）；如果你要搭飛機、火車、船……只要價錢差非常多，那麼大部份的人一定是選便宜的交通工具，怎麼可能去選貴的呢？最重要的是，你絕對不能讓「皮包」丟掉，就算丟了五十元硬幣都會心疼要死，但下午偶爾偷懶睡個5小時的長覺，頂多是罪惡感，沒有「心疼」。

不過，「時間」的價值，往往讓人驚奇，最近有一篇報導指出，英國的經濟學教授已經整理出一條「公式」，可以計算出你的「時間成本」是多少，這條公式是：你的每小時時間價值=(你的時薪x ((100-稅率)/100))/每小時居住成本，譬如「自己煮一頓晚餐」這種事情，應該是「省錢」的，不過，如果加入了「時間」成本呢?對男性來說，一餐等於要花15.72美元，對女性來說等於一餐要花14.30美元！

這數字令人吃驚，因為英國人平常外食，男性平均消費只有7.31美元，而女性是7.24美元，換句話說，我們都以為，在家煮晚餐很「省」，沒錯，從我們荷包所出去的錢的確是變少了，但如果你計算入「時間成本」，在家煮飯所需「成本」，竟然是外食的「二倍」多！

這點讓很多人肯定無法茍同！畢竟自己煮晚餐，自然有自己煮晚餐的樂趣，不是嗎？此外自己煮晚餐，避免吃到不營養或受污染的食物，平均壽命可能也會比較長，不是嗎？另外，自己煮晚餐，那種「省錢」的快感，也會讓自己更快樂，不是嗎！

這公式所計算出的「二倍」結論，的確有一個漏洞，它是假設，如果你將煮晚餐的那個時間，不要煮晚餐，而到外面去花平常原料的二倍錢來快快吃個東西，然後將煮飯的時間省下來來「工作」。沒錯，來「工作」吧！這樣的假設實在不太對，但，仔細想想，這好像也是奮鬥的一種方法。

「金錢」重要，還是「時間」重要？

你真的有碰過任何一個視「時間」比「金錢」還重要的人嗎？

我覺得「我」就是耶。

而且，我完全支持那個「煮餐成本是外食二倍」的驚人公式，我的確是視時間如命的，的確是願意將煮飯的時間拿來工作的。上次與半生不熟的朋友聊天，談「時間管理」，突然不知為何聯想到小時候看故事書的一個「守財奴」的故事，這個守財奴，將自己的存款全部換成一大顆金塊，然後小心翼翼的藏起來，那付吝嗇的表情，畫在故事書上面栩栩如生，到現在都還記得，不過，守財奴至少有一點，肯定做得很好，那就是他一定是一個比一般人還要有錢的人。我不是守財奴，不過我對「時間」之吝嗇，已經到了「守時間奴」的地步，有人說我很會運用時間，其實是因為我視時間如生命，守時間為奴隸的緣故，我真的是一個視「時間」比「金錢」還重要的人！

這個「時間吝嗇守則」，影響了我的時間管理，哈佛大學最近有一篇研究，發現人類做的各種決定其實和他們「買東西」所做的決定，使用了腦中的同一條線路，我們的大腦的ventromedial prefrontal cortex區塊會計算「價值」，如果今天看到兩位乞丐，我們決定捐款給右邊的那一位，那是因為，右邊的那一位在我們腦中計算出來的「價值」較高。從這邊可以知道，為何許多人常常無法「把握時光」？那是因為，我們打從心理不相信「時間有價」，或是將時間的價值「誤算成太低」了，所以我們無法好好的抓住時光，讓它太快溜走。

反之，如果視時間如命，認為時間的價值比金錢還高？那應該就能「把握時光」！問題是，為何我們大部份都無法接受，在家煮飯所需的成本，真的是比外食還要整整多出一倍呢？

是因為，以下４點：

一、大部份的人類並不是處於「隨時有任務」的狀態：大部份的人是為別人做事的，自動自發的意願不高，所以，當我們突然多出一個小時，我們並不是立刻就有事情在手邊可做！就是因為這樣，當我們真的外食，來省下一小時的煮餐時間，我們也不會去珍惜那多出來的一個小時，我們會寧可搭老半天的車，慢慢、慢慢的多花三小時回家，沒關係，「反正這段時間早點回家，也沒事做！」

二、大部份的人類並不是「隨處」都可以做事：就算第一點不正確，大部份的人依然只有在限定某些地方才能「工作」，當我們不在工作崗位時，我們就無法做出真的有意義的事情，如果現在因為飛機延遲而待在機場，大部份的人是「沒事可做」的；如果今天因為車子拋錨而必須走路回家，大部份的人是「一邊走一邊放空」的，大部份的人是無法在非工作場合以外的地方還在利用自己的時間來做一些事情，於是，反正現在也無法回到辦公室或書桌前，這段時間怎麼浪費都沒關係了，也造成時間的大量揮霍。

三、大部份人類在「今天」的時間，對「未來」沒有明確的投資效應：倘若今天存了500元，明天就多500元可花，非常清楚，但時間呢？大部份的人，今天多了5小時，並不會覺得因為今天善用它，明天也會跟著多出了5小時甚至更多！由於我們對今天「多出來」的時間幾乎「沒感覺」，不認為多出來的這段時間，可以拿來做某些事，對未來直接產生好處，所以我們大量的揮霍現在的時間，大量的大量的用掉他們。

四、大部份人類缺乏「短期目標」，因此對於「花時間」沒有疼痛感：每個人都有夢想，但很少人有「短期目標」，老闆叫我明天要交報告，是大家唯一的短期目標，一般人是不會自己設短期目標的，由於沒有短期目標，因此當我們在「花時間」的時候就好像穿著厚鞋子走碎石路，完全不會感覺到磨擦、損耗的「疼痛感」，我們完全沒有感覺我們在「花時間」，不會感覺到時間一分一秒的被消費，於是，我們的時間就會以百分百秒的時間、不知不覺的被消費掉了。

看完以上四點，或許你可以去follow很棒的時間管理方法，這我不懂，但，如果你也和我一樣，變成一個「時間吝嗇鬼」，或「時間守財奴」，那麼，你自然的可以將時間運用得很好！注意，那不會是「最好」，但比起很多號稱很會時間管理、但做的事卻沒有我們多的人來說，時間的運用是很重要的。

而想要當一個超強的時間吝嗇鬼，也很簡單，只要將以上四點都翻成「正」的就好了，這也是我的方法：

一、確定自己處於「隨時有任務」的狀態：時時都有任務，而這些任務絕不只是「瑣事」譬如要買什麼東西、要回哪些人電話……這些事通通都記得零零落落也沒關係，它們不甚重要。但我隨時都給自己一些任務做，譬如早期的時候我天天背單字，當時一有時間就來背單字，現在的目標是調配人力、想創意行銷、想創意方向，所以只要一有時間，就馬上開始做這些事情。

二、確定自己「隨處」都可以做事：我的任務天天有好幾樣，最近每天開始慢跑，慢跑之前一定先「上傳」到自己暫存記憶體，一邊跑一邊想某件事，然後跑完再「下載」，我記得當年早安打卡機的點子就是在去年某一次跑步的題目，跑完之後也想出來了。現在有了3G手機，隨處上網，如果真沒任務，也可以隨處給自己一個任務，讓自己「隨處」可以做事，就會開始發現自己的時間每分每秒都在產生價值。

三、確定今天的時間，對未來有明確的投資效果：一開始我以為大量的「記錄」，除了寫部落格，天天也有寫日記的習慣，因此今天的任何空閒的時間都可以被「儲存」，「轉換」成一篇文章，文章也東抓西抓的將當下一些學習全都記錄，到三年後的未來，這些文章還會繼續吸引其他網友來認識我。但後來才知道，以上皆是，但只是「基本」，當我們天天在網路上要在限時內饑渴的搜尋網路的最新發展、最新案例，搜了四年之後，就會知道今天努力的饑渴的的大量閱讀，全部都可以百分百的換成明天可用的知識。

四、設立多重嚴苛的「短期目標」：我們都有夢想，但達成夢想之前，你相信必須完成Ａ、Ｂ、Ｃ、Ｄ、Ｅ…嗎？那麼，就定下Ａ必須在下周一就弄出來，Ｂ必須在下周三就弄出來，Ｃ必須在下下周就弄出來。我給自己設立的目標從來不會超過2個星期，有的時候為了符合這「二周定律」，把自己累得要死，但也就是這樣，每分每秒的時間變得很寶貴。你說，幹嘛這麼急，急什麼？沒有急什麼，只是我是時間的吝嗇鬼罷了，這是一個循環，當你設下大量的短期目標，就會想辦法完成它們，也會更吝嗇自己的時間，更吝嗇自己的時間，你的目標也會跟著「愈設愈短期」，最後變成一個超級有生產力的傢伙。

外食真的很貴，但，假設找到一間不錯的餐館，真的乾淨的、有營養的，一天其實可以省下你昂貴的時間成本，每個人活著一生，最大的資源不是金錢，而是「時間」，時間有不一樣的過法，但願您花了一分鐘閱讀此文，至少了解到一件事──

時間正在一分一秒的流失中，頭也不回。

Why Malaysia Gov Can't Retain His Doctors

2010-05-08T17:00:00.000-07:00

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.

http://blog.thestar.com.my/permalink.asp?cat=1&id=30376

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).

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

2010-05-06T08:25:00.000-07:00

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

http://hsudarren.wordpress.com/2010/05/04/a-doctor-too-many-iii/

http://hsudarren.wordpress.com/2010/05/06/a-doctor-too-many-iv/

Part 3

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

Unit	Number of housemen in the unit
Orthopaedic Department	52
O & G Unit	50
Medical Department	72
Surgical Department	57
Paediatric Department	62

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 ..

Too many doctors in Malaysia

2010-03-26T08:49:00.000-07:00

come across this blog, can't agree more.
Let's share after the jump

http://hsudarren.wordpress.com/2010/...r-too-many-ii/

Malaysia, a country with about 26 million populations, boosts of 24 medical schools now.

Just a few years ago, the number was less than 10. In fact, when my eldest son entered medical school 10 years back, i could count medical schools with my fingers. Now even with my toes and my fingers, I could not do so. Some of the names are so new that I, as a doctor, do not even know they exist until I did some research for this article.

The list is below:

Public universities:

• University of Malaya, Faculty of Medicine

•Universiti Kebangsaan Malaysia, Faculty of Medicine

• Universiti Sains Malaysia, School of Medical Sciences

• Universiti Putra Malaysia, Faculty of Medicine and Health Sciences

• Universiti Malaysia Sabah, School of Medicine

• Universiti Malaysia Sarawak, Faculty of Medicine and Health Sciences

• International Islamic University Malaysia, Kulliyyah of Medicine

• Universiti Teknologi MARA, Faculty of Medicine

• Universiti Sains Islam Malaysia, Faculty of Medicine & Health Sciences

• Universiti Darul Iman,Faculty of Medicine

Private Universities and Colleges’

• UCSI University, Faculty of Medical Sciences – School of Medicine

• Monash University Malaysia, School of Medicine and Health Sciences

• International Medical University, Faculty of Medicine

• AIMST University, Faculty of Medicine and Health Sciences

• Allianze College Of Medical Sciences, Faculty Of Medicine

• Management and Science University, Faculty of Medicine

• Cyberjaya University College of Medical Sciences, Faculty of Medicine

• Royal College of Medicine Perak, School of Medicine

• Melaka Manipal Medical College, School of Medicine

• Penang Medical College, School of Medicine

• MAHSA University College, Faculty Of Medicine

• Newcastle University Medicine Malaysia ( NuMED)

• Taylor’s University College, School of Medicine

• UTAR

These are the medical schools in Malaysia. These schools when fully functional will produce about 4000 doctors a year. There will be thousands more Malaysian doctors being produced overseas, since many Malaysians are studying medicine in UK, Australia, New Zealand, India, Indonesia, Russia, Taiwan and even Ukraine.

The sudden mushrooming of medical schools are apparently due to shortages of doctors in the public sectors. This is because most doctors in government service resign after their compulsory services and opt for the supposedly greener pasture in the private sector.

In most other countries, the logical thing to do to counter this brain drain of doctors to private sector is to find out why doctors are resigning from government service and then try to address the woes of the doctors , and hopefully keep them in service. I call this common logic.

The Malaysian solution , like in many other instances, does not take common logic into account but rather uses the sledgehammer approach. After all, we do have Malaysian logic which is different from common logic practiced in most other countries. For example, if we cannot have spacecraft of our own, we can still produce Astronauts by sending Malaysians into space hitchhiking on other countries’ spacecraft.

In most other countries, the common logic will be to try to improve the working conditions in public sector so that doctors will stay back. But Malaysian logic is sledgehammer logic, and is very different.

If the doctors do not want to stay in government service, then Malaysia shall flood the market with doctors, so goes the Malaysian logic. Never mind that setting up of medical schools and training doctors are expensive businesses. We have petroleum and huge amount of development funds. By building more buildings and buying expensive medical equipment to equip these medical schools, billions will have to be spent and of course, in the Malaysian context, everyone will be happy, down from the planners, the contractors, the parents and all others involved, since the perception is that projects in Malaysia inevitably will have some leakages and wastages and many people are very happy with these leakages and wastages. Never mind that we may have the hardware but we may not have enough qualified people to man these medical schools.

The Malaysian logic seems to be like this: If enough doctors are produced, the market will be saturated with doctors and thus doctors will have no where to go but to stay put in government service.

Well, the people may be clapping hands and rejoicing that with more doctors than are needed, medical costs will come down.

Unfortunately, things do not function like this in medical education. Experience in some countries tells us that some doctors in private practice , when faced with too few patients will charge higher and do more investigations, some of which may not be needed, so instead of medical cost going down , it will go up.

In any advanced nation, the setting of a medical school requires a lot of planning and not on ad hoc basis. Planning that must include where to source for experienced and qualified teachers, where to build new or source for existing teaching hospitals which are big enough for the placement of these medical students to do training. Planning such as facilities, equipments, classrooms, curriculum. In the west, it takes many years of planning for a medical school to be set up; whereas in Malaysia, we see more than 10 in the last 5 years.

In Malaysia, due to the sudden ‘exponential’ increase in medical schools, we have medical schools pinching staff from each other, even the mediocre ones, and with that number of qualified teachers only, it is unavoidable that many teachers may not have the experience and qualification to be medical lecturers.

The early birds (medical schools) are more fortunate. Their students are placed in bigger hospitals like the General Hospitals of Kuala Lumpur or Penang. Now, some of the medical schools just opened have to send their students to smaller district hospitals to do their training. The smaller hospitals are often manned by more junior doctors who are not qualified to be medical teachers, and these hospitals have only very basic facilities and equipment.

This is just the beginning of the problems. For a doctor, graduating from a medical school is the beginning of a life long journey, and the basic medical degree is more like a license to start to really learn how to manage and treat patients.

The most important year after a doctor graduated is the houseman-ship. If a doctor does not have proper houseman training, then he would face a lot of problems later on. He or she may know all the medical knowledge in the world (just for argument sake only since knowledge of medicine is so vast that no one can know everything), but without the proper houseman training, he or she will not get the hand-on experience so crucial and important to doctors. A doctor without proper houseman training is not unlike a person, who has played only racing in the arcade games, suddenly being asked to race in a real life race. He would not have the hands on experience to do well. A doctor without proper houseman training would be like a person given a license to kill and a disaster waiting to happen.

Now, with 4000 doctors being produced in a year, where do we find so many houseman positions for these young doctors? Even now, with some of the medical schools just starting and not yet producing doctors, and the number of doctors being produced is much less than the 4000 , the wards in some of the bigger hospitals are filled with so many housemen that in some wards, there are not enough patients for these housemen to learn management skills. About a year back, I was told, in HKL some of the units have more than 20 housemen. Recently one doctor told me that in some units, it may have even more than that. I was aghast. Since with that many housemen in a single unit, and so few senior officers to guide them and so few patients for them to learn from, how are they going to learn the skill of doctoring?

When there is not enough training for these housemen, what do you think our policy planners do? In the typical Malaysian style, they increase the length of houseman-ship from a year to 2, hoping that the longer time will help to give better exposure to these doctors. Compared to Australia, New Zealand, and United Kingdom, houseman-ship is still one year only. By increasing the length of the houseman-ship, it is a tacit admission that our one year houseman training is not as good as the above mentioned countries. A poorly trained houseman will become a not so good medical officer, and since now most of the specialists are trained internally, it will be a matter of time that future specialists may not be as well trained as present.

Many parents do not know about the actual situation and still encourage their children to take up medicine. They are not told of the actual situation. The day will come when there are simply so many doctors that none are adequately trained. There will come a day when a doctor graduating from a medical school cannot even be placed in a houseman position and that day is actually very near.

Blogging? Facebook? Twitter?

2010-02-07T04:51:00.000-08:00

It's been a long while that i didn't update my blog. Well, I'm just lazy, frankly. But i think that the day i joined Facebook, i'm more involved and iterested in posting over Facebook and receive instant response from friends that i know. Rather than checking blog everyday and receive comments from unknown visitor. MAy be this is the END OF BLOG and the ERA of FACEBOOK and TWITTER? I wonder....

What a surprise!

2009-06-09T04:33:00.000-07:00

Recently I found out that the area I stay got few stalls selling green bean soup (Chinese dessert) which is my favourite in Penang. Didn't ever think about finding some here as this is not that popular 'tong sui' compare to others. I tried out some, nothing great but good to know that I can have some in the future. Happiness is simple. Haha.

Busy, Busy, Busy x3

2009-05-01T05:07:00.000-07:00

Still struggling with my subspecialty rotation. Time is not enough, too many patients (20-30 patients daily by me alone, the only medical officer)to cover and many paper work to do (Discharge summary of every patient, procedure note, referral letter, memo, etc.) Life is even worse when I'm on call that day and post call later. No post call off in my deparment as there is always not enough doctors in service. (Except Anesthetist MO can have a FULL DAY OFF after on call, SO ENVY! :( ) Seriously considering to go back hospital to settle my paper workk during weekend. But, how is my life? Where is the quality of life? Sigh.... Basically now working from 6.30am till 6.30pm now every day (12 hours x 5= 60 hours per week + 1-2 On call Per week ). I just realized that I become easily agitated and irritable. Sigh again. Lucky that my parents are still very healthy and can take care of themselves. Otherwise it would be very sad that I spend most of my time looking after others parents but neglect my own. Seriously don't think that this type of life is reasonable. Anyway, the good thing is, I really learn alot from this rotation, both theory and practical procedure and it does help me to become a better doctor.

Well, another 6 weeks to go.......

Busy life.....

2009-03-08T07:33:00.000-07:00

Recently I just join a new sub specialty rotation in my hospital, the life is hectic. Everyday I need to reach hospital to start my round at 6.30am-7am then continue my clinic up to 2pm, then continue with seeing new patients and doing procedure. If I were lucky the work end at 5pm, otherwise I've been going back only at 6.30pm-7pm after my overnight active call (worked for 36 hours in 2 days). So, this is the life of a doctor in government hospital. Yet our Deputy Health Minister claimed that "Too bad those doctors who work so hard are in wrong profession with unreasonaly low salary" ? Well, it's too much and too heart breaking. Our politicians really don't care about our healthcare system, do they? Big doubt!

p/s: I really don't mind hectic life like this as the rotation only last for 3 months and it's part of the learning process. Besides, I'm serving the public who need our service. However, it doesn't mean that the politicians can ignore/neglect our contribution/sacrifices!

Unfair To Blame Doctor

2008-11-25T07:42:00.001-08:00

Recently, I noticed that our media and public possess bad impression abou doctors, which may not be true. Here are few example and my thought (may not reflect the real condition, but just my opinion)

A child was brought to A&E and noted severely ill and was resuscitated at a district hospital.(In fact, the parent did bring the child seek treatment from a GP and was adviced to seek treatment at major general hospital a day before, however parents didn't do so due to unknown reason) After resuscitation, patient was intubated (ventilated by machine) and awaiting for transfer. Sadly all major general hospital nearby all running out of ventilator, thus patient was kept in the district hospital while the district doctors trying their best to call all over Malaysia to look for ventilator. Unfortunately, patient didn't make it and passed away after 4 hours in district hospital. Family can't understand why patient was not referred to major general hospital at the very first place. But the truth is, the doctors in general hospital refuse to accept this poor child in view of no ventilator available. So, whose fault and who to blame? (I myself had experience of calling whole country looking for ventilator, i've called Hospital Kangar -->Penang-->Ipoh-->KL-->Melaka-->Seremban-->Johor Baru and end up no ventilator available and patient passed away in my A&E. I was upset, but what can i do if our government not willing to invest more money in health care to provide more ventilator for public?)
A child was brought in death (no sign of life on arrival) into a private hospital and the doctors there tried to resuscitate but fail to revive the patient. As cause of death can't be determined, a post mortem is mandatory for cause of death. Parents were told to bring the body to government general hospial for post mortem (as private hospital does not offer post mortem service when medicolegal is an issue), the parents misunderstood that the private doctors ask them to bring the "Living" child to government hospital by their own and died on the way to government hospital, which in fact, the child already died long time ago.
A newspaper editor claimed that a wellknown doctor set a high charges for consultation and causing poor patients losing the chance to seek advice. Well, does he mean that doctor should not charge patient by giving professional advice? So how about other profession like lawyer? If he think the poor deserve the same opportunity for consultation, i would rather say that it should be depend on the doctor own judgement, case by case basis. If the doctor offering a FOC consultation session, it should be alright. If he didn't offer that, too bad but I don't think that the doctor should take the blame as "greedy".

Doctor! My Medication Is Not Enough!

2008-09-03T19:40:00.000-07:00

As a Dr in government hospital, I always face patients complain to me that they can't get complete supply from the government hospital which make them upset. Though i tried to explain to my patients, sometimes I do blame our pharmacy making things messy. However, I just read this comment from MMR blog who is a government hospital pharmacy and I agree that his point is valid.

http://medicine.com.my/wp/?p=4295#comments

Quote:

I am only a base-level pharmacist in a small government hospital and these are some of the issues regarding stocking and supply that we face:

We’re unable to give a full supply of medicines (e.g. 3 months) out to patients all at once because:

a) There isn’t enough money to ensure that at any one time, there will be enough medications to provide full supply for every patient that comes to the pharmacy.

b) For most hospitals, there isn’t enough storage space to keep that mega amount of medicines equivalent to every patient’s full supply. With doctors frequently overprescribing and with polypharmacy being practiced, the amount of medicines that need to be stored is staggering. Incidentally, there is also difficulty in securing the necessary budget to increase storage space.

c) As it has been frequently mentioned, the supply of pharmaceuticals to the govt is monopolized by one particular company resulting in us being unable to procure drugs at a (possibly!) cheaper rate from different companies, thus completely cutting out the middleman in many instances. Additionally, woe betide if there is any disruption in that company’s manufacturing process or logistic operations…the whole of Malaysia automatically faces a shortage. This naturally has happened many times.

d) Overprescribing of medicines by doctors. Many patients nowadays are on an average of 6-10 drugs. The prescribing pattern has been described as ‘one symptom, one pill’. Pharmacists have often tried their best to reduce this problem but frankly speaking, after the 10th time of being shouted at by a doctor who’s indignant that a pharmacist should tell him what drugs may be unnecessary, we find it hard to summon the effort to do so anymore.

e) Patient wastage. Many a time I’ve felt like strangling a patient who has ‘lost’ three whole months of medicines worth around RM2k because he/she left it in the car in the hot sun or misplaced the entire supply of medicines or perhaps their pet cat/dog ate it. So much for my goodwill.

f) For certain patients however, making them come back every month for their medicines results in them being more compliant to the medication therapy as we have the opportunity to ‘nag’ them every month when they come to collect the meds.

These are the current issues that are being faced by us pharmacists in the government. However, I have often taken on requests for full supply on a case-to-case basis, especially for those that are going overseas for a holiday or to perform the Haj.

Personally, I hope that no one takes out their frustration regarding this issue on us poor pharmacists as we are only performing to the best of our abilities within the constraints of ‘policy’. Especially doctors who feel that they are doing so on behalf of their beloved patients.

Really, if I could just give them all the medicines and reduce the number of patients I see every month, I would.

Cheers

from, Mark

Funny Yet Irritating

2008-08-31T02:05:00.001-07:00

Sometimes I think that Malaysia goverment hospital should change the "Hospital" to "Hotel" instead. As the charge is merely $10 per day including 4 meals+ bed, a lot of people started to abuse this welfare. I would like to share some of my experience:
#1. While doing round in ward, I was satisfied about patient's progress and planning to discharge patient, but he refused as he claimed that nobody around at home to look after him as his children planning to go holidays this weekend and request me to keep him in hospital. My response???? It's like this #@+#*$#

#2. My friend told me that in HKL infectious disease ward always full with HIV patients. However there is certain day of the week (can't remember, may be wednesday) when the admission suddenly increase as the next day the ward will serve special dish (?Chicken Rendang) which is the Best of The Week and every drug abuse will come with some funny complaint and admitted 1 day prior to that. After enjoying the special meal then everyone request for discharge. Funny right? LOL......

Poor Doctors: It happens all over the world

2008-07-24T07:45:00.000-07:00

I thought that Malaysia Gov's doctors suffering for underpay problem, then i realize that this even happen in England, so this is the fate for new doctors all over the world===> POOR DOCTORS.

Here is the link and the article.
http://nhsblogdoc.blogspot.com/

"The cynical betrayal of junior hospital doctors continues

posted by Dr John Crippen at 3:12 PM
Doctors' Mess

After five or six years at medical school, most newly qualified doctors have educational loans far higher than other students. And when they start work, most of them have no alternative but to live for at least part of the week in hospital accommodation. The hours may not be as long as they were but the shift system still means unsociable start and finishing times and that makes commuting difficult. Rotating jobs means it is impossible to settle in one area. Buy a house in Birmingham and then your next job is in Manchester. It was hard enough for a newly qualified doctor to buy a house in the first place. Now (s)he is forced to pay huge sums of money for tatty hospital accommodation, it is impossible.

The use of university halls-style rooms in their first year after graduating has been used as an excuse to keep the starting salary of junior doctors low, just £21,000 this year, compared to the average graduate's first salary of £24,000. But the provision of free accommodation has been removed without any compensatory pay rise. (source)

Remember also that newly qualified doctors are not “average” students. They are la crème de la crème. How do other high-flying graduates fare?

As a trainee solicitor in London you will earn £37,500 in year 1, and £41,500 in Year 2. Once you're qualified, this rises to £66,000 plus a bonus scheme. (CMS Cameron McKenna)

Graduate Starting Salaries
STARTING SALARIES for graduate Lawyers have shot through the £60,000 mark for the first time – more than twice the level they were a decade ago. But some graduates can expect to earn less than £15,000 per year in their first graduate role. Newly employed solicitors from London’s top firms have seen salaries rise by sixteen percent in the last twelve months to £64,000. Many trainee solicitors can expect to earn ‘only’ £35,000 – the same amount as trainee accountants. High-earning graduates often see their pay packet swell with a £10,000 Golden Hello on top of their annual earnings.

Investment banker £33,000
Management consultant £24,000 – £35,000
Junior doctor £20,741
Police constable £20,397
Teacher £20,133
Nursery manager £20,000
Nurse £19,683
Civil service administrator £19,387
Paramedic £19,195
Electrical engineer £17,000 – £27,000
Soldier £15,700
Library assistant £15,000
Full-time shop assistant £13,000 – £16,000
Teaching assistant £11,000 – £14,000
Fashion model £10,000 – £15,000
Regional newspaper reporter £10,000
Part-time nursery nurse £7,500 – £10,400 (Student Direct)

So a newly qualified doctor thus earns little more than a nurse or a paramedic. Why bother to train as a doctor?"

I love the end of this article as well, "Why bother to train as a doctor?" In my case, it's just because of passion. However, I'm sure most of us become exhausted very soon when we start service at government hospital. Is there anything that we can do? Our politic leader? Our MMA leader? Silence...........

The Disappearing Doctors

2008-07-09T20:29:00.000-07:00

I've come across this article, it's great! While I hate the "On-Call" System in Msia which require doctors who work for more than 100 hours/week (Eg. like me, who is On call 3 times a week) and earn RM7/hour, I agree that decision making may be good sometimes as we know patient better (attending the patient from the start till the end). Still, it's too much for me to continue working like that for another few years (or even worse, till you retire if you continue working as a medical officer in government hospital).

I love the ending of the article:

"As we consider how to allocate medical and educational dollars, the question becomes, What's more important than healthy children and well-educated physicians? We know the answer: Nothing. But when the next question is, What are we doing to meet the challenge of having enough doctors for enough hours in all of our hospitals, we also know that answer: Nothing."

Here is the link and the article.
http://www.medscape.com/viewarticle/575560_print

The Disappearing Doctors

Posted 07/01/2008

Introduction

The pediatric infectious diseases (PID) team assembles in the hallway for rounds here at the children's hospital where I have worked for twenty-five years. I'm the attending physician during the next two weeks, and the other team members include the PID clinical fellow, two pediatric residents, a medical student, and two pharmacy students.

"Where's Diana?" I ask. Diana, a second-year pediatric resident, is doing a month-long elective on pediatric infectious diseases. On Monday afternoons and Wednesday mornings she is at her primary care continuity clinic. Today is Tuesday. She should be here.

"She was the night float on hem-onc last night, so she's home now," the PID fellow says, using hospital shorthand for hematology-oncology. "She'll be at her continuity clinic tomorrow morning and then here tomorrow afternoon."

"Well, where's Don?" I ask. Don, a third-year pediatric resident, is also taking an elective with PID this month.

"He had to cover the ICU [intensive care unit] today because of some glitch in the schedule. He'll be here tomorrow morning and then gone to his continuity clinic tomorrow afternoon."

Missing Residents

Both residents working with the pid team are elsewhere today. They aren't available to examine their patients, to learn about new symptoms from the parents, to review the results of the most recent lab and radiographic tests, to review the nursing assessments for the past twenty-four hours, or to make recommendations for ongoing care for their patients. The PID fellow tried to do their work today as well as her own.

Residents like Diana and Don—young physicians learning to be clinical specialists—have long been the mainstay of medical care in teaching hospitals. Because residents traditionally worked in hospitals in the name of receiving education and because altruism is a hallmark of doctors, physicians-in-training have provided a considerable amount of clinical care while working long hours for relatively short pay. What's going on here? Why aren't Diana and Don on PID rounds as they were supposed to be? It's the result of cockamamie resident physician work schedules that look more like Bingo cards than a comprehensive system for providing coordinated medical care or educating future medical specialists. The erratic schedules are the unintended consequences of the new rules on resident work hours.

In 2003 the Accreditation Council for Graduate Medical Education (ACGME), which accredits U.S. medical training programs, instituted rules for resident work hours, sometimes called "the eighty-hour workweek"; the new rules limit residents' duty hours to no more than eighty hours a week. These rules govern the working conditions of the 100,000 young doctors-in-training in teaching hospitals across the United States and were developed both to protect patients from potentially unsafe medical practices by sleep-deprived physicians and to improve working and learning conditions for residents. The work rules, among other stipulations, limit both the number of consecutive days in a week and the number of consecutive hours in a shift that a physician-in-training can work; in addition, the rules require rest periods of at least ten hours between shifts.

Nobody wants procedures or important decisions to be made by exhausted, blurry-eyed, muddle-brained doctors, so the intent was to form medical teams that would work in rotating shifts, thus providing the physicians with adequate time off. As a result, several times a day, responsibility for patient care shifts as it is passed from team member to team member. Although several studies suggest that compliance with the new work rules reduces wandering attention on the part of the residents, might reduce actual or near-miss car accidents involving exhausted residents who've worked extended hours, and appears to reduce serious medical errors in ICUs, other studies are ambiguous about the outcomes of the rule changes. Furthermore, the validity of the methods and analyses in these studies and the generalizability of the results are open to discussion. In short, the total impact of the new rules on physician performance and learning, as well as on patient care and safety, remains largely unknown.

Sprinting Through Care

So we begin our rounds without Diana and Don. Today, like every day, we'll design therapeutic strategies for very sick children who have rare or complicated or difficult-to-treat infections. Many of these children have compromised immune systems caused by an accident of nature or by chemotherapy for cancer or by immunosuppressing drugs to prevent a transplanted organ from being rejected. As we walk through one of the wards, a first-year resident stops me in the hallway.

"Dr. G, could I ask you a question?"

"Sure."

"We have a patient with hypogammaglobulinemia and a protein-losing enteropathy. Should we continue his IVIG and trim-sulfa?" The resident has just described, in these few words, a patient with low antibody levels, most likely because too much protein, including antibodies, is passing into his stools. She's asking if the child should continue to receive intravenous immunoglobulin therapy to replace the antibodies and if the child should continue to receive the antibiotic trimethoprim-sulfamethoxazole.

"Well, that's complicated," I answer. "For starters, how old is the child? Why does he have a protein-losing enteropathy, and how long has he had it?"

The resident shuffles the papers in her hand. "Um, I really don't know him very well. I'm just cross-covering because his primary resident is 'post-call'." Translation: She's filling in for the patient's resident physician who was on duty overnight and, because of resident work hour rules, is unavailable today.

"I can't begin to answer your question without knowing the details," I say. "Why is the patient on the trim-sulfa, anyway?"

"Don't know."

"Will you be calling in our team to consult about this patient?" I ask.

"I don't think so. The senior resident told me to ask you about it."

"Well, I can't make recommendations about stopping treatment until I understand the whole situation. Put in for a consult and we'll figure it all out."

Is she a bad resident for asking me for a recommendation on a patient I don't know? No; like all residents, she has been given responsibility for the care of a very ill patient during the current eight-or ten-or twelve-hour shift, but she didn't take care of him yesterday and probably won't take care of him tomorrow. She doesn't know the full story of this patient's recent illness, doesn't know the long-term plans, and wasn't part of the previous decision making to design the patient's current treatment. This resident is filling an open shift in the schedule, and her goal is to place a check in the box beside the item on her list that says, "Ask PID about stopping IVIG and TMP-SMX."

Is this a bad hospital? No; stop-gap measures designed to provide physician care to all patients around the clock, seven days a week, are found in every teaching hospital in the United States. By limiting the number of work hours of each resident, however, the new ACGME rules have effectively decreased the hospital's resident physician workforce by 25 percent—in other words, a full quarter of them have gone missing.

The problem is that losing 25 percent of the workforce hasn't been accompanied by hiring additional physicians. As a regulatory agency, the ACGME issues mandates to ensure that young physicians receive excellent clinical training; it usually doesn't approve adding increased numbers of residents to a training program just to plug a hole in a hospital's need for clinicians.

A hospital's inability to increase the number of resident physicians isn't the only barrier to improved staffing—most hospitals can't afford increased numbers of residents anyway. At the same time that the new rules have come into effect, the resources to pay for medical care are vanishing. Medicaid and Medicare payments for health care services are decreasing, and insurance payments are following this lead. Furthermore, more and more patients—forty-seven million currently—have no insurance, which means that they don't pay—because they can't pay—the bill. Although so-called physician extenders (such as physician assistants and nurse practitioners) might take on some of the tasks of the missing physicians-in-training, nursing practice isn't medical practice; even advanced practice nurses or physician assistants haven't had the comprehensive training required to be good doctors. In addition, many physician extenders command salaries similar to those of physicians-in-training yet work only forty hours a week; hiring them as replacements would mean a 100 percent increase in costs.

Keeping An Eye On The Clock

We continue our rounds and enter the staff room, where an intern, seated at a laptop computer, is feverishly keyboarding a progress note that documents the current status and treatment plans of one of his patients.

A senior resident enters. "What are you doing here?" she asks the intern.

"Finishing up my notes."

"You can't do that. You've got to get out of here."

"But, the notes…"

"I'll do them for you. Make a list."

"I also wanted to check the rash on the kid with Kawasaki disease…"

"You can't. You've got to go home."

Apparently the intern in the staff room is up against the limits of the work rules and has been told to leave the hospital. There's no wiggle room. The ACGME requires training programs to report the actual hours spent in the hospital; it leaves it up to the training programs to figure out how to get the work done in the time allotted. If the intern continues on duty beyond the dictates of the rules, our training program might be cited for noncompliance. The penalty for too many citations: probation for the training program or possibly withdrawing the program's ACGME accreditation. A training program on probation or without accreditation has an extremely hard time attracting excellent resident physicians.

We proceed to the next ward. There we meet another resident who, earlier, had submitted a request for a PID consultation.

"Let's talk about the boy admitted last night with the neck mass," I say to her.

"Yeah…tell me what to do with him," she answers.

"Rather than my telling you what to do, let's think it through together so you'll understand how to do work-ups of kids with cervical lymphadenopathy."

"I don't have time for that.Please, Dr. G,just tell me what to do."

Unintended Consequences

Besides ensuring excellent medical treatment for patients, the ACGME work rules were intended to keep residents alert so that they could fully engage in the work and education needed to become fine physicians. The rules, however, are backfiring. Residents no longer are able to observe the timing of a patient's response to an intervention; they can't follow the tempo of a fever or the bloom-and-fade cycles of a rash even when, as responsible physicians would, they sincerely want to. Their heads are crammed with the facts they've learned during medical school, but they can't see firsthand the course of a birth or a gall bladder attack or the phases of recovery from a surgical procedure and then integrate those facts into informed decision making. Instead of producing physicians with high professional standards who see their patients through to the end (of labor, of an operation, of an illness, of a life), the current system is creating a legion of shift-worker physicians who leave when the clock strikes a certain hour rather than when the job has been completed.

In evaluating their training programs, residents often ask for increased autonomy. They realize that in the future they'll be solely responsible for the care of their patients, and they worry that without a certain amount of autonomy during their training, they won't be adequately prepared for independent decision making. Yet with their current here-today-and-gone-tomorrow schedules, they can't be given increased autonomy—they won't be around for the next step or haven't been around for the last step. They don't have the big picture.

The children's hospital where I work contains what I consider the world's most precious treasure: children who are the future of our society. The other great treasure in my hospital is the young physicians of tomorrow who will carry forward our medical values, traditions, and practices. The reason that the doctors at my children's hospital are disappearing or aren't there when they're needed is, simply, inadequate resources to compensate for the restrictions of the new work rules and the resulting workforce reduction.

It's always about the money. In terms of the new ACGME regulations and providing medical care for children, we (meaning our society) can't seem to figure out the money part.Yes,to some extent, we might be able to work"smarter" with new technologies and information systems. Yes, we need to figure out how to streamline communication among the many team members. Indeed, we need resources to create real teams.

As we consider how to allocate medical and educational dollars, the question becomes, What's more important than healthy children and well-educated physicians? We know the answer: Nothing. But when the next question is, What are we doing to meet the challenge of having enough doctors for enough hours in all of our hospitals, we also know that answer: Nothing.

Does Government Have Killing License?

2008-06-27T01:28:00.000-07:00

Last post I discussed about doctors' killing license, and now I would like to share about government role in Malaysia health care. Recently our PM claimed that our country facing financial crisis and need to cut down fuel subsidy and a lot of government project and expenses for example minister entertainment allowance. This sounds quite fair as whole country need to work together while facing financial crisis. However when I realized that ministry of Health also need to cut budget for 10% I start wondering what the hell that our leaders are thinking about. Let me explain how does it affect our health care service from the point of view of a MO from a district hospital.

1. Not enough budget to buy medical equipment and medicine. Though government never order formally stop buying new equipment and medicine, but it'll issue notice that no more extra budget for buying medicine/instrument, if u want to live with limited budget, the only way stop using expensive medicine and start using the cheaper medicine. It may not be as good but government doctor need to face it. Recently one patient organized a press conference complaining that H Seremban not giving the expensive psychiatric drug which he usually given by UM Medical Center and was replaced with cheaper drug which worry him the cheaper drug may not work for him. And oh yes, don't u doubt why he stop getting medicine from UMMC? It's because UMMC start to "half-privatize" its service and patients need to pay in full amount for medicine (few hundreds dollars)instead of paying subsidized price as before(RM50 per month) in order to cut down government finance burden. So don't u agree that our government have some " license" to allow them to provide cheaper and may be substandard treatment to his people but letting front line staffs like doctors taking all the blame?

2. Over time claim: our health care workers are always insufficient. We may need 6 ambulance drivers,5 medical assistants(MA) and 4 nurses per shift in a district hospital Accident and Emergency Department. In fact, we may only have 3 drivers, 1 nurse and 3 MA working(why always insufficient in health care?because health care workers work the hardest compare to other government department with similar salary. Thus lots of health care workers leave government when they feel that "it's enough."). When patients are too many to handle at any time, driver,nurse, MA need to work extra shift and claim OT. However there is a rule in government law that states "government servant can't claim OT more 30% of their basic monthly." when hospital budget is enough, H. Director will allow these claim even it exceed 30 % (as 30 % is only few hundreds dollars that can be easily exceed after few extra shift.) Now? PM cut down every budget and H. Director found that there is not enough money to
pay for salary+ OT, so Director announce that OT will be allowed only up to 30 %. So what will happen? No pay? Then no work! When ambulance driver not enough but we still have patient awaiting ambulance to rescue them, no driver is willing to come work extra shift. When nurse and MA not enough to handle big amount of patient load, no one willing to come and work extra shift, thus shortfall and negligence will happen. So who is the loser? It's the patient and the health care staffs! Patients may be dying and the staff will be burden and take the blame. All these can be avoided, if our government care more about its staff and its people. Increase health care staff salary (equivalent to their workload), hire more staff, pay their OT in full as a token of appreciation for their hard job. Our government sure have other better way to save money (eg stop sending Monkeys for space traveling, investigate those corrupted politician and freeze their illegal asset, stop saving not performing GLC like MAS and Proton.) But to sacrifice our people life and health? PM and ministers, what the hell that u are thinking? This sound like our government have the Killing License to kill his people just because they want to save some penny with price of patients life and welfare. Please do something, our politicians, if u are really caring about our people.

Does Doctor Have Killing License?

2008-06-21T03:00:00.000-07:00

I was upset when our Deputy MOH claimed that doctors actually "have the license to kill". Well, may be he tried to say that doctors may have the right to decide when to stop resuscitation (which does not equal to "killing" someone) when they feel the chance of survival is dim. However, this doesn't mean that doctor has the "killing license" to cover his negligence upon patient's death.
As a doctor, I've encountered many death which sometime I/my colleagues suggest to family members for No Active Resuscitation as the prognosis was poor. Sometime they agree, sometime they don't. However, so far I haven't encounter any miracle, all passed away inevitalby.
Sometime, I learn from previoius patient's death and choose another type of treatment when encounter similar clinical picture and sometime the patient survived. The previous death do help me to improve my judgement to handle similar problems in the journey of practising medicine. However, I wouldn't agree that this is so called " Killing License".
So, do u think that doctors have killing license? Share with me please.

RM2.70 for petrol now....

2008-06-05T06:20:00.001-07:00

Are u one of these unlucky one last night? In order to save some dollars in pocket to fight inflation?
What happen to our country? A fuel exporting country now refuse to subsidy fuel and yet continue burden the citizens with HIGHEST import tax on cars. I'm not sure the government is ready to change their habit (eg. using small cc car, less visiting oversea using public money, reduce "Space Traveling" and so on) but i'm sure all of us is going to have very tough time from now. Sigh again.

Malaysia Public Health Care

2008-06-02T23:44:00.000-07:00

Health care is an expensive welfare that every country facing funding problem. (Including Japan/Taiwan/China/US). Currently Malaysia government subsidies 90% cost of the health care system. Government hospital charge RM1 for every patient who visit Accident and Emergency (A&E) or government clinic (Klinik Kesihatan) and Klinik Pakar for RM5-15/visit including dr's consultation/investigation/treatment. For those who admitted hospital charge RM 10/day including 4 meals(breakfast/lunch/tea time/dinner), nursing care, dr's consultation, investigation and treatment. Medical equipment and treatment is expensive, for eg MRI cost RM600-1000/scan, ordinary blood investigation (full blood count/renal or liver profile) cost RM50-150, drug for lowering blood pressure/cholesterol/sugar cost RM0.50-5.0/tablet (1-3 tablets/day). The cost may be terribly high if public need to pay in full amount. That's the reason why people always shocked with the bill when they seek treatment at private hospital.

It's important to create a SAFETY NET for the poor as everybody has the right accessing Basic Health Care Service. However, under current condition, as government reluctant to increase the funding(due to financial/political reason), the Imbalance of Supply/Demand causing a lot of problem which MOST OF THE TIME is the FRONTLINE HEALTH WORKERS taking the BLAME.

As government providing low cost service, the amount of patient load is terrifying. Everybody (including poor/middle class/rich) seeking treatment from gov hosp but the resources are limited(reasons as above). Supply/Demand is imbalance. Government refuse to raise funding and unable to raise charge (the VOTE is important), health workers welfare is sacrificed (UNDERPAY, not enough man power, struggling with limited resource) hence patients best interest also affected.

REAL SCENARIO:
Anyone can visit any government hospital medical ward (Seremban/KL/Penang/Klang/Kajang) which is patient overload, filled with extension beds until no space for people to walk/stand.
3-5 nurses/shift looking after 30-50 patients per ward with quite a number of them need closed monitoring. 1-2 specialist (only main hosp), 2-4Medical officer, 1-3 House officer (only main hosp)per ward. Imagine if u were the medical staff nurse, how can u look after so many ill patients at the same time? eg 4 nurses looking after 40 patients at H. Seremban?Come on, if our government got the money to send astronaut to aerospace for "Space travelling", why don't u spend the money like hiring more nurses? Thus, shortfall will present no matter what with limited man power.

I strongly believe that,
ONE mistake is personal fault
2 errors are incidental
3 errors are occasional
REGULAR errors is SYSTEM FAILURE!

How can our PUBLIC/POLITICIAN blaming individual medical staff for SYSTEM FAILURE?
In every field there will be 'Rat Shit spoiling the porridge", I don't protect those medical staff who is not performing (as i observe there are ALOTS especially those HIGHER POST SENIOR STAFF using MOUTH only not moving their ass to work), I'm depressed as medical doctor serving public in government hospital struggling with various limitation, the PUBLIC nowadays only pointing finger and not appreciating our good job/effort.

Waiting hours too long at government clinic/A&E?
-My colleague come review patient at 7am daily till 10-11am then go medical clinic see patient with number of patient 100/clinic and only 2-4 dr working(which the OFFICIAL CLINIC HOURS IS 9AM-1PM), and being complained by patient for coming late. REMINDER: NO extra doctor sitting in clinic only. U need to running around within hospital as clinic/ward always looking for doctors, eg patient collapse in ward, patients complaining/yelling at clinic for long waiting time. Do our new MOH Dato Liaw know this (never serve as a DOCTOR in Gov Hosp) who is so ambitiously want to cut down the waiting time? Provide ADEAQUATE DOCTOR please! Before start talking Hoo-Haa, study the real problem and work it out. If keep on saying" the doctor without loving kindness please leave gov hosp bla bla bla", i'm sure more doctors are leaving soon and HE who is not even a doctor should be sitting in hospital seeing patient himself in the near future.

My dear minister and our Public, do u think that 3-5 doctors seeing 100 patient in 2-3 hours is reasonable? This is SPECIALIST CLINIC eg. Medicine, Rheumatology, Nephrology. These patients need adequate examination and review (unlike the common cold or cough) which need 20-40 minutes/patient. Should we compromise these patients best interest in order to "SEE but not REVIEW" these patient at clinic? If that's the case, why don't we send them back to Klinik Kesihatan? What's the difference between Specialist Clinic and ordinary gov clinic?

Offering gov doctor with Salary of RM3-4k but working like a Cow does not make any sense. Our country is wasting money for those gigantic "White Elephant" project but not able to raise the health worker paycheck to a REASONABLE rate. Doctor's on call for 24 hours got RM170=RM7/hours, Foot Massage cost us RM60 for 60 minutes, don't u think that the on call rate is humiliating this profession as if the knowledge/professional skill can't even compare with a foot therapist? Money is not the MOST IMPORTANT factor, but be fair and reasonable. U can't keep on subsidy those BIG GLC like MAS/Proton but continue sacrificing those people who did their hard work to serve the country and people.

Comparing the charges and the service/treatment offered by gov hosp, i think it's good enough even u comparing it to other country. Remember, U Get What U Pay. If the service is so good (air condition ward, plenty of nurses/doctors, most advance technology/treatment) and the cost u need to pay is merely RM1, what will happen? Everybody will rush to gov hosp and end up flooding the whole country gov hosp with patients.At the end, it'll back to the same situation with Supply/Demand Imbalance.

Nothing is free, other than BASIC HEALTH CARE SERVICE, we should take care of our own body. Will u blame others if u not taking good care of your car and finally the engine just break down? Same line of thinking, how can public blaming others/doctors/government if u are over-eating, overweight, smoking non-stop, drink alcohol like water, drunk and drive, taking Ecstacy, careless driving, sleep late wake up late, never exercise? U should responsible for your OWN BODY/OWN GOOD HEALTH. I never sympathy for those who drunk then accident as they DESERVE it.

We can't neglect the poor by privatising WHOLE HEALTH CARE SERVICE. It's a nightmare and inhuman for the poor. We need to provide SAFETY NET for the poor with BASIC HEALTH SERVICE. If u are badly injured in an accident which need emergency operation, GOV should provide this with minimum charge. If u are unlucky and was diagnosed having Cancer, GOV should provide treatment with minimum charge. If u are pregnant and going to deliver, GOV should provide mid-wife/doctor's aid with minimum charge.

If a country/society doesn't provide Basic Health Service to the poor, it's not only inhuman but it'll cause society instability. The poor losing hope/faith in gov will create chaos/riot and eventually everybody will be in big trouble. (Can't we imagine similar condition Myanmar/Africa?)

However, Basic Health Care has its limitation. For example, we don't provide the latest therapy but the most cost efficient therapy. Quantity supervene quality. Like ordinary chemotherapy for cancer may cost RM1000-3000/ cycle of treatment, compare with the latest chemotherapy with less side effect (Nausea/Vomit/Hair drop) and more efficient (may or may not prolong patients life for 6 months-1 year compare to ordinary chemotherapy) which cost RM10,000-30,000/cycle, ordinary regime is the choice. Another example, we know that Impotence (Man unable to erect) is a Disease, but should we include Viagra (around RM50/tablet) in Basic Health Service?

Sadly, I think Life Isn't Equal, Not Even Same PRICE (Though we always claim that life is PRICELESS). U Get What U Pay, that's the principle. Europe country providing marvelous welfare is based on the expense of High Tax Rate (around 40-50% for income tax, compare with M'sia, no tax for those earning less than RM25,000 annually and Max is around 24%). However, they also facing problem with rising cost of health care and running out of budget. (No country should spend all their budget in Health Service alone Right?)

For those who can afford the medical expenses, u should consider private service as Basic Health Care should never full fill everybody demand, eg. air-condition ward, plenty of dr/nurse who attending your every single complaint (non-urgent), immediate response for non-urgent call, complete/routine but may not truly indicated test like X-ray/Scan/blood test any or every time u visit dr. And for the rich one, why should u fighting with the poor for our limited Health Resources?

That's why i STRONGLY AGAINST providing 1ST CLASS in Gov Hosp. Patients who admitted to 1st class pay the full room fee only (around RM200-350/day) but still enjoying the subsidy treatment/investigation. For those who want and can afford 1st class, u should go to private hospital. And OUR GOV/ Minister should revise the policy, make those who admitted to 1st class in Gov Hosp pay in full amount for the treatment/investigation/doctors and nurses service as they can afford to pay more. By serving these 1st class patients now (Usually POLITICIAN/SUPER VIP/and some middle class, eg our Ex-PM Dr.M, some Big Businessman) who can afford the full cost of health care, it's unfair to the poor as OUR GOV ALLOW THE RICH "SHARING"(sometimes it's ROBBING the poor, eg Dr M can have immediate heart operation at Institut Jantung Negara when he need while the rest of the public, or the poor, need to wait for 6-12 months for their slot of operation) THE LIMITED RESOURSES WITH THE POOR.

I'm sure we can do better to improve our Health Service. But our public, please don't abuse our limited resources by visiting A&E for non-emergency condition, asking for unnecessary investigation. And please don't blaming/complaining the front line health worker for not serving u up to your heart content. WE(front line health worker) serve and sacrifice because of good faith, not because WE OWE U, or We Should Serve U Like Master and Slave. Be grateful and respect. If not, more people will leave government health care service and it's not the POLITICIAN/VIP/RICH will suffer, it's THE POOR AND THE PUBLIC.

I'm looking forward for that time of change to come.

Palm Centro

2008-06-01T01:28:00.000-07:00

Just got my new toy, Palm Centro 1 month ago. I've been using Palm Zire 71, Z72 then Life Drive (which was driving me mad with 5-10 crashes/day) later switch to WM ==>Dell Axim 51V. Finally Palm manage to get me back to it with latest product, Palm Centro.I'm very happy with Centro as it handle my PIM and medical programs nicely. Anyone who is interested can read this review from Palminfocenter which is quite informative.

Doctors, Why Are U So Irritable?

2008-06-01T01:26:00.001-07:00

Recently, I noticed that my fellow colleagues and even my girl friend who just completed her housemanship become more and more iiritable after joining medical field. When i look back in my medical life, I suddenly realized that Even I Myself also become easily irritated. May be i can share a few "Reality Problem/Factors" that causing this profession, Doctors, become more and more life taxing and less satisfaction.I was doing night shift alone (10pm to 8am) at Accident and Emergency department(district hospital does not have enough doctor, thus only one Dr per night). At 12am,after settling and admitting one old gentleman who just had an myocardial infarction (Layman: Heart Attack) which took me 2 hours, I looked at my desk, patients' cards are piling up. Let's see what kind of patients do we have:-a 20 y.o girl,c/o (c/o=complaints of) having fever + cough + RN (RN=runny nose) for 2 days-48 y.o man, c/o skin itchiness for 2 weeks-3 months old baby girl c/o crying while breast feeding and unable to sleep, normal temperature (and baby become very comfortable when i saw her)-17 y.o boy c/o diarrhea and abdominal pain-44 y.o man c/o headache and request for MC-22 y.o man c/o toothache (yes, it's toothache, I'm a DOCTOR, not dentist, and my A&E doesn't has any dentist around)- 33 y.o lady with another 2 kids (8 yo and 4yo) c/o fever+RN- and bla...bla...bla...many many more...... which WE medical staffs labeled as GREEN CASE (non-emergency) (Very typical picture of how our public abusing our A&E service, A&E should be only for EMERGENCY!)then my nurse inform me that the headache patient was yelling outside complaining he was wating for 2 hours. Though my nurse explained that there was an emergency patient with heart attack, he still shouting around saying "So u mean my headache is not emergency?If I die because brain cancer, can u responsible for it?" Finally, I saw him and discharge him with some pain killers and the MOST IMPORTANT--->MC.After struggling to finish all non-emergency patients, it's 4am. Then another mother brought in a 1 year old baby boy complaining that baby was having fever from 6pm, though visited a private doctor and was given some medication, but the fever still persist. With exhausted body/spirit, I told the mother that it's a normal course for fever to settle in 3-5 days, no matter what medicine u take, not even "bomoh" medicine. SO very unlucky or stupidly, I've mentioned an improper or so called "unprofessional" word---> "bomoh", the mother start yelling at me, "Don't u think I'm stupid! I come from KL and not like people here who are stupid !(only God knows why people staying here suddenly become stupid) What's your name? I'll complaint to your boss and Health minister for your improper language! I was looking for a private hospital with specialist which doesn't exist here. I'm so stupid to come here and see only ordinary doctor like u." Though I tried to apology, all effort in vain and she left with anger. So, I'll end up receiving complaining letter later and to write another explain letter for it then.After this angry mother left, suddenly I heard that another ambulance coming , apparently there were 3 young guys who had drunken and drive involved in an motor-vehicle-accident and were severely injured. 2 guys had open fractures of upper and lower limbs respectively and the last guys was unconscious with sign of head injury. Resuscitation was carried out immediately. 2 men were transferred to Town General Hospital for emergency operation while the last guy didn't look good. After one hour resuscitating, his blood pressure dropping and CPR (cardio-pulmonary resuscitation) was carried out. After another one hour, we failed and he passed away. Now the time was 7.30am.Police came and ask some questions, then request for a post-mortem for this guy to identify his cause of death. ( In Malaysia,All patient who pass away in the motor-vehicle accident require post-mortem to confirm cause of death.) so i quickly change and proceed with post-mortem, open his skull and examine his brain, hmm.....so there was some intracranial bleeding and skull fracture, so cause of death was confirmed= Severe head injury.After finish filling up all the documentation required (burial permit, death certificate and bla, bla, bla.....). Finally, i can leave my hospital. And now it was 9.30am. Rush back to my room took a shower and grasp something into my mouth, i totally collapsed onto my bed. So, that end my story of night duty. But wait! There will be another night duty tonight! So Wish Me Good Luck, ok?

I'm a Blogger now!

2008-06-01T01:22:00.000-07:00

I never thought about to join blogger team as i know I'm lazy to update my blog consistently. However, my sisters and friends have started their blogs and invite me to join them. Since I've written some articles in some forums, I think I may just share those articles in my blog and recording my opinion and some personal stories as a doctor who serves in a government hospital. Please share with me if u have some thought about my post/articles.May all the being be well and happy and get the adequate aid from health care worker when they need.