Unfair To Blame Doctor

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)

1. 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?)
2. 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.
3.  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!

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

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

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

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

Jane R. GilsdorfHealth Aff. 2008;27(3):850-854. ©2008 Project HOPE

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?

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?

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.