When the Health Ministry fails, blame the doctors!

[Adrian Wong]

Many of you know by now that our Health Ministry has decided to extend housemanship for new doctors by 1 year, starting from 2008. Their reason? Poor performance by new doctors. Longer training will give them more experience and make them better doctors.

Sounds good, doesn't it? In fact, V. K. Chin of The Star even gushed about how great this would be. If anyone has any doubt of his position as a government spin-doctor, his article should put those doubts to rest.

I had intended to write in much earlier, but better late than never. I drafted off this e-mail and sent it to The Star and The Sun. Let's see who dares to post it.

Dear Editor,

I'm writing in reference to the recent announcement by Health Minister Datuk Seri Dr Chua Soi Lek that housemanship will be extended by one year, and V. K. Chin's comment on the same issue.

I have to strongly disagree with both Dr. Chua and V. K. Chin. Let us be truly honest and say that this is really nothing more than a ploy by the Health Ministry to covertly extend the government service of doctors to 5 years.

The quality of our doctors has never been dictated by the length of training as housemen. There is NO guarantee that doctors who have gone through 2 years of housemanship will be better trained than doctors who have gone through only 1 year.

Medicine is a continuous process of learning, making mistakes and learning from them. It continues LONG after a doctor finishes his/her housemanship. The fact that a portion of that process is called the housemanship is really a matter of semantics.

After a doctor finishes housemanship, he/she still has to complete another three years of government service. Unlike what V. K. Chin suggests, their training does NOT stop the second their housemanship is over. It goes on as they serve in the government, and long after they finish that long mandatory public service.

Even if they are strongly convinced that a longer housemanship is required, why can't they reduce the length of government service by a similar length of time? After all, this is already the practice at some hospitals. These hospitals have implemented an extended housemanship where the doctors go through five specialties over 1.5 years. During the extra half a year, the housemans are called junior MOs and this extra half a year counts towards their three-year government service.

I'm sure the Health Ministry is fully aware of this system. Why can't they just apply this policy to all hospitals, instead of intentionally extending the total number of years doctors have to serve in the government? Is it truly about improving the quality of the doctors, or merely extending the length of their service?

If the Health Ministry is really concerned about improving the quality of our doctors, there are so many other things they can look into. For example, why derecognize external specialist programmes in favour of our own Masters programme? Is our Masters programme truly superior, or is it merely a way to force our specialists to remain in Malaysia because it is NOT recognized anywhere in the world?

In a profession that deals with matters of life and death, it is also disconcerting to see the Health Ministry implement racially-based fast-track programmes like SLAB (Skim Latihan Akademik Bumiputra). Those who qualify for this programme are trained as specialists right after their one-year housemanship and paid a much higher salary. Those who do not qualify have to complete their three years of government service (plus one year of housemanship) before they are allowed to apply for the same specialist training programme. Shouldn't our specialist programmes be based on meritocracy? After all, it is our rakyat's health at stake here, isn't it?

Let's come back to the hot topic of housemanship. Many people assume the danger from these young doctors come from the fact that they are inexperienced. That cannot be further from the truth. Inexperience breeds caution. Housemen are inordinately careful because they KNOW they are inexperienced. Our teachers' mantra that we should FIRST DO NO HARM still rings in our ears.

If any houseman is dangerous, it is only because the system made them so. Instead of being treated with at least the dignity we accord a poor beggar, we treat them like dogs. Housemen have been subjected to long hours of work, sometimes beyond 72 hours of continuous duty. If anything makes a young doctor dangerous, it is the lack of sleep and rest. I have yet to meet anyone who can function at 100% after a full day of work, much less back-to-back calls and 7-day weeks.

In other professions that involve the lives of others (e.g. commercial pilots), rest is mandatory and strictly enforced. Even in the US and UK, doctors are required to rest after working for a certain number of hours. Why are we not implementing the same system here? Are the lives of our rakyat less valuable? I would have thought this whole housemanship issue is about protecting the lives of our rakyat. Evidently, it's not.

With that, I rest my case. I sincerely hope that the Health Ministry will at least be HONEST about the whole issue and just admit they cannot attract enough doctors to stay on in public service. If they must enslave our doctors for another year, at least let them know YOU need them that badly. Don't make it all about their "poor performance" when it is YOU who failed them and the rakyat.

Note : Updated it when I noticed I missed a salient point.

[plasma]

This seem to be a spin from the recent mishaps involving a little baby, some actions needed to be taken.

But aren't housemans the ones doing most of the work in the hospitals?

[rusty]

IMHO, it's isn't truly a bad thing. How else would there be enough workforce in the government hospital? Both my grandmas was admitted into government hospitals, and their care is top notch (one in Universiti Hospital, the other in Melacca General Hospital). Furthermore my mother was treated extremely well in Selayang Hospital to diagnose her gastric problem. How about lately my girlfriend was warded for dengue fever who was also treated with great care at UH. If it's not the sufficient supply (through forced employment) of doctors medical service by government hospitals wouldn't be this good.

Just because of one blotch up by a government staff, the public cry for blood. And the government have to find ways to fix it. At least they are doing something which is fixing the issue of inexperience doctors. What about other government department which doesn't seems to be doing anything at all? the department of environment? the prime minister department (totally ignoring the recent demonstrations)? Works minister?

Yes, i'm very defensive of our government run health care system simply put the general misconception they are inefficient. Before my mom went for endoscopy at Selayang, she first went to a private specialist at taman tun. Not only was she forced to wait (popular tactic in ALL hospitals), her appointment was delayed at last moment notice. Mind you that endoscopy requires the patient to fast for at least 12 hours. so imagine what pain it must have been not eating for more then 12 hours and having gastric at the same time. My gf too was put into similar situation at Megah specialist center. waited for almost an hour for the doctor who lived at taman tun which is just a stones throw. and failed to diagnose it as dengue. plus we had to pay a hefty bill almost Rm200 for a bunch of unneeded medication. her treatment at UH was RM350 for 3 days stay (5 meals a day) and many other lab test (checking blood count). and the best part is it's subsidized by the government when it's confirmed dengue case (full cash refund on the spot).

So, has the government health care wrong it's citizens? especially now with an extra year of service for doctors to make sure the rakyat gets the best medical attention.

[Adrian Wong]

Originally Posted by plasma

This seem to be a spin from the recent mishaps involving a little baby, some actions needed to be taken.

But aren't housemans the ones doing most of the work in the hospitals?

Actually, I don't think the houseman was at fault. There is supposed to be an MO covering him. But if the MO is too lazy/tired, then he/she will be sleeping the shift off, leaving the houseman to handle everything.

It is partially (at least) the specialist's fault because he asked the houseman to inject the antibiotic over the phone, without making sure he knows how to do it... or whether he's supervised.

IMHO, if any action needs to be taken, it has to be proper training of housemen. Right now, they are being used to do menial work. When I started off as a houseman, I was ridiculed and scolded for ASKING how to do certain things. The idea seems to be, you are expected to know how everything is done.

Unfortunately, even the most brilliant houseman will not know the hospital protocols and practices. Refusing to teach them is how you get to such problems as housemen wrongly administering drugs. Refusing to give them enough rest is how you get housemen to confuse similarly-sounding drugs.

FYI, even nurses are given the day off after an overnight shift. Doctors have to CONTINUE working their day shift after an overnight shift, and some are asked to do back-to-back calls... sometimes more than 3 days.

[Adrian Wong]

Originally Posted by rusty

IMHO, it's isn't truly a bad thing. How else would there be enough workforce in the government hospital? Both my grandmas was admitted into government hospitals, and their care is top notch (one in Universiti Hospital, the other in Melacca General Hospital). Furthermore my mother was treated extremely well in Selayang Hospital to diagnose her gastric problem. How about lately my girlfriend was warded for dengue fever who was also treated with great care at UH. If it's not the sufficient supply (through forced employment) of doctors medical service by government hospitals wouldn't be this good.

Actually, getting the workforce is NOT difficult. For a small country, we have a really large number of colleges churning out doctors every year. My college alone produces about 300 doctors a year, and it's on the increase.

The issue of workforce is really about 'retention'. Right now, the government is relying solely on threat to force doctors to serve. Other countries only have a mandatory 1 year housemanship. We tacked on a 3 year government service on top of that, and now add an additional year. If you do not complete all 5 years, you CANNOT practice privately in Malaysia.

Private practice isn't as lucrative as it is made out to be. Yes, private hospitals charge a lot, but doctors overall do not earn that much. If they do, it's generally because they work like crazy. I know a surgeon who is doing very well but that's because he works 7 days a week and rarely goes home until late at night.

Yet many other doctors are faltering in private practice, merely because there is excess supply of some specialists in the market. We are churning out a LOT of doctors, and that's a fact. The issue the government should be asking is WHY can't they retain them?

I don't think money is the only reason why doctors leave government service. Many are leaving for Australia where the pay is essentially the same. I asked them why, and the answer certainly was not money. In fact, they have to invest a lot of their money to migrate to a job that pays essentially the same.

The big issue here is working condition. Many doctors are leaving for better working conditions. I personally believe most doctors join the profession to serve the people. But I don't think even the most altruistic person can accept functioning at less than 100% mental capacity just to "fill a slot".

I believe what most doctors are asking is a reasonable working condition, where they get enough rest. Countries like the US, UK, Australia already enforce work time restrictions and this has resulted in better healthcare. Why can't we do the same?

If we can do the same, I'm pretty sure many doctors would remain. But I doubt it will happen, because it has been our government's policy to flood to market with doctors... so at least some will have no choice but to stick in public service. IMHO, that's a BAD policy. It's cheap for the government but expensive (health-wise) for the people.

Originally Posted by rusty

Just because of one blotch up by a government staff, the public cry for blood. And the government have to find ways to fix it. At least they are doing something which is fixing the issue of inexperience doctors. What about other government department which doesn't seems to be doing anything at all? the department of environment? the prime minister department (totally ignoring the recent demonstrations)? Works minister?

Well, the government isn't really interested in fixing things. It takes too much effort. What they are doing now is blaming it on "inexperienced housemen" and using that excuse to extend government service.

If countries like the US and the UK can train their housemen in ONE YEAR, why can't we do it? The truth is the LENGTH of training has little effect on the QUALITY of training. With bad training (as a result of overwork, no training, etc.), you can train a houseman for 10 years and still get a lousy doctor.

Originally Posted by rusty

Yes, i'm very defensive of our government run health care system simply put the general misconception they are inefficient. Before my mom went for endoscopy at Selayang, she first went to a private specialist at taman tun. Not only was she forced to wait (popular tactic in ALL hospitals), her appointment was delayed at last moment notice. Mind you that endoscopy requires the patient to fast for at least 12 hours. so imagine what pain it must have been not eating for more then 12 hours and having gastric at the same time. My gf too was put into similar situation at Megah specialist center. waited for almost an hour for the doctor who lived at taman tun which is just a stones throw. and failed to diagnose it as dengue. plus we had to pay a hefty bill almost Rm200 for a bunch of unneeded medication. her treatment at UH was RM350 for 3 days stay (5 meals a day) and many other lab test (checking blood count). and the best part is it's subsidized by the government when it's confirmed dengue case (full cash refund on the spot).

Actually, our healthcare system itself is GOOD. I'm not saying that we have bad healthcare. But it is on a slide downhill. If we do not reform the system, we will end up with a bad healthcare system. DYKT corruption is also snarling its way through our healthcare system? Doctors and nurses are being "rewarded" for recommending certain drugs, prostheses and other medical products over their competitors? It is the beginning of the end IMHO.

TBH, government hospitals generally have the best equipment. They also have very good doctors running them. I personally do not like some of them (for their attitudes), but I can't help respecting them for their knowledge and dedication to the service. But I would not generalize and say that one is better than the other.

IMHO, there are pros and cons to both private and government hospitals. You may have several bad experiences in private hospitals, but I have recently (just days ago) seen how efficient one was. I have also heard and seen my fair share of problems in government hospitals.

Originally Posted by rusty

So, has the government health care wrong it's citizens? especially now with an extra year of service for doctors to make sure the rakyat gets the best medical attention.

Ahhh.. That is where I would most strongly disagree with you. An extra year of service will not get you the BEST medical attention. It just reduces the cost of our health programme because having more local doctors would mean our government can do without expensive "imports" from Pakistan and elsewhere.

It is all about the money and nothing about better healthcare. I have not heard A WORD about proper housemen training programmes, or better working conditions, or even enforced rest for our government doctors. It is really all about the money.

[rusty]

point taken, as for doctors migrating to the UK and Australia, it's most probably due to the strong labor laws. hence the good working condition. I do have to agree that we are somewhat lacking in this part.

however as for the part of doctors performing better overseas, other then the more humane working conditions, it's also due to a supporting industry, lawyers, and insurance. civil rights are tightly uphold in those countries, hence the ease of getting a lawyer to fight for patients right/compensation whenever there's a blotch up. this can be a contributing factor for doctors to be more thorough with their work, hence, more professional. so, other then working conditions alone, the sense of responsibility is equally as important.
as for us, either we close one eye, or the government compensate. i'm not sure what will happen to the doctor/medical staff that's responsible.

anyways, as for corruption in the medical line, it's rather inevertable looking at the state how the government is run. depending on which hospitals, some have influential medical staff which demands for their choice of medical supplies. while there is still a small portion where the store keeper plays boss and decide what to buy depending on which salesman service him best (most of my customers/distributors service store keepers since the result is immediate). IMHO, having a store keeper which buys without medical knowledge more damaging then medical staff that's been rewarded for taking a competitor brand. anyways, that's going way out of topic since there are bad apples in every field regardless position in work/social strata.

[peaz]

imho, if you want dedicated staffs, you have to treat them well. Otherwise, you'd just get disgruntled staffs which would not work their 100% or maybe even 50% no matter that kind of restrains you implement.

seriously, to quote an example, if you want your car to be fixed well, pay the mechanic reasonably and don't undercut and bargain too much. Happy mechanic = good service. Of course, a sly one will always be sly no matter what you do. So do choose a trustable one too. haha

[Adrian Wong]

Originally Posted by rusty

point taken, as for doctors migrating to the UK and Australia, it's most probably due to the strong labor laws. hence the good working condition. I do have to agree that we are somewhat lacking in this part.

however as for the part of doctors performing better overseas, other then the more humane working conditions, it's also due to a supporting industry, lawyers, and insurance. civil rights are tightly uphold in those countries, hence the ease of getting a lawyer to fight for patients right/compensation whenever there's a blotch up. this can be a contributing factor for doctors to be more thorough with their work, hence, more professional. so, other then working conditions alone, the sense of responsibility is equally as important.
as for us, either we close one eye, or the government compensate. i'm not sure what will happen to the doctor/medical staff that's responsible.

anyways, as for corruption in the medical line, it's rather inevertable looking at the state how the government is run. depending on which hospitals, some have influential medical staff which demands for their choice of medical supplies. while there is still a small portion where the store keeper plays boss and decide what to buy depending on which salesman service him best (most of my customers/distributors service store keepers since the result is immediate). IMHO, having a store keeper which buys without medical knowledge more damaging then medical staff that's been rewarded for taking a competitor brand. anyways, that's going way out of topic since there are bad apples in every field regardless position in work/social strata.

Actually, the legal fraternity is killing the medical profession in litigious countries like the US.

DYKT : Due to insane insurance rates, many O&G practitioners are forced to either quit.. or only practice Gynaecology in the US? This does NOT improve the quality of healthcare. Instead, it reduces the number of available practitioners, drives prices up and increases the burden and risk on those who practising.

IMHO, doctors are like everyone else. They are human. Making mistakes is a GIVEN. Even when they don't make mistakes, FAILURE is a certainty in some cases. They are not Gods. To punish them for being human is really excessive. You don't see the same treatment being applied to other professions.

What excessive overwatch and litigation do is force doctors to keep thinking about risk and liability. DYKT there have been many cases where doctors refuse to help dying patients merely because by helping them, they would be exposed to litigation? DYKT there have also been cases where doctors helped people in life-threatening situations and yet were successfully sued by those they helped for inane things like not getting their consent before helping them?

At the end of the day, such practices result in a bunch of doctors who are more worried about their licenses than real doctors who are interested in helping people in trouble. But what can we do? This is the system that the people asked for.

Regarding corruption, our government has to do something about it. If there are options, ALL those available options must be presented to the patient for him/her to choose. Otherwise, the drugs and other equipment must be purchased based on their merits and cost, not how pretty and sexy their sales reps are... or how much commission the Head of Department gets for the sale.

Also, the government MUST pay a salary that commensurates with the sacrifice of these doctors and the risks they accept each and every day. Otherwise, our public healthcare system will run itself into the ground. Right now, the only way the government can retain staff is by FORCING them legally. Are disgruntled doctors what we want in our hospitals?

IMHO, do away with stupid projects like our Angkasawan, North, South, East, West "Economic Corridors", Port Klang Free Zone and we will have BILLIONS of ringgit to pay our doctors AND other government servants.

[Adrian Wong]

Ooops.. Just forgot I sent The Star an updated comment (see above). I just updated it above. Missed a salient point earlier.

[Adrian Wong]

BTW, my comments came out in The Star two days ago but it was HEAVILY sanitised. No mention of the SLAB programme or our own Masters programme. What's the point of printing my comments if they skip the salient points?

I didn't even bother to cut out the piece of trash.