Saturday, August 18, 2007

Producing Competent Doctors in Malaysia

Sometimes it is very difficult to understand politics, and in particular, our politicians. Everytime an election come by, universities are promised to states where votes are needed. Sometimes, as part of those promises, a medical schools is thrown in, just to win more votes. I'm sure the politicians will claim that this is all part of a grand plan. If so, none of us are aware of it except them.

It is true that having a university and medical school, brings with it developmental funds and also some commerce. It develops the state. I was told that Kampar was a sleepy town until MCA brought TAR university there. It is now buzzing. Students, after all, have to rent homes in which to sleep and go to eating establishments to fill their bellies while the universities attempt (successfully or not) to fill their minds.

Commerce aside, surely along the way, some thought must be given to two important issues. Especially where medical schools are concern. Firstly, are there too many? Secondly, how do we maintain standards?

Are there too many medical schools in Malaysia? At the last count, there are 19 medical school in Malaysia, a land of 27 million people. If each medical school spits out 100 doctors per year, there will be 1,900 doctors entering service yearly from local universities. Add to that about 500-1,000 doctors returning home from abroad, then you have about 2,500-3,000 doctors, entering service yearly. This is a big number. Not so many old doctors leave service yearly. There will be a net gain in number of doctors entering service. Of course politicians always say that there is a shortage of doctors. They all justify flooding the market with doctors as a means of controlling doctors professional fees, which they argue is the reason for rising medical cost. Alas, a quick look at the medical bill of patients discharged from hospitals and medical centers will easily show that a large part of the bill is made up of hospital charges, something which the politicians make no attempt to control.

As I understand it, there is no shortage of doctors in Malaysia, just a severe mal-distribution. Most doctors leaving public hospitals start their practice in the main towns like KL, Penang, Johore Bahru, Malacca, Ipoh, and the like. There is a shortage of doctors in the interior of Pahang, Kelantan, Sabah, and Sarawak. The last two is also partly government sponsored shortage, because there is a law forbiding West Malaysian doctors from working in East Malaysia, without special permission.

With so many medical schools, how do we maintain standards. It is very frightening to note that some public medical schools are initiated with just one or two lecturers per department, or in some medical schools, one or two lecturers per medical school. Maybe only the opposition wants to talk about this problem. The few lecturers are recruited often from foreign countries, whose medical degrees may not be recognized in Malaysia. Often times they are recruited in a "just in time" manner probably arriving on the same flights bringing the students in.

Just to fulfill promises made during the election campaign, medical schools are started without adequate planning and staffing. Medical lecturers are then recruited from all over, of various sorts, some not even speaking English (the lingua franca of the medical fraternity), and whose degrees are doubtful. How then can we have good doctors for our rakyat, when the teachers of doctors are doubtful? When the teacher is a monkey, is it surprising that the student suddenly gains a liking for bananas.

It is often said that when the VVIPs are sick, they have their own personal doctors, of the highest quality in the land, or some VVIPs even go overseas for minor suegery (like not so long ago, a VVIP went to Australia for a simple nose operation). The ordinary rakyat have to face the "half past six doctors". I was told that some of our KL public hospitals emergency rooms look like emergency rooms in some south Asian or middle eastern hospitals.

It is not entirely true that Malaysians are not willing to help teach in local medical schools. You must see the amount of redtape that one have to go to, to be employed. Frankly speaking, the working conditions in local medical schools is really something else, and I am not talking about difficult students. Even my old boss, the late Tan Sri Prof TJ Danaraj, had his fair share of problems with the University of Malaya and the Government of Malaysia, about passing and failing students, in the good old days.

We tried to broach the subjects of some of us, "senior specialist" helping to teach and see patients in the public universities. Alas no, we are told. Thank you, but no thanks. If we do that, they are very afraid that we will steal their patients. Yet they will allow their teaching staff to hold "private practice" clinics, and steal the publics time to collect private practice money. A coronary angiogram by the lecturer on university time will have to wait 1 month, but on his private practice time, can be done tomorrow.

I only wish that the politicians who decide public policies take cognizance that poorly trained doctors are a greater danger to our society then the bus driver who killed 20 passengers recently. How I wish that when our VVIPs are sick, they have to go for treatment, unannounced, at our local public hospital emergency department and line up like the rakyat. Perhaps then they will see what harm, their medical education policy can do? But alas, that is not going to happen.

The next time a VVIPs motorcade zooms past you during rush hour remember that you just waste a few minutes. The same thing is happening in our emergency rooms are lives are just simple being wasted because we got the government we voted for.

Update: Thanks to MMR for featuring this post.


Sheena said...

While I agree that the "shortage of doctors" is probably a mal-distribution issue, rather than a n actual shortage of Malaysian medical graduates, I question the accuracy of your statement that there is a law forbidding West M'sian doctors from coming to Sabah & Sarawak. If anything, West M'sian doctors are ENCOURAGED to come here, by virtue of their increase in housing allowance, something that is not available to Sabahans & Sarawakians who practise locally, and it is relatively easy for KL to reassign MOs to hospitals in Sabah & S'wak. Something that might not be as easy if as you say, there is indeed a law.

And while I understand your concern that the lecturers from overseas may not be qualified, etc., all the same, the bulk of them working in A&Es are fairly competent, and some are probably even more competent than local doctors, just that their degrees are not recognised locally.

To address the issue as a whole, one would expect LAN to play a role in this, something which is not happening as vigorously as it should, considering these universities exist to produce doctors; and of course, Kementerian Kesihatan to also monitor these universities. Unfortunately, the question is, how well will the public react to a medical university being deemed "unfit" when there are bigger issues at hand that determine why some people cannot enter public universities? I can't blame the KK for wanting to tread carefully after the fiasco that was Russian medical universities' degress a few years' ago. All the same, a little too much caution means that we still get inundated with doctors who quite possibly have not been trained well... Question is, has this problem manifested yet?

Chin Yit said...

Dr Ng

While the undergraduate medical education in Malaysia leaves something to be desired, do you think if you would support the local Masters programme?

Those who completed the local Masters could take FRCS, FRCR exams and end up with a UK qualification as well. Not FRCP though, as it is nominated.

Singapore new Residency programme seems quite like a fast track and very well organised. Perhaps senior physicians in M'sia like your good self can offer the authority some advice on how to improve the local Masters.