Sunday, January 16, 2011

Sunday Star: MMA: Send the young ones to rural areas... By CHRISTINA TAN

MMA: Send the young ones to rural areas


PETALING JAYA: The Health Ministry should make it compulsory for younger specialists to serve in remote areas to reduce the country’s dependency on foreign specialists, said the Malaysian Medical Association (MMA).

Its president Dr David Quek said contract specialists and medical officers have been serving in remote areas in Malaysia for many years.

He said to overcome the shortage at district hospitals, locally trained doctors should ideally be deployed there. “But many young specialists do not want to leave the towns and cities, thus creating a problem.”

He said it was time to work out a more structured programme, under which the junior but qualified specialists or advanced trainee specialists could take turns to provide services at district hospitals.
“Perhaps we can work out a rotational posting of a few months to two years,” he said.

Dr Quek was responding to a recent statement by Health Minister Datuk Seri Liow Tiong Lai that the Government was hiring qualified foreign specialists on a contractual basis to provide improved access to medical services in district hospitals and help reduce congestion in general hospitals.

The ministry would work directly with the governments of Egypt, India, Pakistan and Sri Lanka to bring quality specialists in six disciplines – internal medicine, paediatric, surgery, obstetrics and gynaecology, orthopaedic and anaesthesia.

Dr Quek said it was a genuine concern that some of these foreign doctors might lack commitment or medical professionalism.

“Foreign doctors working in a different environment from their own country may have cultural differences, which sometimes cause patient-doctor miscommunication and misunderstanding,” he said.

Dr Quek said although there were perks in place for young doctors to serve in remote areas, the Government should also give them the guarantee to return to urban choice hospitals for post-graduate training as well as better hardship allowances and tax breaks.

He added that working in district hospitals could provide good experience for young specialists and help reduce the need for patients to be always referred to the tertiary hospitals.

“We urge all young doctors to consider their career paths and serve the public dutifully.”


The Full Email Interview with The Star Reporter:

1) If it is compulsory for all specialists with the government to serve at the rural areas, does is that mean that the shortage of such experts at rural areas can be overcome and the government do no have to import foreign specialists to be placed at rural areas?

At this point in time, the govt and the MOH only makes it compulsory to serve the govt for 2 years after the 2-year housemanship training--a total of 4years.

At the current time, once completed the housemanship training, the newly minted Medical Officers (MOs) can be deployed anywhere in the country on the basis of need, which is why many of these more junior doctors are posted to more remote and rural areas, or smaller district hospitals.

But, many of these facilities remain understaffed by MOs, that is why Medical Assistants (also called assistant medical officers, but not really trained doctors) have been utilised for these functions. Ideally all such posts should be filled by trained doctors, with the MAs helping to look after more mundane and manual aspects of medical care under supervision.

When it comes to specialists, unfortunately these are really not usually posted to these remoter or rural areas, because there is shortage even in the urban tertiary specialist hospitals. So for a long time, few if any are sent anywhere to the district hospitals. Usually senior medical officers/registrars or trainee specialists are sent to perform some simpler surgeries in some of these district hospitals, so that fewer need to be referred to the city hospitals.

For example when I was in my earlier MO days in JB, I was posted on weekly rotation basis to Kluang District hospital to look after some Obstetric and Gynecology clinics and surgeries, where I had the opportunity to perform Caesarian sections, more complex deliveries, and some other surgeries like miscarriages, etc. after my consultant in JB Hospital certified that I was capable of performing these safely. Of course we do have to make important judgement calls to refer more difficult and complex cases to Hospital JB. this is always based on the patient safety factor, if we feel incompetent or outside our purview of skill or training, then we should refer upwards for more specialised care, i.e. to tertiary city hospitals.

These days however, the expectations are higher from the public, and most of these are performed by qualified specialists where possible, rether than just registrars, but there is a clear need for distributing more specialised care to the district levels to ease the congestion in tertiary city hospitals.

Most of the district hospitals have been upgraded recently and can certainly perform more complex medical or surgical procedures, if there are enough manpower to do this. Hence the need to import some of these specialists from abroad to fill this need. But this is a stop-gap measure and not the optimum approach.

Perhaps it is time to work out a more structured programme where junior but qualified specialists or advanced trainee specialists can take turns to consistently provide such services at these district hospitals--as this will count as very valuable hands-on experience or even skills development for advancement in their careers or for promotion prospects of these doctors.
2) Are the government hospitals in the cities and the bigger towns have more than enough specialists?

Unfortunately even these are often insufficient because of the huge demand for such specialised care. We do suffer from a shortage of specialists in many disciplines still, including special surgeries e.g. neurosurgery, cardiothoracic surgery, some special orthopedic surgery,  paediatric surgery, cancer specialists, anaesthetists, etc.

Many of these are actually available in most of the city private hospitals, which create this sad dichotomy of private vs. public access to such special care. Sometimes many very highly skilled specialists are rehired on an ad hoc basis to help out the public hospital shortages, neurosurgeons are often the ones who have contributed.

We must find better incentives and remuneration packages to help retain such specialists in the public sector, and perhaps also ensure that good senior specialists are not retired too early--55 is too young for many. Although the perks offered by the MOH is much much better these days, they still lag behind what can be reimbursed in the private sector--sometimes it is the internal bureaucratic bickering and unpleasant working conditions which cause many senior doctors to leave.
3) You also mentioned that young specialists are reluctant to serve in rural areas. Why? Because of family commitment or other reasons?

In general, most young specialists or for that matter, most doctors prefer urban living. For many they are reluctant to leave for more difficult postings in the remote or rural areas, sometimes because of the posting being too far from their loved ones and families, but this is now no longer a sufficient excuse.

The MMA feels that younger doctors must do their part to contribute their share of national social duty to participate in all healthcare areas of need. Of course we will fight very hard of these postings to be offered with greater guarantees of timely return (6 months, 1 to 2 years maximum) to postings of their choice, with no lost of seniority or promotion prospects, if anything, these should be extra points in favour of preferential treatment by the MOH. But, all doctors must be prepared to serve anywhere in such needed services, (which can be computerised for fairer distribution allocation), but with strict career plan structures attached, with perks, hardship allowances, additional points for promotion/special training preference, etc.
4) Why it is important for the young doctors/specialists to serve in rural areas? What kind of experience that they can gain when serving in rural areas? How it will benefit them?

In many instances, the more rural/remote areas provide a greater number and variety of possible hands-on experiences for the younger doctors. In large city hospitals with many doctors all vying for training and experience, this can be sometimes short and inadequate. Also, in smaller hospitals, it is possible for younger doctors under training or in the earlier part of their specialist career, to be given more time and opportunity to learn by reading more, accessing the internet more consistently and honing their skills, and clinical acumen.

The more experience one gets as a doctor the better one becomes, especailly when these are well-studied and carefully though about. The more procedures or surgeries that one perform well, the better the skills too. Perhaps, the MOH can come up with greater structured programmes which can enhance such experiences and training. Periodic oversight and supervision is of course very important to enable these younger specialists or trainees to interact and learn from their senior mentors.
5) In you opinion, specialists should serve at least for how many year in the rural areas.

For many, this is a loaded question, but for the purposes of national service and duty,perhaps we can work out a rotational postings of perhaps a few months to perhaps 1-2 years maximum. We know that some specialists have actually opted to remain in these areas, after accepting such posts. So not every one finds such deployment too objectionable as to wish to leave as soon as possible.

My China Press interview is below:
Malaysia has been having contract doctors working in the country for many years now. Some are specialists while other are medical officers who have served in remote unpopular sectors. The contract is usually for 2 to 5 years, renewable, depending on the quality and assessment of the service provided by individual foreign doctors.
In the past many were of mediocre standards and most were not renewed, unless they provide critical services in very remote sites such as in interiors of Sabah and Sarawak.

 Currently in MOH upgraded hospitals there appears to be shortage of specialists designated to provide some secndary care. So this is the rationale for the contract doctors specialists. Ideally our own trained doctors should be deployed to these hospital, but may younger specialists do not want to leave the major towns and cities, which create such a problem.

 Perhaps the MOH need to be more forceful in this implementation so that these specialists can play their public duty and responsibilities. Nowadays the perks and incentives for young specialists are quite good, although not nearly as good as in the private sector, but the private sector is getting saturated too!
Working in thes district hospitals can provide good experience training for younger specialists too and help reduce the need for patients to be always referred to the largest tertiary hospitals for more difficult operations, so the MMA supports this.

This is genuine concern that some of these foreign doctors may lack commitment or medical professionalism. Having foreign doctors working in a different environment from their own country may have cultural differences which sometimes cause patient-doctor miscommunication and misunderstanding.
MMA is most concerned with quality issues and patient safety and there must be better mechanisms to check and evaluate the service quality of such contracted specialists. We do not want our rakyat to suffer from poor quality service of medical or surgical care, which can cause harm or even unnecessary complications or death.

If local specialists are willing to work in these areas of need, we are convinced that their career goals and paths will be much enhanced. Service in more remote or hardship areas are always as looked upon as a qualitfying point for faster promotion and perhaps better incentives. Persuading our local doctors to serve anywhere in Malaysia is a challenge.

In the near future, with so many medical graduates coming into service, there will likely be a glut of medical officers who would have to fight very hard for limited training posts for specialist training. By then we are more likely to produce more locally trained specialists if the training structure and programs are enhanced now. The MOH should look into this aspect of more structured careers paths for all medical officers, so that the doctor an know how his final goal and position can be, rather than muddle along, as simply extra pairs of working hands!

We are not sure which disciplines are truly lacking, but the distribution of doctors in the country can be made even better with greater planning and also greater determrination so that doctors cannot simply say no, when they are posted to less attractive areas. Our perks are already in place, but guarantees to return to urban choice hospitals for postgraduate training would help, as are better incentive hardship allowances and tax breaks.

 The MMA urges all younger doctors to seriously consider their career paths and serve dutifully for the rakyat as well as work very hard to gain as much experience and skills as possible to become excellent doctors specialists and also become competent professionals to serve the country and rakyat.

Dr David Quek
President, MMA

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