Wednesday, November 16, 2011

The Standards of Medical Education in Malaysia and Its Acceptability

The Standards of Medical Education in Malaysia and Its Acceptability
Dr. David KL Quek,
MBBS, MRCP, FRCP, FAMM, FCCP, FASCC, FAPSC, FNHAM, FACC, FAFPM (Hon.)
Immediate Past President, Malaysian Medical Association (MMA)

(Lecture presented at the Medico-Legal Society of Malaysia Conference, Royale Chulan Hotel, Kuala Lumpur, on 16 November 2011)


Glut of Medical Graduates—Too Many, Too Soon…
The past 5 to 10 years have been a watershed period for medical education in the country. During this time, Malaysia has embarked on an ambitious if misguided (in my opinion) approach to rapidly attaining ‘self-sufficiency’ in health care providers for the nation’s perceived needs and demands. For doctors, it was finally announced that there is now a directed plan by the government to try and achieve a doctor-population ratio of 1:400 from the current (2010) 1:903.

To achieve this, some 34 medical schools have been now licensed by the Ministry of Higher Education (MOHE), with almost 50 medical programmes (these include public medical schools teaming up with other foreign or local medical schools to form for-profit private joint medical programmes). The objective is to generate the requisite medical graduates to quickly fill in the projected and computed vacancies for the various public sector health facilities. The ultimate goal is to become a country with the so-called ‘recognised’ developed status doctor-population ratio of under 1:400. And we aim to do this in a short span of under 10 years—by 2020! 






By comparison, the United Kingdom has some 32 medical schools for a population of 67 million, producing some 7,500 medical graduates per year. It is good to remember that the UK has had a long hallowed tradition of excellent medical services and education for centuries, with an extensive cohort of ready-made clinical teachers, professors and academicians. We are just about 45 years since we began our first medical programme at the University of Malaya, in 1965.


In UK, the annual output of medical graduates is around 7,500 and they are trained in 140 hospitals; in Australia 3,400 graduates are trained in 60 hospitals; in Hong Kong, 350 graduates in 13 hospitals; and in Singapore 150 graduates in 4 hospitals.  In Malaysia, 2008, there were 2,274 graduates undergoing training in 38 hospitals and, since then, the number has increased tremendously, so much so that the Ministry of Health has had to increase the number of accredited hospitals for housemanship training, barely scraping by with sometimes just a single clinical specialist for each discipline, at more remote district hospitals.


And the truth is that we really don’t have a happy history of strong medical educational expertise and consistency of academicians; most of our senior and experienced medical specialists and professionals are in the private sector, or they would have migrated overseas. (It is estimated that as many as 40-50% of Singapore’s health service personnel are manned by Malaysian medical graduates!)

A few dedicated senior doctors are in our medical schools, but most are driven and run by relatively ‘young’ post-graduates or even specialist in training, whose ability to impart and inculcate ethical healthcare values and inspiration for compassionate care may be untutored, wanting or uninspired.

(I would at this juncture like to apologise to our younger colleagues out there, that this is not a disparaging remark to belittle their efforts at medical education or their skills—age and seniority are not requisites for medical excellence, for sure. Indeed when we are young, hungry, and foolish even, we tend to have the best and most aggressive approach to learning and hopefully teaching special skills—“see one, do one, teach one”.[1] I began as a lecturer at the age of 29 years, and I fully recognise that we can all be good dedicated teachers, when we choose to become one—yet there is no denying that experience and seniority helps create a sense of stability and perhaps more importantly, ethical balance and professional equipoise, particularly in the field of medical education and the hugely important responsibility and privilege of training medical professionals!)

Yet by 2020, we are targeted to produce some 5000 medical graduates every year for our projected population of 35 million, excluding those others who might be returning from foreign medical colleges. This is by any measure a humongous number of new medical graduates, which any middle-income country can ill afford to sustain or worse to develop a sensible program at accommodating the requisite progressive training of young interns or even to provide a quality health service!

Table 2.4.: Number of Annual Practicing Certificates Issued 
According to State and Sector, 2007 to 2009.
STATE

2007
2008
2009
Public Sector
Private Sector
Public Sector
Private Sector
Public Sector
Private Sector
KUALA LUMPUR
2,239
1,762
2,590
1,881
 2,797
 1,952
LABUAN
18
16
12
17
 12
 17
PUTRAJAYA
254
9
257
10
 294
 10
JOHOR
612
981
752
1,041
 933
 1,072
KEDAH
446
458
484
483
 580
 482
KELANTAN
637
209
784
207
 926
 218
MELAKA
306
378
322
363
 374
 406
NEGERI SEMBILAN
354
341
401
401
 532
 372
PAHANG
340
355
440
378
 489
 385
PULAU PINANG
514
874
559
938
 683
 960
PERAK
662
803
759
835
 924
 854
PERLIS
95
28
120
28
 139
 38
SELANGOR
1,198
2,337
1,393
2,508
 1,692
 2,624
TERENGGANU
260
166
266
182
 335
 193
SABAH
462
342
592
358
 696
 379
SARAWAK
471
357
543
378
 605
 382
TOTAL
8,868
9,416
10,274
10,008
 12,011
 10,344
GRAND TOTAL
18,284
20,282
22,355


Malaysian Medical Council—Annual Report 2009



By 2011, we suddenly realized that we had taken on more than we could chew, literally! And this is not simply because of the huge financial burden of reimbursing these young doctors; almost double that number from just a few short years before! Since 2008, there was an unprecedented hike of public sector doctors jumping from 12,000 to almost 21,000 by early 2011, which appear to totally overwhelm the capacity of the public sector facilities to cater to this sudden influx of so many medical graduates. This glut has placed at severe risk the quality, the consistency and the efficiency of apprenticing these young trainee doctors![2]

This unforeseen supply glut (together with the recent introduction of the 2-year foundational housemanship period) has created a bottleneck of poorly anticipated training or residency programmes.[3] We have now a reversal of the ratio of public vs. private sector doctors, by more than 2:1 (~21,000 vs. 10,500)!

Houseman training hospital wards are now awash with white coats of medical interns (some as many as 50-60 per shift, per department!), scampering about with somewhat aimless, under-instructed and under-prepared purposes. Harassed and hassled medical officers, registrars and specialists now have great difficulty remembering even the names of their charges and most cannot guarantee the adequacy of the proctor-apprentice contact time relationship.[4]

What’s the Beef on Medical Education?
At the risk of sounding self-important and elitist, I would venture to state that the medical graduate is expected to be different from that of other professions, including our counterpoint nemesis—the lawyers! Medical education has by long tradition been exceptionally controlled and regulated.
Our ethical and professional boundaries are jealously guarded and inculcated because of our singular privilege of exercising our ‘bedside’ manners i.e. having expected and unimpeded access to our patient’s medical histories of symptoms, their innermost thoughts, secrets and also that special license to bodily contact and intrusions i.e. the medical physical examination, and the mental examination.[5]
This traditional ritual is more than simple routine. It is now considered as an integral exercise, which can reinforce and enhance the physician-patient encounter and relationship, even if there is that constant unequal tension of antipodal opposites—that paternalistic giving vs. the pliant receiving and the surrendering of one’s innermost self to some extent. However, this dynamic is now changing, with greater patient empowerment these days.[6]
This discrepancy of the doctor-patient relationship and asymmetric privilege carries immense responsibilities, self-control and conscientious self-abnegation on the part of the physician, the doctor. This concept has to be incessantly inculcated so that the physician’s hitherto uninitiated ‘blank slate’ mindset becomes habituated toward embracing this professional ethos. Of course we expect that the acquired medical professionalism and skill must be of a certain ‘standard’, be Hippocratically-modeled and be universally acceptable!
Thus, it is not surprising that we expect stringent and well-defined clinical pathways and regulatory mechanisms which are directed toward ensuring patient safety, reducing medical errors, safeguarding against potential physician abuse, while at the same time also addressing or ameliorating medico-legal concerns.
Students under training are rarely allowed to practice independently on their own, unless rigorously supervised. Thus, medical students have very limited hands-on experience, while in medical school—they are expected to have closer and greater ‘hand-holding’ guardianship and proctorship. Hence, medical schools must adhere to the mandate for adequate and comprehensive clinical material as well as proficient teachers! So we need good teaching hospitals, clinics, wide range of disease or illness spread, with wide spectrum patients, as well as good experienced and dedicated teachers and professors!
All medical graduates are expected to further hone their experience and skills in internship and residency (medical officer) programmes following graduation, before they can be fully registered as medical practitioners and certified to practice autonomously. Depending on the discipline or specialty that one wishes to pursue, the duration of residency or apprenticeship programme varies. Even then for some highly specialized disciplines, post-specialist experience (and ongoing further training) is critical to ensure the highest standards of skills required to function as acknowledged experts. It is a travesty of good apprenticeship; if the new intern is left on his or her own device to muddle through what is probably the most critical formative period of the doctor’s career.
It is no longer acceptable that sporadic exposure to some esoteric or mundane ailment will do for the young learning doctor, most training hospitals and institutions are now insisting on greater structure and more hands-on supervised approaches.[7]
Our unique professional learning-teaching structure dictates that the fresh medical graduates would need more in-depth practical training and closer supervision. Clearly this is crucial because in many instances we are dealing with extremely narrow tolerable margins of errors and possible life and death encounters. While no doctor is infallible, medical mistakes and lapses are not readily acceptable options, and the consequences are too dire for society or the patients and/or their families to bear.
Each and every medical graduate must therefore, experience that arduous if rigorous and preferably well-structured apprenticeship-internship programme, and be personally certified as safe and competent by a host of supervising seniors, to ensure that the final product is as sound and safe for our Malaysian rakyat, or for that matter, for any other patient anywhere around the world!
However, it is also increasingly clear that haphazard and poorly planned approaches to instituting change and innovation can lead to severe disruptions of service and training within health systems, as recently experienced by the United Kingdom’s hurried implementation of the so-called ‘Modernising Medical Careers’ initiative.[8]
In 2002, there was an attempt to transform postgraduate medical education and training in the United Kingdom. This ill-fated initiative called “Modernising Medical Careers” plunged the entire system of training application and implementation of junior doctors into complete disarray, with many good and qualified trainees failing to get job interviews. This heavily criticized debacle lasted some years until the Tooke Report in 2008 highlighted and recommended some 47 rectifications to offset the weaknesses of this scheme.[9] Thus, transformation of health care structure, training and systems need gradual progressive initiatives rather than revolutionary frissons of disruptive madness, even if well-intentioned!
Let’s return to the question of medical education for our nation’s needs.

Foreign and Local Medical Schools Malaise
I am sure that most of us are aware that we have nearly as many Malaysian students studying abroad as at home for a medical degree. That many young Malaysians and their parents hanker for such a tertiary education in medicine is legendary—year in year out, we have vociferous complaints of inadequate medical seats for so many of our aspiring young students. Many aspirants unfortunately do not fully comprehend what it really means to want to become a doctor. Many too would find the cheapest, perhaps the easiest way in which to achieve this result, that they become vulnerable to the untested promises of so many medical programmes, which are now available to them!
What irks us is that there have been mounting complaints that some of these very questionable foreign medical schools have educational programmes that have been formed purely as business concerns. These medical programmes have blossomed of late, to cater for the lucrative foreign medical students from third world countries, or as luck would have it, even from middle-income nations such as Malaysia. Worse, the end product i.e. the foreign medical graduates appear to be of dubious quality with grossly inadequate clinical training and very divergent foreign experiences.
We have Russian, Indonesian or Ukrainian universities offering medical programmes strictly for foreigners in the English language just for the sake of it, when many if not most of the teaching staff have problems even speaking, much less mastering the English language. Medical graduates are expected to leave upon graduation and not practice in the host country! So, one wonders as to the commitment and trustworthy responsibilities and duties of such medical schools!
Whether the standards, communication skills and didactic quality of these dubious medical schools are as good as expected, is therefore difficult to determine; although on paper, the programmes appear to meet the minimum standards of most medicals schools around the world. Diploma paper mills are often more attractive on the surface and self-claims, than its true worth in depth and practice!
So for parents and students wishing to invest in such medical programmes, please seriously reconsider the options, it’s not just the medical degree from ‘any’ university, but ‘the’ prestige and quality of the medical university or college that truly matters!
These concerns also apply equally to some of the local private medical schools, which have sprouted up recently. Our own mushrooming newer local medical schools and programmes unfortunately also appear to suffer such predicaments.
Therein lies the difficulty for quality assessment of these programmes, and the Malaysian Medical Council faces an unenviable dilemma of having to balance a hard-nosed strict sanctions approach to deny or to approve such standards based on a minimum of requirements, and then possibly sacrificing some quality parameters, or earn the wrath of parents, medical school agents and politically-linked investors/detractors.
The formation of these newer medical schools are more often than not, politically motivated—election promises by the government as pork barrel quid pro quo. It has become an accepted norm that every state should have at least one medical school.
The public wants this, so the government complies, notwithstanding the fact that the requisite standard ground rules cannot be applied and that fulfillment of time-honored quality cannot be assured. This leads to the ‘compliant’ lowering or ‘adjustment’ of the minimum standards for establishing these schools. The pressure is to have as many medical student numbers and intakes as possible to cater to the demand rather than to worry about the quality of the medical graduate, or the capacity to deliver in terms of teaching staff and the necessary appropriate standards of excellence.
A Recent Example: Recently a local private medical school has been set up with just one professor of surgery, and 2 associate professors of orthopaedic surgery and obstetrics. Others recruited were young trainee lecturers on a lecturer-training scheme as part of the school’s postgraduate programme. Yet, the ‘standard’ paper work detailing the syllabi and the course programme appear intact and adequate. There are also ‘sufficient’ teacher to student ratios, based on arbitrary naming and recruitment of ‘teachers and instructors’ whose qualifications and experience are undisclosed. Can just about anyone become a medical school teacher or professor, these days?!
So theoretically, this program passed muster and was duly awarded the license by the MOHE, as well as the temporary recognition to begin the medical undergraduate programme, by the MQA and MMC. There are just paper plans of where these students would be placed for clinical teaching and in which hospitals, which as many of us know, are already under siege from the surfeit of medical graduates already present! There are no plans to build a dedicated teaching hospital; and even if there was, this attempt would be fraught with difficulties of staff and personnel shortage as well! The brutal truth is that such a piecemeal slipshod medical school starting off this way can at best be described as incredible—perhaps only possible in this nation!
Indeed this has been the trend over the past few years of recruiting medical teachers in as nonchalant a manner as possible. Isn’t this a travesty of our expected medical excellence when it comes to medical teaching? Isn't this a shame that it is now acceptable that anyone will do when it comes to being considered as medical school teachers—what happened to the concept that only the best and the most academic doctors are recruited as teachers and professors? How would the finished product of medical graduates be, if and when the teachers teaching them, are as mediocre or as uninspiring as the basis of their lacklustre recruitment has been?
Non-clinical teachers (many not registrable as doctors in this country to practice) are imported from our neighbouring nations to fill the quota of our chronically short teaching staff. Young professors are elevated, as are instructors promoted, without adequate quality assurance standards, to simply provide the minimum teacher-student ratio. Sometimes these are contracted on part-time ad hoc basis, and tasked with scheduled but unregulated point-of-contact teaching hours, which short-sell the impact of the teaching quality. Patient simulators and simulated clinical teaching are more the norm than real life student-patient contact.
Thus, we hear of anonymous complaints of disparate and substandard teaching and learning experiences. Many students are left on their own to muddle along, in what are increasingly known as “self-learning” modes and even that touted catchphrase of “instilling of self-responsibility and maturity”! Except that many of our young charges are not quite mature or ready enough for such unsupervised learning! But perhaps, I wrongly underestimate them, in which case, I humbly apologise…
But sadly, unless the student is exposed to better medical schools and teaching, they would not have known any better. My own niece, who was enrolled in one local private medical school for one semester before transferring to the National University of Singapore, faced a huge educational and cultural shock! The quality of teaching and programmes are worlds apart, but luckily she is coping well because clearly NUS did their homework when assessing which exceptional student to accept into their very high standard medical school!
But alas, do our medical students have any recourse to complain? I fear not, because there is simply no mechanism to do so; neither is there, any straightforward comparison of quality and standards—ignorance is bliss, so it seems. Thus, caveat emptor is the buzzword!
Whereas some of our neighboring universities are pushing their standards higher and higher, while chasing the globalised expectations of excellence and prestige, we in Malaysia appears to be doing the opposite—just provide the seats because there is great demand, produce the numbers, and let the quality deliver itself, as if economics alone would suffice to temper the emboldened but invisible hand of the free market for profits!
Conversely, and out of sync with many developed nations around the globe, our students are clamouring for more and more medical seats. The lure of becoming a doctor appears an unquenchable one for many a young Malaysian chasing that vocational dream to become a professional, with a supposedly assured job post-graduation. The oft-painted picture that the doctor would not starve and would almost always be assured of having a decent, somewhat respected, even luxurious quality of life, remains the colour-blinded vision and dream of many an aspiring student! Sadly for many, the reality is quite the opposite. In the near future, this could become a nightmare!

So, Can we do better?
It is clear now that with the ever-increasing numbers of medical graduates coming on-stream, there is an urgent and compelling need to systematically address their training-internship programmes, so that there is sufficient work and experience which can be imparted, shared or taught. There has to be more structure and planning, and less ad hoc piecemeal slotting into whatever vacancies there are to be had.
Teachers, proctors and supervisors have to be identified and their job descriptions clearly spelt out so that proper logbooks, minimum professional tasks and learning skills can be properly taught, documented and approved. The objective must be to ensure that at the end of each posting to a discipline, the house officer would be certified as competent in some minimum core skills and also be safe as an independent medical practitioner, ready to embark on to another level of his or her career.
The MMA has been urging the training hospitals to ensure that there is a better-defined career path for each house officer or trainee. After going through the mandatory rotations, there should be mechanisms to allow the trainee to embark on a planned rather than a haphazard chancy career development pathway. It is unfair to simply slot these freshly brewed medical officers into every available vacant discipline just to fill them, although of course some compulsory distribution to rural or remote postings would still have to be worked into the system as part of their national service.
But simply jostling these young medical officers into vacant and unpopular service areas without much supervision is also highly irregular, even irresponsible, although this may be inevitable, for some. For those brighter trainees with clearer goals and determination, i.e. those who aspire for specialist training, they can be encouraged to take and quickly pass preliminary specialist examinations, so that they may be placed on fast track toward specialty training opportunities. Of course those who volunteer or who have been earmarked for remoter postings should be given priority to choices of specialty or advanced career paths, upon stipulated return.
Unfortunately our available seats for post-graduate specialist training are quite severely in short supply. Annually our major university and hospital trainee posts number less than 800, which means that increasingly, the greater majority of medical officers completing their internship, would be left by the wayside of unfocussed and directionless service. But what do we do with these exponentially growing numbers, which will be the majority of these unplaced or misplaced junior medical officers?
Already enough young trainees have been querying if there are indeed sufficient places for them to train or to work towards some form of specialist training—many fear rightly that there would not be enough places, and that competition for the rare postgraduate programmes, severe.
We must recognize that such unprecedented numbers of medical graduates place a severe strain on the available system for such postgraduate medical training. We simply would not be able to cope and a time will surely come when, medical officers would have to compete even for simple service jobs. There may be no guaranteed placements with either internship programmes or any other programme!
The time may come when fresh graduates might have to apply and wait for vacancies, and they may also be selected based on other criteria such as graduates from more prestigious medical schools, those with better grades or honours, those with better testimonials from teachers/professors, or worse, those with political strings and cables!
Already, recently, the Health Ministry and Public Services Commission have asked the MMC to seriously reconsider the necessity for compulsory service for our medical officers, principally because of the huge number of interns completing their service.
In June this year, house officers are no longer employed as permanent service civil servants, but instead as contract workers. Thus, their forward service as automatic medical officers would no longer be guaranteed. In October this year, the ongoing glut of house officers has led to the MOH towards embarking on a mandatory rotational shift basis of work and training—no longer will overtime be paid, but a fixed shift allowance! These are the signs of our system bursting at the seams!
Why is shift rotation unacceptable in our current service of training house officers?[10] Because, as of now, there is no mechanism of ensuring that the quality of supervision and teaching can be consistent, especially for those who have been earmarked for nocturnal shifts. Such ‘graveyard’ shifts are notorious for lack of senior doctors reliably being available for attending to the many patients presenting in the night or early hours. There is also fear of lack of continuity of care both for the patient and the intern, the latter’s learning skills may be curtailed by disjointed passing over of cases and patients to temporary shift-empowered trainees—transitional responsibilities are known to lead to greater missed diagnoses, mishaps and errors.
Despite such serious concerns, which have been raised by many senior physicians, the MOH has seen fit to push forward this major shift in practice! For many of us doctors, we are appalled that this has come to pass. Such changes are not for the betterment of the houseman training programmes, but simply to stop gap and whittle down the yawning financial and administrative bungles, which have resulted from such an explosive medical graduate glut!
If there had been more planning, this could have been avoided. We could have transformed more controlled numbers of medical graduates into more competent doctors by ensuring that we have in place systematic training modules for general or family practice, emergency medicine, administration and health management, public health, etc. But we must get these administrative steps in place before these unwieldy numbers overwhelm us totally!
Thus, there must be an urgent moratorium not just on the number of medical schools, or programmes, but also the number of medical student intake or graduates. The rampant production of medical graduates must be drastically checked to ensure that only the best and most well equipped can be allowed to continue. No medical school should be allowed to arbitrarily increase its intake or output, and neither must there be 2 or 3 batches of intake, which makes a mockery of good or even adequately high quality medical education, both for undergraduate and postgraduate programmes.
Recently, a senior medical specialist and prolific health commentator, Dr. L. Pagalavan[11],[12] has proposed the following, and this is worth re-emphasising:
Tactics that control the number of fresh graduates entering the local workforce
                 Continuous reevaluation of future requirement for health workers.
                 Controlling the number of Malaysians being admitted and graduating from medical schools. This can be achieved through:
        Creation of a body to oversee the quality of medical education, the functions of which may be similar to the Council on Medical Education in the United States.
        Introduction of standards to improve the quality of medical education, e.g. requiring a basic university degree before acceptance into a professional degree program (as in some parts of the world), establishing minimum expectations in a medical curriculum, and a minimum number of full-time medical faculty. Following the Flexner Report which advocated these changes (and more) in similar circumstances to the present in Malaysia, a large proportion of medical schools in the United States merged or closed, and the average physician quality improved significantly.
        A standardized examination for all newly graduated medical practitioners entering the workforce.
        Review of requirements for admission and graduation.
        Review of school recruitment practices.
      Manage student and parent expectations.

All of these points, I have already alluded to in my above discussion. The ball is strictly at the feet of the Ministries of Health and Higher Education.
What do we want or wish for? Just the numbers game, or should we ensure more importantly, the product i.e. quality medical doctors, and ultimately, the safety of our populace? There must be a better alignment and cohesion of purpose and vision, and not just reliance on whimsical bureaucratic or political expediency!
Who would you rather have at the end of the day to look after you when you are ill, when you are older and who would you perhaps entrust the healthcare of your children, your loved ones? Just a barely competent inadequately trained doctor, or the slightly stressed, overworked but experienced and highly skilled one?

Conclusion
The standards of our medical education are falling. This is an unacceptable trend, which should not be allowed to continue. If we do not take drastic remedial steps and actions to stall this slide, we might see a deteriorating climate of healthcare services in the country, with possible lowering of our medical professionalism and our clinical expertise as a whole. We might be reduced to the standards of some of the third world countries’ health services, where excellence is a rarity than a norm.

We could see a decline in our competitiveness, our competence and a deteriorating belief in ourselves, as a developed nation—perhaps to be bogged down once again in a quicksand trap of mediocrity and ‘tidak apa’ lackadaisical mindset. We might soon be having so many poor quality doctors and medical graduates who may be unemployed, even unemployable, and not trusted to be good enough to be our healthcare providers!

Potentially, there could be greater chances of endangering of patient safety and lives, for medical mishaps and errors, and greater risks for medico-legal challenges. Finally, the quality of our health service could deteriorate so much that our routine services would be called into question, with possibly the skeptical questioning of the integrity and foundations of our health service. Instead of trust in our health service, we could see the reversed medical tourism of more and more of our own citizens to other neighbouring countries with perceived higher standards of care and excellence of service!

Disclosure:
I am the immediate past president of the Malaysian Medical Association, and have been arguing against the glut of medical schools and graduates in the country. I am also a 3-term elected member of the Malaysian Medical Council (since 2004—2013), where despite our independent stance as individual autonomous members, we have to abide by collective decision-making and policy determinations, as well as to respect certain Official Secrets Act mandates.

I have taught undergraduate medical students at the Universiti Kebangsaan Malaysia (National University of Malaysia) from 1985-1991. Since then, I have been actively involved in post-graduate teaching in cardiovascular medicine as well as in medical professionalism and medical ethics.

References:    

[1] Patricia J. Numann. See One, Do One, Teach One. J Fam Practice online. Contemporary Surgery (Editorial). http://www.jfponline.com/Pages.asp?AID=293 (Accessed 2 November 2011)
[2] Loh Foon Fong. Houseman Glut: Too many new doctors and too few hospitals to train them, in The Star, Saturday, 27 November 2010, pgs 1, 4.
[3] MMA Press Statement on the Extension of Housemanship to 2 years. August 4, 2009.
[4] Richard Lim and Loh Foon FongCleaning house. The Star, 12 December 2010

[5] Abraham Verghese, Erika Brady, Cari Costanzo Kapur, and Ralph I. Horwitz. The Bedside Evaluation: Ritual and Reason. Ann Intern Med. 2011;155:550-553.

[6] Jerome Groopman. How Doctors Think. Mariner Books, Houghton Mufflin Company, New York, 2008.
[7] Tan TC, Tan KT, Tee JCS. An End to “See One, Do One and Teach One” Residency Training Programme – Impact of the Training, Education, Surgical Accreditation and Assessment (TESA) Programme on Medical Care and Patients’ Safety. Ann Acad Med Singapore 2007;36:756-9. www.annals.edu.sg/PDF/36VolNo9Sep2007/V36N9p756.pdf (accessed 28 November 2010)
[8] Department of Health. Unfinished Business – Proposals for the Reform of the Senior House Officer Grade. London: Department of Health, 2002.
[9] Department of Health. Implementing the Tooke Report: Department of Health Update. London, DS, November 2008
[10] Malaysian Medical Council’s stand on issues raised by the YDP at the MMC meeting on 12/04/11.
[11] Pagalavan Letchumanan. For Future Doctors: Physician Workforce Planning in Malaysia: Better Coordination Needed, July 27, 2011. http://pagalavan.com/2011/07/27/for-future-doctors-physician-workforce-planning-in-malaysia-bettercoordination-needed/ (accessed 08 Nov 2011)
[12] Flexner A. Medical education in the United States and Canada: a report to the Carnegie Foundation for the Advancement of Teaching. New York: Carnegie Foundation for the Advancement of Teaching, 1910.
























16 comments:

andre das said...

I respect you for your tenacity and determination to try and do something which many of my clinician friends have expressed their surrender.
As for me, I have lost one of the biggest motivator and passion in training house officers ( and medical students sometimes) because of their sheer numbers and that is helping the good become better because its now helping the many become "safe".

Dr D Quek said...

I think everyone of us have to keep trying to improve the situation, and finally perhaps we may collectively influence something of a sensible reversal of our fortunes by the authorities that be! I urge our public doctors who are engaged in the thankless task of training our HOs and MOs to continue to do their best, and not to give in!

Game1980 said...

Hi Singapore produces about 350 doctors who train in 7 hospitals (CGH, SGH, TTSH, JGH, KTPH, IMH, NUH)

Dr D Quek said...

Thanks for the correction for Singapore's data! There are now 200+ medical graduates from NUS and another 50 from Duke's Graduate medical school. NTU will be having a joint program with Imperial College from London, soon.

Dr D Quek said...

A correction is in order. Prof Emeritus Alex Delilkan informs me that the UM medical faculty was started in 1962, although the clinical training commenced in 1965 in Hospital KL, then. UM will be celebrating its golden anniversary in 2012. I stand corrected, Thanks Prof. Delilkan!

dHarjma said...

Every problem presents a new opportunity.

Graduates from "inferior" medical schools can make it in the best hospitals in the US based on merit and determination. Why are we complaining about an oversupply of doctors?

All we need to do now make the best out of the situation (oversupply of graduates) by revamping post graduate medical education to be selective, efficient, quick and merit based.

A system that chooses selects only the best regardless of place of graduation and trains them well.

Dr D Quek said...

Every medical school will always produce some exceptional graduates, even world beaters, for those who are determined and therefore good enough to venture forth--perhaps in 'poorer equiped' med schools, this number would be fewer... The trouble is with the majority of undertrained graduates who would be saddled with their potential inadequacies and yet be recognised/allowed to practice in our nation--who will then represent or protect the public's interests and safety?

Ming Han said...

Good day, Doctor. I am graduating soon from biomedical sciences in UKM. Although I have a general interest in medical sciences, I don’t find doing lab works interesting. I do feel that doctors have a more interesting job compare to scientists. Therefore, I jump on onto the newly founded Perdana University Graduate School of Medicine once I heard about it (and i am accepted, sem starting this sept). However, I am made aware (by Dr Pagal)that the US curriculum system might not be suitable in Malaysia as we have different healthcare systems, and also that PUGSOM do not has its own teaching hospital. May I know what do you think about PUGSOM? What can I do in order to ensure myself to be a good physician after I graduate? Since the degree is only recognized in Malaysia, how will it affect my career in the future? Also, considering the “overproduction” of medical doctors in Malaysia now, do you think it’s a good idea to pursue this career? Do you have any advice for me? Thanks in advance.

Olivia said...

Dear Dr. Quek,

May I have your email address please as I wish to seek your advice and opinion on my career in medical education. What you have described in your blog is taking place in my medical school. Hope to get a reply from you. Thank you very much.

Olivia

Olivia said...

Sorry, my email add is olivia.tee@gmail.com

PatrickJB said...

The more the merrier! Anybody (not the government) has the right to decide what they want to become.

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AZNIAL RAHMAT said...
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