Sunday Star: Quality first, not quantity... By Dr MILTON LUM

Quality first, not quantity

By Dr MILTON LUM

Sunday Star, 09 Jan 2011

Recent media focus on the number of housemen and the attitudes of some of them raises questions about the quality of medical education, and by extension, the quality of healthcare patients will be receiving in the future.

ONE of the basic principles taught to all medical undergraduate and postgraduate students is Primum non nocere, ie, first do no harm. It is a reminder to doctors to always consider that an intervention can lead to harm to the patient, however well intentioned it may be.

This principle is even more relevant today than in yesteryears.

Prior to World War II, the doctor’s responsibility to the patient was relatively simpler. It involved making a diagnosis and prescribing a treatment, which the patient may or may not respond to, depending on the patient’s physical state, and the illness he or she was suffering from.

 

 

In spite of the fact that there was, and still is, a marked shortage of medical educators in Malaysia, the expansion of medical schools has continued unabated.

It was not very different from a lottery. Medical knowledge and the range of diagnostic and therapeutic modalities then were limited. Specialists and other healthcare professionals, apart from nurses, were almost unheard of, and their services were only available to the well heeled.

There has been an explosion in medical knowledge, and the range of diagnostics and therapeutics has increased tremendously. Healthcare is one of the fastest growing sectors of many economies and is provided in many instances by a team of healthcare professionals, led by the doctor.

Specialists and specialty services are available in almost every nook and corner of the country, and if not available, access is provided by the state through ambulances and flying doctor services in the more remote areas.

Modern healthcare, however, is not without risks. The publication of To err is human by the Institute of Medicine in the United States in 1999, and similar reports from the United Kingdom and Australia, drew attention to adverse events that resulted from medical errors, the causes of which were human factors and system failures.

It is now generally accepted that the incidence of adverse events from hospitalisations is about 10%, with single digit figures for mortality and morbidity.

This was summed up succinctly by Sir Cyril Chantler in 1998: “Medicine used to be simple, ineffective, and relatively safe. Now it is complex, effective, and potentially dangerous.”

There are currently 24 medical schools providing undergraduate training for Malaysia’s population of 28 million. Countries with similar populations like Australia (22 million), Taiwan (23 million) and Canada (34 million) have 19, 11, and 17 medical schools respectively. – Source: United Nations

Recent media focus on the number of housemen and the attitudes of some of them raises questions about the quality of medical education, and by extension, the quality of healthcare patients will be receiving in the future.

The solutions announced to date are interim measures that do not adequately address fundamental issues which have their genesis upon the students’ admission into medical school. This article seeks to draw the reader’s attention to some of the issues and challenges that need to be addressed.

Learning medicine
There are more applications for entry to medical schools worldwide. Many young people want to become doctors, whether of their own volition, or at the behest of their parents.

High academic qualifications are the sole criteria for admission to all public medical schools in Malaysia, except University Sains Malaysia (USM), which requires an interview as well.

In general, the private medical schools also require high academic qualifications and an interview as well. Some also require applicants to pass an aptitude test.

Although the minimum academic qualifications for entry into medical schools are prescribed by the Malaysian Qualification Agency (MQA), there are claims of non-compliance by some private medical schools. There are also claims that some private medical schools take in more students than permitted.

The situation in foreign medical schools is varied.

Medical schools in advanced economies adhere strictly to high academic requirement, as well as assessments of the aptitude of the applicants.

However, some medical schools in developing countries admit students whose academic results would not even qualify them to enter a university in Malaysia for other courses with lesser entry requirements. Many of such students gain entry through the agencies of these medical schools.

It is necessary to emphasise that selection for entry into medical school implies selection for the medical profession. Findings from studies worldwide confirm that although some students have achieved the academic standards required for entry into medical school, they are not suitable for a career in medicine. It is in the interest of the public and such students that they should not gain admission, rather than to have to leave the course or the profession subsequently.

The issues and challenges that need to be addressed include:

● Should academic qualifications be the sole criteria for entry into medical schools?

● What is the role of interviews and/or aptitude tests?

● How robust is the monitoring of the compliance of Malaysian medical schools to the MQA’s minimum entry qualifications?

● How robust is the monitoring of the adherence of foreign medical schools to the MQA’s minimum entry requirements?

● What should be done to Malaysians admitted to local and/or foreign medical schools without MQA’s minimum entry requirements?

Medical schools
There are currently 24 medical schools providing undergraduate training for Malaysia’s population of 28 million (Source: International Medical Education Directory). Countries with similar populations like Australia (22 million), Taiwan (23 million) and Canada (34 million) have 19, 11 and 17 medical schools respectively (Source: United Nations).

Although there was a dichotomy between public and private medical schools in Malaysia previously, the margins have been blurred in the past few years. Some public medical schools have established twinning arrangements with universities abroad and the fees for students who enrol in such courses are not different from that charged by private medical schools in Malaysia.

Our ASEAN neighbours, Indonesia, Singapore, Thailand, and Philippines with populations of 238 million, 5 million, 67 million, and 94 million respectively have 35, 2, 12, and 41 medical schools respectively.

With the establishment of more medical schools already approved by the Higher Education Ministry, Malaysia may soon join the ranks of countries like Germany, Italy, and the United Kingdom who have 41, 42, and 44 medical schools respectively for populations of 82 million, 60 million, and 62 million respectively.

The issue is compounded by the fact that the government recognises more than 370 medical qualifications worldwide. The list of recognised medical schools was inherited from our colonial masters and added to over the years.

In addition, graduates from unrecognised medical schools can sit for the Medical Qualifying Examination (MQE) of the Malaysian Medical Council (MMC) and, upon passing, will be registered. The examination is the final year examination of the Universiti Malaya, Universiti Kebangsaan Malaysia, and University Sains Malaysia who conduct the examination on behalf of the MMC.

There are some who question the validity of these examinations. However, they have not provided any material to substantiate their suspicions. An analysis would reveal that those who fail the MQE usually have very poor results at SPM and STPM levels.

In spite of the fact that there was, and still is, a marked shortage of medical educators in Malaysia, the expansion of medical schools has continued unabated. Some private medical schools have teaching staff who are mainly foreigners from Myanmar, the Indian sub-continent, and the Middle East. Some of them do not speak any of the local languages, and some have no previous teaching experience.

It is not only the number, but also the quality of medical educators that is crucial in producing doctors that will make a positive impact on the public’s health. Medical educators are role models for students. It is well known that a deficient doctor is reflective of a deficient teacher; just as a child’s conduct is reflective of the parent’s.

Local medical schools are given time-limited accreditation after assessments by teams comprising representatives from the Malaysian Qualification Agency, Health Ministry, and the MMC.

However, it is impossible to accredit all the foreign medical schools recognised by the Government for manpower, logistical, and financial reasons.

Most governments in developed economies recognise their limitations in assessing the quality of medical education of foreign medical graduates. They require all those who want to practise medicine, particularly foreign graduates, to pass a licensing examination.

Many Malaysian doctors who have practised abroad, particularly those above 40 years, have passed these licensing examinations without difficulty simply because of the quality of medical education they received.

Many in the medical profession have stated publicly their concern that there is more emphasis on the quantity instead of the quality of the graduates. The consequences in other areas of studies may not be significant, but in healthcare, it can be a matter of life and death for a patient or potential patient, which means all the population.

The issues and challenges that need to be addressed include:

● How many doctors does the country need, and by extension, how many medical schools does the country need?

● What is the quality of medical education in recognised local medical schools, and how robust is its monitoring?

● What is the quality of medical education in recognised foreign medical schools, and how robust is its monitoring?

● Should not all medical graduates, particularly those from foreign medical schools, whether recognised or unrecognised currently, be required to pass a licensing examination before they are permitted to practise in Malaysia?

● What is the role of agencies of foreign medical schools and how robust is its monitoring?

Housemenship
During the course of the newly graduated doctors’ future practice, there will be continuing advances in medical science and clinical practice, healthcare delivery and financing, increasing expectations of patients and the public, and changes in societal attitudes.

The MMC has listed five basic ingredients of Good Medical Practice. They are professional integrity, communication skills, ethical behaviour, treating patients with dignity, and being a team player.

By itself, the basic knowledge and skills taught in medical schools is insufficient. The housemenship period is the time to make a start in the development of the ingredients of Good Medical Practice.

Young doctors have to develop his or her professional competences, skills, and behaviours so that they are better placed to serve and improve the care and health of their patients. They have to learn to always put the interests of their patients first and that the doctors’ professional practices affect the experiences of patients and their families.

The skills of continuing professional development have to be developed so that their practices can advance in accordance to changes in medical knowledge and practices.

In short, the housemenship period is a time when the newly graduated doctor transitions from theory to practice.

Learning during the housemenship period is not only from books and journals, but also experiential, with the latter playing a significant role. There has to be sufficient quality teachers for this aspect of the young doctors’ training. The teachers, who are usually specialists, have a crucial role to play as they are role models for young doctors.

There has to be exposure to sufficient numbers of patients for young doctors to gain the experience required for independent practice. For example, they have to be exposed to the different ways in which the common conditions, appendicitis and urinary tract infections, present. Failure to make an accurate diagnosis will lead to threats to life, in the case of the former, and long term consequences, in the case of the latter.

When there are few patients relative to the many housemen, it will, inevitably, have a negative impact on the latter’s training.

The statement of Sir William Osler, the father of modern Medicine, is particularly relevant: “Medicine is learned by the bedside and not in the classroom. Let not your conceptions of disease come from words heard in the lecture room or read from the books. See and then reason, and compare and control. But, see first.”

Many specialists report that they find it increasingly difficult to cope with the dual tasks of providing care to patients and training housemen, with the former always having to take priority over the latter. It is disconcerting to hear some specialists state that they do not even know the names of some housemen assigned to their wards and clinics “because there are so many of them!”

The issues and challenges that need to be addressed include:

● How many housemenship training hospitals does the country need?

● How many specialists are needed for housemenship training?

● What is the quality of housemenship training and how robust is its monitoring?

Too many doctors?
With the current rate at which Malaysian doctors are graduating from medical schools, both locally and abroad, the country will reach its overall doctor population target of one doctor for 600 population within three to four years, and a ratio of one doctor for about 400 population or less by 2020.

There will have to be 5,000 to 7,000 Medical Officer posts in the public sector available annually within the next five years for the young doctors after completion of their housemenship training, and after that it will be anybody’s guess.

If there are insufficient posts, how many can be absorbed by the private sector, which is already saturated in many areas?

There will be no employment problems for doctors of good quality, but the prospect of unemployment is a possibility for the mediocre, and possibly, some of the average ones.

When the costs to the state or to the individual of producing one doctor are considered, the question arises whether it makes economic sense to flood the market with doctors. The laws of supply and demand do not apply to doctors simply because doctors are not only suppliers but also play a significant role on the demand side of the equation.

Studies from the developed economies have shown that a small number of doctors account for the majority of complaints and medical errors, where human factors are involved. Poor quality doctors will inevitably contribute to medical errors, morbidity, mortality, and consequential increase in healthcare expenditure.

Going forward
The current problem of housemenship training has its genesis in medical schools. It raises questions and challenges about the quality and quantity of medical graduates, some of which have been discussed above.

The resolution of the problem can only be possible if a comprehensive approach is taken. Ad hoc measures will not solve the problem. Moratoria and increasing the number of hospitals for housemenship may be part of the solution, but they are at best, interim measures.

The fundamental issues have to be addressed before the situation gets out of hand.

Medical schools have to be held accountable for the quality of their graduates. The principle that society’s health is more important than profits has to be adhered to at all times, particularly by the private medical schools.

We owe future generations a healthcare delivery system founded on patient safety and quality of care in which quality doctors have a crucial role to play. The consequences of having significant numbers of poor quality personnel in other areas of human activity may not be significant, but in healthcare, it can be a matter of life and death for all the population.

Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.

“医生过剩”是个问题吗？

“医生过剩”是个问题吗？

当今特约 2011年1月3日 晚上 10点02分

 

分享 43

文：傅向红

 

马来西亚医药协会（MMA）的医疗教育委员会在2008年曾经推估，国内医生人力将在2015年开始过剩。最近《星报》（star）根据医药协会主席郭光龙（David Quek）的部落格撰文，报道实习医生人数爆增三倍——从2008年2297人到2010年的6253人——的新闻 ，再次把医生过剩的“问题”带到国人眼前。

 

过剩与否，一般乃根据世界卫生组织的定义或其它先进国所达成的平均值而推算。马来西亚卫生部所定的医生人口比目标为2015年达1：600，2020年达1：400。超过这些数字，到底会带来什么影响呢？医生过剩该成为国家卫生政策的关注点吗？国家可以如何介入？

医病之间资讯不平等

按照最简单的经济学供需逻辑来看，医生过剩肯定会加剧各级别、类型医生之间的竞争，更多的替代性选择和市场机制或可以淘汰服务不周、品质不好的医疗服务，未必是件坏事。因此，部分医疗经济学家认为，“医生人力过剩”不是问题，无需国家政策介入。

但也有其它医疗经济学家指出，医疗服务不同于一般商品，供需之间或医生病人之间，资讯不对等（information asymmetry），会形成交易过程不对等的权力关系，让医疗服务购买者或病人处于非常不利的位子，因此无法形成有效的市场竞争淘汰劣质服务的机制。

医疗资源城乡分布不均

除了资讯不对等，医生人口比的数字，还有一个陷阱，那就是资源分布的问题。一国的医生人口比，往往反映的只是平均值，无法反映广大区域内的城乡差异。

若回顾2008年医药协会与卫生部的争论，当时卫生总监伊斯迈马利肯即以“分布不均”，反驳前者有关“医生过剩”的说法。当时马利肯指出，未来几年人口增长、人口结构改变（比如人口老化）、公家卫生服务持续扩大等，所需要的医生人力将随之增加，“过剩”之说恐怕过早。

马 利肯所言不无道理，不过卫生部和高教部仍然在2010年尾，针对国内的医疗课程（medical programmes）准备踩煞车，拟定五年的暂缓令（five-year moratorium）。截至2010年为止，全国共有25家医学院（Berita MMA vol.40(2), Feb 2010）。医学院和医疗课程的开设，其实跟医生人力息息相关，同时也会牵动医疗教育的品质。这个暂缓令，既是针对医生产量过剩，同时也是针对教学医院 （teaching hospital）及临床教学资源不足而设。与此同时，卫生部还把实习年数（housemanship）从原有的一年，增加到两年，确保实习的品质不受实 习医生人数爆增所影响，并借此计划重新分配医疗资源。

强制服务规划不周

简单来说，医生人数只是数字游戏，资源分布和服务品质才是关键。主要争论点，恐怕不是要不要国家政策介入，而是国家政策可以如何介入。根据世界卫生组织的一项研究报告，实习制度和强制服务（compulsory service）是第二次世界大战后，许多国家解决医疗资源分布不均的政策手段。

一 般而言，各国医生皆会对强制服务表示不满。相比于其他专业，例如律师、会计师、工程师、精算师等，医师是唯一面对国家强制服务的专业。对此，马来西亚医药 协会曾经在1970年代发起激烈的辩论，以向国家表达不满。但如果规划得当，强制服务不仅可以应付分布不均的问题，还可以减低医生的不满，并提升专科培训 及整体医疗服务品质。

马来西亚的实习制度和强制服务政策，多年来一直被医药协会诟病，主要原因正是规划不当及没有咨询利益相关者（即医生）的意见。所谓规划不当，包括没有为偏远地区医疗服务者提供便利（例如房屋和交通津贴）和诱因（例如优质的临床专科导师）。

区域执照配额有头没尾

除 了强制服务，区域划分（zoning）也是重要的医疗资源分配手段之一。医生人力市场，其实是个多层级的市场。就国际竞争来说，先进国家平均薪资诱人，必 然占据优势，比较容易留住各国的优秀人力；就国内市场来说，都市人口密度高，医疗设备集中且先进，相比于偏远地区和乡镇，可以说是占据了各种资源优势，是 医生们的首选。如今发达国家的医疗人力市场经已饱和，缓和了国际间的医疗人力流动，比较成为问题的，是后发展国家内的城乡差异，再加上后发展国家之间相互 竞争保健旅游业，保健旅游业多集中在都市地区，使得城乡差异的拉扯进一步加剧。

区 域划分乃透过区域执照配额达成分配的目的，也就是根据地里人口比例分配诊所或医院执照数目。卫生部曾经表示要制定区域划分制，不过至今仍无具体的政策内 容。由于地理特征和人口分布的特殊性，东马地广、山多、人稀，所需要的恐怕不是更多的诊所或医院这类硬体设备，而是流动医疗服务，例如流动诊所或飞行医 生，才能深入到山区服务，并且减少浪费。

国家和利益集团强势主导

医 生过剩的议题之所以不断浮现，主要是马来西亚医药协会长期关注和介入。从医疗人力市场来看，医疗服务提供者人数增加，对已经入场提供服务的医生来说，就是 更剧烈的竞争，尤其是在城市地区开业的基层医生，同时面对财团医院和拥挤人力市场的竞争压力。因此，他们自然特别关心医生过剩的问题。但由于医生团体有其 自身利益，媒体如果过度依赖医生团体提供政策意见，议题方向恐怕会被其利益视野所框限。

马 来西亚医疗制度的根本问题，是国家和利益集团强势主导政策讨论，只有医生的权益和国家官僚的意见得以成为“议题”，有关品质管理、效率和消费者权益的面 向，则不被讨论和看见。跟分配不均一样，医疗服务的品质和效率，也讲求细致的管理技术，但由于医生团体影响力庞大，为了避免争议，国家往往倾向于闭门制定 政策，导致政策资讯不透明。民间缺乏资讯，消费者缺乏组织，自然无法形成保卫消费者权益的集体力量，更不用说是有效讨论和监督医疗政策的机制，并陷入恶性 循环，进一步巩固国家和利益集团强势主导的局面。这些，才是民众面对的卫生制度挑战。

Berita Harian Questions on 1Care Health Restructuring

Berita Harian Questions on 1Care Health Restructuring

    1. What is the benefit/purpose of upgrading the GPs as gatekeeper, where everyone must choose/appointed GPs as their family doctor?

Most countries around the world are facing rising healthcare costs with greater and greater numbers of the citizens paying more out-of-pocket (OOP), i.e. paying for health or medical care with their own money. In Malaysia, this portion has reached around 40%, which is considered high. Insurance health schemes and other payment modes are still low in Malaysia, ranging from 7 to 14% only; with the rest coming from govt subsidised payments mainly from public service healthcare services.

Right now, many people who do not wish to wait for the subsidised health care provided by the public sector are opting for paying for private medical care usually by directly going to hospitals and private specialists for secondary or tertiary specialised care.

This is thought to be an expensive way for accessing healthcare. It is thought that by making the GPs or primary care doctors act as gate-keeper, this direct referral to special care can be better controlled and reduced, therefore also limiting the rise in healthcare costs and expenditure. But this has not been universally shown to be the case in most countries trying this model.

The reform that the MOH is choosing is modeled after the NHS of UK, where GPs must see the patient first before any referral to more specialised care, unless there are true emergencies. Also all citizens/residemts are mandated to be registered with one GP or primary care doctor, and they cannot change doctor easily or doctor-hop or doctor-shop without paying extra. This will help limit excessive and sometimes unneeded healthcare tests and costs.

We wonder whether this is feasible in Malaysia because most people have got used to the current system where everyone can choose as they wish, which doctor or public or private clinic or hospital to go to. This quite strict restriction of choice may not be acceptable to most people.

Can the govt or MOH guarantee quick and unfettered access to healthcare for the public with this new scheme? Would this perhaps make the private sector as bureaucratic or slow as both payment or registration will now be centrally or regionally controlled?

Would gate-keeping result in delay in seeing specialists or necessary surgery? Who would be responsible if there had been too much delay which result in bad or fatal outcomes? How would the MOH indemnify patients who might be harmed by such a change?

Would the public really want to have such a strict cut back on choice of service, doctors and specialists? Would there be too much control by the gate-keeping GP or MO who might be bothered by too much cost-containment or negative incentive payments or reimbursements?

There have been much criticism regarding the UK NHS, with many people questioning the wait times and slow services, but most accept this, because the costs of such an integrated service is borne by already-collected special taxes, controlled by regional health trusts. Also there is a fair bit of cost sharing and co-payment i.e. the patient still has to pay extra for each item of prescribed medicines etc, which can make many give up on some more expensive medicines or regular compliance with these medicines, esp. for chronic ailments such as hypertension, diabetes, heart disease, arthritis, etc.



    2. What is MMA's role in realising the proposed 1Care should the government decide to embrace the new healthcare system?


The MMA (Malaysian Medical Association) is very concerned that such a drastic change without the necessary details to the implementation would be premature and would cause a lot of disarray in the health services available to the public.

The MMA fully supports the concept that every Malaysian be given guaranteed equitable and ready access to a reasonable basket of healthcare services, without cost being a factor to obstruct seeking of such care or services. Basic care is a human right which should be ensured.

However, whether this 1Care restructuring is the best method is right now, quite uncertain.

We need a clearer plan on how this method of integration and implementation of the healthcare services can be worked out seamlessly, with the practical and financial aspects fully understood by every stakeholder. The MMA is worried that there are still too many unknowns.

How much would this really cost the rakyat in terms of additional costs, either by additional taxes or payment of social health insurance (SHI) premiums--2, 3 or 5% or more? How much would employers have to pay? How do we pay for our dependents, at what quantum? Can the low-earning worker afford this new model of SHI?

Would civil servants be exempt or would the govt pay their portions so that this is fairer for all others who are paying? If this part is to be from the already allocated tax revenues, then why should the private sector pay extra for a collective and possibly more restrictive type of healthcare services?

Is our current health system so bad that we have to change this so drastically? If it ain't broke why change it? Is this another sort of GST-like extra tax, which would make every rakyat contribute some more, with little to show for the change?

How would doctors and the private healthcare sector be reimbursed/paid, since most of the 7000+ GP clinics around the country have been self-funded without govt incentives or assistance, and also that most if not all pay yearly income taxes already?

How can this be given the same payment schemes of public sector clinics (now numbering 800+) which are fully funded by government funds to date? Would there be unfair preferential allocations of patients or registrations or payments?

What about the private medical centres and hospitals which the government has been encouraging to expand these past 10-20 years? Would they suffer from over-restriction of referrals from the gatekeeping roles of primary care doctors? Who pays for specialised care?

How much of this integrated care would be consumed by administrative costs, which might be huge and wasteful.

Also there has been talk of only Family Medicine specialists (FMS) being the ones controlling all these primary care services, but these number only less than 200 and are all within the public sector!?

What then is the exact role of GPs, just an employed worker for the FMS? Would the GP role be subservient to these FMS, and what sort of quality assurance or qualifications are now to be made necessary for GPs to benefit more fully? Is this fair to the GPs, the rakyat?

    3. Do you have any suggestion pertaining to 1Care? Btway, how many GPs or doctor do we have now. Is it enough to cover the Malaysian population (doctor patient ratio)?

The MMA agrees that we have a shortage of doctors in the country at this present moment in time, especially the poor distribution around the coutnry and the maldistribution to remote or rural communities especially in Sabah and Sarawak. Currently there is a doctor-population ratio of 1:900 (end 2010, doctor number 32,000), but the government wishes to quickly increase this to 1:400 by 2020, which means a total doctor number of around 85,000 to 90,000.

But the MMA has already expressed serious concerns that we are producing these doctors too quickly without adequate care as to the quality of doctors so graduated. We do not need so many doctors so quickly when our training facilities, hospitals cannot cope with their proper training and apprenticeship.  We expect a severe glut or excess number of doctors who would do poorly and increase competition without the necessary increase in quality or safety of service for our rakyat!

While we support government efforts to streamline and improve the healthcare system in the country, we also ask that there be a more comprehensive approach to the restructuring plans.

We must have a detailed blueprint on every aspect of the newly planned scheme, so that all the stakeholders (doctors, other healthcare providers, hospitals, third party payers, insurers from every sector) can comprehensively debate and improve the potential problems, which are bound to arise.

Powerpoint flow-charts which are impermanent and freely modifiable, without the necessary details or minutiae are clearly not enough!

Until this detailed document is available, it is too premature to accept this plan without careful thoughts, and we believe that this 1Care reform plan may be very difficult to implement. This may lead to severe breakdown of the services which would face unsure or unfamiliar new grounds.

With additional co-payments from the rakyat, the MMA wonders whether such a change would really improve the system or merely costs more without the attendant benefits expected by our more discerning and knowledgeable citizens.

In short, we urge the government to ready itself with a more comprehensive plan which should be written down in detail, so that all these uncertainties can be addressed and overcome, so as to lessen the unintended consequences of this restructured 1Care health plan.


Dr David KL Quek
President, MMA

malaysiakini: Moratorium won't solve healthcare problems.... Dr Ong Hean Teik

Moratorium won't solve healthcare problems

Dr Ong Hean Teik
Dec 15, 2010
12:25pm

A moratorium on new medical courses in Malaysia will not solve the main problem faced by our healthcare system today, namely the large numbers of housemen with poor skills and questionable competencies.

Since these poorly trained doctors come from foreign as well as local institutions, stopping local medical intake does nothing to solve the issue.

What is needed now is a training system to improve the abilities of these young doctors, and even to weed out those who do not have the desire or competency to practice medicine.

Some may have hoped that registering a lot of housemen will ultimately solve three problems; fill vacancies in the Health Ministry, reduce healthcare costs by increasing doctor supplies and achieve a developed country status with a doctor-population ratio of 1: 400.

However, in our haste, we have registered poorly trained housemen, exposing them to a system that is not ready to cope with the numbers and their inability.

The call for action comes not from private doctors seeking to protect their rice-bowl; rather it is from dedicated senior government doctors who are worried about the future when these housemen take up increasingly responsible positions in public healthcare institutions.

Poorly trained doctors will be a burden to the Health Ministry, and may have to spend an increasing proportion of its budget on doctor salaries since such incompetent doctors will not be able to attract fee-paying patients who are very sensitive towards doctor competency.

No patient, no matter how poor, deserves an incompetent doctor, and no one, no matter how powerful can feel totally safe once incompetency creeps into the healthcare system.

We already have in place a system to train and assess our housemen. What is now needed is to formalise the system and have an end-of-housemanship examination.

Housemen must be transparently graded, with one-third coming from consultant's assessment, one-third from a theory paper and one-third coming from a practical examination.

After all, housemanship is only the beginning of a doctors' educational process. With many examinations still to go through, the houseman should not worry about a formal end-of-housemanship assessment. Those who do well should be rewarded with posting of their choice and entry to specialist training programs.

The majority should pass and proceed onto service as responsible medical officers. The really incompetent or disinterested ones should repeat their housemanship postings.

In the near future, the MMC must de-recognise poor-quality medical schools whether locally or abroad, without fear of political pressure.

The country cannot support 4000-6000 new doctors annually into the infinite future.

It should not be too difficult for the Ministry to calculate how many doctors are required annually, then seek to limit new medical registration to the calculated numbers.

Whatever the numbers, the aim must be to finally produce only capable, competent and dedicated doctors. Medical education, and the medical profession, should be for those interested in the art of healing, not those seeking financial rewards.

The public must try to understand that on this issue of having a competent medical workforce, doctors in both private practice and government service are speaking with one voice and truly have the interests of our community at heart.
Dr ONG HEAN TEIK is a cardiologist consultant in Penang

The Star: Delist poor quality med schools.... By LOH FOON FONG

Delist poor quality med schools

By LOH FOON FONG
foonfong@thestar.com.my

Thursday December 2, 2010

PETALING JAYA: The Malaysian Medical Association wants the Government to stop issuing licences to new medical schools and de-recognise existing ones which are of poor quality.

Its president Dr David Quek said stringent quality mechanisms should also be imposed on existing schools to ensure students are not short-changed.

“If medical schools do not have sufficient teachers or cannot offer adequate patient contact time, their student numbers should be reduced,” he said in an e-mail interview.

Recently, The Star reported that a high number of medical students graduating each year had crowded limited resources resulting in many housemen not having enough patients for adequate training with supervisors being overworked.

Sources also voiced concern that many graduates from lesser-known medical schools did not have adequate core knowledge to treat patients.

Dr Quek urged the Health Ministry to act quickly by sending “weak” new graduates for re-training.

In his blog on MMA News December 2010, he said there were 31,000 doctors and housemen and the Ministry wanted to reduce the doctor-population ratio by achieving 85,000 doctors for a projected 35 million population by 2020.

“This goal of trying to achieve so many doctors in so short a time is happening way too fast and too soon,” he said, adding that the issue was not about doctors wanting to protect their ‘turf’, rather their concern over patient safety.

While there were complaints of a glut in some hospitals, in rural hospitals in Sabah, housemen were complaining of being overworked.

A houseman, who declined to be named, said rural hospitals suffered from a severe lack of doctors and housemen had to work round the clock to care for patients.

“We have to be ‘on-call’ continuously for a whole week and go without sleep on some nights,” he said in an e-mail.

A mother of a houseman based at Hospital Universiti Kebangsaan Malaysia in Cheras also complained that her daughter’s feet had swelled after having to stand for long hours every day.

Acknowledging that there was a severe shortage of doctors in certain hospitals, Dr Quek said the Health Ministry should work out a better distribution mechanism to overcome the problem.

NST: Editorial: In need of senior doctors

NST: Editorial: In need of senior doctors

2010/12/01

THE president of the Malaysian Medical Association has expressed doubts over the strategy of producing medical graduates as fast as possible to help address the shortage of doctors as it could lead to a "serious glut of doctors" and a "possible erosion of standards". Undoubtedly, the dramatic increase in the number of medical students and medical schools in the last decade --- from four 10 years ago to more than 20 today -- has posed challenges in terms of quality, staffing and infrastructure. 

 

However, just because fresh medical graduates are starting to tax the training hospitals -- more than 3,600 this year, and some 4,000 to 5,000 from next year -- it does not necessarily mean that we will face a serious oversupply problem. On the contrary, as we have just over 31,000 doctors and we need 85,000 in 10 years, it is more than likely that we will need every medical graduate that we can produce.
Certainly, as the sharp rise in numbers has resulted in a glut of housemen and the training hospitals are struggling to meet the demands of training the next generation of doctors, there is cause for concern. Needless to say, as housemanship is an essential component of medical training, it is vital to make sure that the interns get the necessary hands-on clinical experience and skills.

The problem seems to be insufficient senior doctors to train and supervise the new crop of housemen. As it is, the Health Ministry has pressed smaller hospitals into service, and is looking to hiring foreign specialists to help the training hospitals cope with the influx of fresh medical graduates. Just as we have looked outside the public medical faculties to address the doctor shortage, perhaps we should utilise settings beyond the government hospitals to help shoulder the training load.

As far as the dubious quality of the graduates from questionable foreign and local medical schools is concerned, as it is the task of the Malaysian Medical Council to regulate and review these institutions to make sure they measure up to the expected standards, there should be no question about any "dilemma" in carrying out its task. Either someone is good enough to be accepted into an accredited medical school, or he or she is not, and either an institution is fit to be recognised, or it is not.

That said, the challenge is not just to make more places available for more students as a solution to the doctor shortage, but also to make sure that this does not affect the quality of teaching and training that they receive.


Read more: In need of senior doctors http://www.nst.com.my/nst/articles/16med/Article/#ixzz16uTfFhKA