Sunday, 17 April 2011

Random Articles in the Internet: For Future Doctors: Housemanship, Medical Officer and Postgraduate Training

For Future Doctors: Housemanship, Medical Officer and Postgraduate Training (Part 1)
I received more than 10 000 visitors to my blog posting on “The General Misconception of Doctors Part 1 & Part 2” since 08/09/2010. I also had many comments supporting my article. Surprisingly, most of the comments were from medical students and young doctors who just started housemanship or just completed. I also had some overseas doctors giving their comment, not sure whether they are Malaysians or ex-Malaysians?
Even though many supported my articles, I also had few asking me to tell them what is in store during housemanship and postgraduate training in detail. Thus I thought it is about time I give them the full detail, to my knowledge, about the current and future situation in Malaysia. There was a person who asked me to write some positive aspect of being a doctor. Well, I only have 1, a total satisfaction of treating a patient till recovery. But always remember, you can only cure sometimes. I have had a medical student who refused to go to the ward after seeing a young boy dying of Leukaemia. Well, this will be a daily affair once you set foot into the medical field. Be prepared to see people die no matter what you do. To comfort always but to cure sometimes should be your motto!
1)      Housemanship
I will divide this section into 3 subsections, explaining what has been happening since 1990s in housemanship training;
1a) Before 2000
Before 2000, the housemanship training use to have 4 monthly rotations in Obstetrics & Gynaecology, Medicine or Paediatric and Surgery or Orthopaedic. After the 1 year training, you will be transferred to rural or semirural areas to serve in district hospitals or Klinik Kesihatans (KK) (health clinics). Most of the time, these rural postings are a wonderful experience but a little bit scary due to lack of senior people to consult or assist you.
One of the major faults in this system is the fact that if you do Medicine, you will miss Paediatric and if you do Surgery, you will miss Ortho. Only O&G was made compulsory. Thus, the government felt it was inadequate. Many will go to KK and District Hospitals without doing Paediatrics/Medicine and Orthopaedics/Surgery. A lot of the time, you need to depend on the senior nurses or Medical Assistants (MA). I must say that during that time, the nurses and MAs were excellent. They were second to doctors, not to be compared with the current generation of nurses and MAs.
BTW, just to mention, the HO’s take home salary before 2000 use to be RM 1648!! Pathetic isn’t it? You won’t even be able to buy a car/house. The car loan interest rate than was 6-8%! You will get RM 20 for each on-call that you do! This “On Call” allowance was only introduced in 1994. Prior to that, you are not paid a single cent for your “On-Calls”, free labour for the government mah……………..
1b)  After 2000
Around the year 2000-2002, a new posting known as junior medical officer postings was introduced after housemanship. This is also known as the 4th and 5th HO posting. It was 3 month posting in either medicine/paediatric or surgery/ortho depending on which that you did not do during the 1 year housmanship as above. After completing the 4th and 5th postings, you will be posted to rural or district as a Medical Officer.
1c)  Since 2008
Since 2008, housemanship training has been extended to 2 years. This means you will be completing all the major postings before being transferred out.
2)      Life as a Houseofficer (HO)
When I did my Housemanship in 1990s, there were only 2-3 HOs in each ward of 40-60 patients. It was a tough life.  You are the front liners who will see the patients for the first time upon admission. You’re supposed to take the medical history of the patient, do a physical examination, take blood investigations and come to a diagnosis. In fact, you’re supposed to start the initial treatment and management of the patients. There won’t be any medical officers or specialist in the ward. Most of them will come only in the afternoon to see the patients. This means, you’re the boss in the ward and the life of the patient is in your hands! It is a very stressful life, where on top of all the existing patients in the ward, you also need to see all the new admissions. The new admissions can be about 20-30 admissions/day, divided between each of the 2-3 houseofficers.
You start your work around 7.00am everyday especially if you are doing medical or O&G postings by taking the ward patient’s blood. Then, you will be doing the clinical rounds with the Medical Officers and Specialist of the ward. After finishing the rounds, you need to carry out all the orders by the specialist and at the same time, clerk all the new admissions! You also have to run down to radiology department to get urgent appointments, go to the blood bank to get urgent bloods, trace results urgently etc etc. Of course, you may not finish your work by 5pm. If you are “On Call” on that day, you need to con’t your work throughout the night till the next morning 8am. And now, don’t think you can go back to your room and rest! You are supposed to con’t with the work on the next day as usual! You are basically a professional coolie!
As a HO, you need to do at least 10 calls a month, which means once every 3 days. I have even done continuous day calls before, never saw sunlight for 2-3 days! For each calls, we were paid RM 20 then, now it has gone up to RM 100 since 2006 ( please read my MMA article on “Government doctors: Past, Present and Future”). I use to say that you can earn better by working in Mc Donald’s!
Whatever said and done, I enjoyed my Housemanship simply because I had good colleagues who helped each other very well. I also enjoyed learning all the skills and procedures during my housemanship. Housemanship is the only time where you can learn all the necessary skills in doing procedures like CVP line, Chest tube, Peritoneal Dialysis etc etc. Thus, as I said before, if you became a doctor for passion and to help people, then you will enjoy housemanship. But if you choose medicine for glory, good life and money, it is during this time that you will realise that medicine is not for you. That’s the reason why, many will get a mental breakdown during housemanship. They never expected their life to be like this! Many still think that being a doctor is sitting in a clinic and seeing “cough and cold” cases. Being a doctor is more than that.
Of course, the situation has changed recently. With the tremendous increase in the number of doctors produced, we have almost 6-8 HOs in each ward of 40 patients. In fact, surgical department with 2 wards, sometimes has more than 40 HOs!! The workload will definitely be lower but you will lose out in your training. How many procedures would you be able to learn with so many of you in a ward? I have even seen some HOs leaving the medical department without doing a single CVP line or Chest tube. Only those who are eager to learn will succeed. The rests are just given a license to kill… Sorry to say!
3)      Rules and Regulation during Housemanship
There are few rules and regulations that you need to know as a HO. You will be given a log book for each posting. This log book needs to be signed off at the end of each posting by the department. The Head of Department (HOD) has the right to extend the training if he/she feels that you are not competent enough to be released. The extension is for a minimum of 3 months but can go on as long as the HOD feels adequate. Unfortunately, many of the HOD take the easy way out. No matter how incompetent the HO is, they usually let them go as they feel that it will not make any difference in extending their postings and of course less problem to the department. To me, I think it is very selfish for some of the HOD to think like this. Remember, these doctors are the one who is going to be released to the community with a “license to kill”.
As a government servant, you will be given 25 days annual leave. As a HO, these 25 days will be divided equally between the 3 postings that you do in a year. Any extra leaves including MCs, maternity leave and emergency leaves are considered as an extension of housemanship training. For example, if you take 1 week MC during a medical posting, your medical posting will be extended by one week, unless you want to deduct your annual leave allocated for that particular posting. This is one of the reasons why I always advise doctors/soon to be doctors not to get married during housemanship. Pregnancy will not reduce your workload as you need to do the same number of calls with the rest and it will only extend your housemanship even longer.
For Future Doctors: Housemanship, Medical Officer and Postgraduate Training (Part 2)
It has been more than 2 weeks since I last posted on this topic. I have been quite busy lately with increasing workload in my hospital as well as some renovation work going on in my house. In this Part 2, I will write more about what to expect after finishing your 2 years Housemanship posting in Ministry of Health.
1)      Compulsory Service
I am sure everyone knows about the compulsory service for doctors in government service. According to Medical Act 1970, a medical graduate has to undergo compulsory service with the government for at least 4 years. This includes the Housemanship which is now 2 years. This means that you need to serve the government for another 2 years before you decide to leave the service.
2)      District/Rural postings
As I have said in my first part, after completion of your housemanship, you will likely be transferred to rural clinics or district hospitals. With the recent influx of large number of doctors, almost everyone will be transferred to rural areas, mainly Sabah and Sarawak. You can see this from various letters posted in almost every newspaper recently, embarrassingly by parents of “so-called” grown up doctors!
From my experience, district posting is a wonderful experience. Working alone without anyone to consult immediately, gives you a lot of experience. Remember, other than X-rays and some simple blood test, you don’t have anything else in these hospitals. Usually there will be about 3-5 Medical Officers (MO) in each district hospitals. When you are “on-call”, you are all alone and need to manage the A&E department as well as all the wards including obstetrics cases. It is really scary at times, especially if you are working in district hospitals which are far away from the nearest General Hospital. If you are preparing to sit for any exams then this is the time to do your revision as the workload is generally lower than in general hospitals.
The same goes for those who are posted to health clinics (Klinik Kesihatan). These clinics are usually situated in rural and semirural areas. Most of the time there will be 1-2 MOs in each clinic. The major bulk of patients that you see in these clinics are antenatal and outpatient cases. There will also be a lot of administrative work to do in these clinics including school visits, running various health campaigns and public health talks. In cases of any outbreaks, you will be called to assist in containing the outbreak. Basically you are the primary healthcare providers. Many doctors do not like the administrative work that they are supposed to do, and the meetings that you need to attend!
Even though it is a good experience to do rural/district postings, please do not stay long in these clinics/hospitals if you intend to do postgraduate studies. A maximum of 1 year should be adequate. The reason I say so is because you will lose the momentum to further your studies after some time of good life in these centres. Since the workload is lower, you will get carried away with relax life compared to your housemanship training.
This rural/district postings are usually given extra points when you apply for your Master’s programme even though it does not guarantee a place. At the same time you can use your free time to prepare for your exams like MRCP Part 1, MRCOG Part 1 etc etc. After passing your Part 1, you can request to be transferred to the General Hospital for continuation of your training. Again, this may become a problem in the future as the number of post may be limited and it may be increasingly difficult to get a place in bigger hospitals.
I think people who grumble about going to rural and district postings should just give-up medicine. If you choose medicine to help and treat sick people, then these postings is where you really see the real life of people. You will learn a lot about their social life and the struggle they go through daily which you do not see when you work in general hospitals. You will also realise that people here appreciate you better than urban people. I would advise each and every doctor to do rural/semirural and district postings for at least a year after completing your housemanship.

For Future Doctors: Housemanship, Medical Officer and Postgraduate Training (Part 3)
 It has been more than 1 month since I last wrote on this topic, the last being on rural postings. I have been extremely busy for the month of October with increasing load of patients in my hospital as well as some domestic house renovation. My house kitchen renovation has been successfully completed but I am yet to complete the painting works, which I am doing myself!
Let’s look at the postgraduate training in Malaysia. I have written about housemanship, district/rural postings and problems of oversupply of doctors in the near future. The issue of oversupply of doctors by 2015 will lead to another very big issue: postgraduate training. Many of the budding doctors and medical students are not aware that the postgraduate training in Malaysia has many limitations and problems. At this point of time, most postgraduate trainings are dependent on Master’s programme conducted by the local universities. Once upon a time, we were totally dependent on UK-based exams and training but unfortunately we lost it along the way. Currently, only MRCP (UK) – Internal Medicine, MRCPCH (UK) – Paediatric and MRCOG (UK) can be done in Malaysia. FRCS (for surgeons) used to be available to Malaysians but not anymore. None of our hospitals are recognised as a training centre for FRCS, which is now known as MRCS. Thus, for any surgical field in Malaysia, you will need to do Master’s programme!
MRCP (UK) – Internal Medicine
Membership of the Royal College of Physicians (UK) is a well-known exam all over the whole. It has a very strong reputation as an entry exam for speciality training in UK as well as in other parts of the world.  It is conducted regularly, usually 3 times a year in various countries. Malaysia is one of the centres for the MRCP exams, all 3 parts.
MRCP Part 1 can be taken about a year after your graduation. It is a theory paper. After passing your Part 1, you need to clear your Part 2 (written paper) and Part 3 (clinical) within 7 years. It is usually coordinated by University of Malaya, where the exams are usually held. Just for your info, the passing rate for MRCP (UK) is always around 45-50% worldwide! You need to have a proposer to sit for these exams, who can verify that you have undergone sufficient training to sit for the exam. If you fail miserably, your proposer will be notified.
Since MRCP (UK) is not a specialist exam in the UK, the Ministry of Health, Malaysia only recognises and gazette’s you as a specialist after undergoing further training of 18 months post MRCP (UK). You will need to submit a log book and recommendation by your HOD before being gazetted. This rule applies for all other overseas degrees which include MRCPCH and MRCOG. You need to undergo this gazettement process in order for you to be recognised as a Physician by the National Specialist Register (NSR).
MRCPCH (UK)
MRCPCH is similar to MRCP (UK) but meant for those who wants to become a Paediatrician. It‘s examination structure is similar to MRCP (UK).
MRCOG (UK)
MRCOG has 2 parts but the second part has both written and clinical component. However, you need to undergo training in O&G department for at least 4 years before being allowed to sit for Part 2 exams. One of the major issues in sitting for MRCOG is the fact that there are not many MRCOG holders in MOH to sign as a proposer for you!
Master’s programme
Now, this is where a big problem is going to appear soon. For all other fields, you are totally dependent on Master’s programme. This includes all surgical fields. Master’s programme is a fixed 4 year programme.
In order for you to be eligible to apply for the Master’s programme, you should have completed at least 3 years of service with good SKT marks of at least 85% and above, recommendation from Head of Department and confirmed in service. You also need to attend an exam or an interview before being selected for certain disciplines.
The major problem that I foresee in the future will be the number of places that are being offered. As of this year, the total number of places available is only 600, all disciplines included. Imagine, with 6000 new doctors coming into the market every year from now onwards, only 10% is going to get into the Master’s programme annually. Furthermore, you must understand that the selection process is never transparent, the typical Malaysian scenario as well as the quota system! Most of it is done by the Universities.
The government is planning to increase the number to 800 next year but the situation is rather critical in the Universities as there are not many Senior Professors to supervise the programme. I must say that the standard of Master’s graduates have dropped significantly over the last 5-10 years. We have Master’s graduates who can’t do surgery but have passed the exams! I just hope that the Master’s programme do not become another “specialists mill” like our undergraduate medical schools!
There are 2 types of Master’s programme, the open and closed system. In the closed system, you will do the entire 4 years within the university, like in UKM Hospital, UH and USM Hospital. The open system may have various programmes, like 2 years in MOH hospitals and another 2 years in the Universities etc. You may even do the entire 4 years in MOH hospitals for some of the fields.
After completing your Master’s programme, you need to undergo another 6 months of gazettement process before being recognised as a specialist. Furthermore, you will be bonded for 5-7 years for receiving scholarship during the programme, which is compulsory!
Subspecialty training
With the advancement in medical field, every discipline now has subspecialty training. As such, everyone will try to do certain subspecialty after gazettment as a specialist by MOH. Generally, the subspecialist training is about 3 years except for certain field like Cardiothoracic and Urology which may take 4 years. Again, whether you get a place or not depends on availability of post and demand for that particular field. For example, the waiting time for Gastroenterology training can even go as far as 1-2 years.
Recently, to overcome this major problem, MOH has taken another step backwards. You can only apply for subspecialty training 1 year after you have been gazetted as a specialist. For MRCP holders, this means 2 and half years after passing MRCP (UK)!
Usually, the subspecialty training is divided into 2 parts, the first part (the first 2 years) will be done locally and the 2nd part (remaining 1 year) will be done overseas. The MOH will provide a fully paid scholarship for overseas training of 1 year but you will be bonded for 3 years. If you have received undergraduate scholarship and Master’s scholarship, you will be bonded a total of 20 years in service!!
Singapore
One good advantage that we have is Singapore. Unfortunately, only UKM and UM undergraduate degrees are recognised in Singapore. Our Master’s degrees are NOT recognised elsewhere. Thus, we would not be able to work in Singapore with any other medical degrees or even with our Master’s degree.
However, Singapore does recognise MRCP, MRCPCH, MRCOG and MRCS. Thus, if you have any of these degrees, it supersedes the undergraduate degree and you should be able to get a job in Singapore. Singapore is also a recognised centre for MRCS Part 3 training, which you can’t do in Malaysia. So, if you have MRCS Part 1 & 2, you can go to Singapore to finish your MRCS training and sit for the Part 3.
I must say that Singapore’s postgraduate training is more structured and organised with their BST (Basic Specialist Training) and AST (Advanced Specialist Training) programmes. I have written about this in my MMA article “Back from the Future: From 1st world to 3rd world”.
For all of you out there; budding doctors, medical students, houseofficers and medical officers;  the future is very bleak for the medical field in Malaysia. The oversupply of doctors will get to you sooner or later. My advice to those who insist on doing medicine for passion is to choose an undergraduate course that is recognised internationally. Then, pursue a postgraduate degree that is also recognised internationally. If not, you will end up with a lot of frustration in the future. Jobless doctors in the future will be a reality!
If you have any questions or comments, please feel free to respond.
Posted by Putra Medical Students at 11:32
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