Sep 11, 2010

general misconception of being a doctor

I never did like to tell people that I meet that I am a doctor, for 3 reasons. Firstly because they would look me in a different light as if I am a sublime being that have perfect power to decide the life and death of another being (at times, I do, I guess). Secondly, they would be thinking I am a rich young fella living in a mansion with several toy dogs and annual round-the-world trips. Lastly, they would start asking me whether or not I know their children, siblings, cousin siblings, or nieces/nephews who are doctors or future doctors.

I got so fed up on the last reason that I will usually have a pre-emptive conversation as follow.

Uncle: what do you do for a living?

Me: Working in hospital?

Uncle: A doctor?

Me: Errr... (contemplating secrecy).. Yeah..

Uncle: Oh.. u know I have a nephew...

Me: (I interrupted) Let me guess a doctor or studying doctor, right? Nowadays every few person is a doctor. Just like the growing numbers of diabetics and hypertensives.

Uncle: Yeah, you're right. Yeah, I got doctor nephew and few nieces studying medicine.

Here's an article worthy of a read by high-schoolers and parents who are super-determined to let their children take up medicine and practise medicine. Unknown to them, some practice takes a lifetime.

I combined Part 1 and Part 2 on General Misconception of Being A Doctor, gloomily detailed out by Dr Pagalavan, a Consultant Rheumatologist.

Over the last few months, many budding doctors have contacted me to ask about the future prospects of doing medicine. Of course I gave them a depressing night after informing them of the current and future prospects of doctors in Malaysia. During these discussions I realise that many of these people do not understand a lot of issues surrounding the field of medicine. Thus I was obliged to write this article to wake up these people from their dream of “guaranteed” life if you were to become a doctor!

1) Guaranteed Job and Good salary/can make money

Many parents still believe that being a doctor guarantee their children’s future. Well, it may be so before but not in another 5-10 years time. You can read about these issues in my MMA articles column. 20 years ago we only had 3 medical schools producing about 400 doctors a year but now we have almost 30 medical schools in the country (the highest per capita population in the world). Last year alone, almost 4000 new doctors started housemanship in Ministry of Health (MOH). The number will further increase in coming years when all the medical schools start to produce their graduates. I believe it will reach a figure of 6000/year by 2015.

This is where issues arise. Even now, the MOH is struggling to place these doctors in various hospitals in the country. We have almost 30-40 houseofficers in each department now not knowing what to do every day. Their training is compromised and they are being released after that without proper training with license to kill! I may sound negative but this is the reality. Even district hospitals are being used to train houseofficers now, starting 2010. As you would have read in the papers recently of parents complaining that their child has been transferred to East Malaysia after completing housemanship, it is a known fact that the shortage of doctors at this point of time is in East Malaysia. As our MOH Director General had said, most doctors will be sent to Sabah and Sarawak from this year on wards.

What’s going to happen in the next few years? Again, my prediction is, there will be surplus of doctors by 2015. There will more bodies than post in MOH by 2015. Doctors most likely will need to queue up to be posted in government service. You will be sent to rural and East Malaysia to serve. Any appeal will not be entertained. If you think this would not happen, please look at the nurses! 5 years ago, the government began to approve numerous nursing colleges due to shortage of nurses. Now, we have surplus of nurses without any jobs. I know of nurses who are currently working in petrol stations! BTW, the MOH is currently considering introducing common entry exams for all medical graduates. Only those who pass this exam will be given housemanship post. This will happen soon.

Furthermore there may be a pay cut for doctors when all the post are filled. One of the allowance known as critical allowance of RM 750 will be removed once all the posts are filled. Critical allowance is never a fixed allowance and is usually reviewed every 3 years. As you know, the pharmacist’s critical allowance is going to be removed if not already.

I had one budding doctor who said that the reason she wanted to do medicine is because it is the only field where you have a guaranteed job and a starting salary of RM 6000. Well, I have talked about guaranteed job issue above but she is definitely wrong in stating that the starting salary. The starting salary of HO has gone up over the last 5 years; no doubt about it (please read my MMA article). However, the starting salary of HO currently is about RM 3500 to about RM4000 after including the on-call allowance. Remember, your salary only increases about RM 70/year. You will only reach a salary of RM 6000 after 7 years of service as a medical officer, when you are promoted to U48 according to current promotional prospect in civil service introduced end of last year! BTW, other than the difference of critical allowance, a doctor’s salary is only RM 200 more than a pharmacist in civil service!

2) Medical degree recognition

If I can’t work in Malaysia, I can go to Singapore or Australia to work, right?

Again, another misconception. Many do not know that medicine is a very peculiar field and cannot be compared to any other profession. In order for you to work in another country, your degree needs to be recognised by the Medical Council of the other country. If it is not recognised, you would not be able to work there. For your information, only UKM and UM degrees are recognised in Singapore.

Almost all medical degrees from Malaysia are NOT recognised elsewhere. Malaysia Boleh mah! Only Monash University Malaysia’s medical degree is recognised by Australian Medical Council and thus you would be able to work in Australia/New Zealand. Some of the private medical colleges do twinning programmes with external universities from Ireland/UK/India etc. These may be recognised depending on which degree and where you graduate from.

3) Housemanship & Compulsory service

I have mentioned a little about housemanship above. As you know the housemanship has been extended to 2 years since 2008. Even though it is good for your own training but it does prolong your future postgraduate training. After Housemanship you have to undergo another 2 years of compulsory service before you decide to resign for private practise or pursue your postgraduate degree. It is during this compulsory service that you will be posted to anywhere in the country.

Furthermore, housemanship is not an easy posting. Even though the numbers of HOs have increased tremendously over the last 2 years, it is still a very exhausting job. Many have had a mental breakdown during housemanship. I just heard of a houseman who is on psychiatric MC for the last 2 months! It seems she thought that being a doctor is just like sitting in a clinic and seeing cold cases (probably she thought she can become a GP immediately!)

4) Hard work and post graduate training

20-30 years ago, being an MBBS holder itself is good enough. You can easily open a clinic and become a GP and well respected by the community. But things are changing. Even GP practise is a speciality by itself in many countries (Master in Family Medicine/FRACGP etc). Malaysia is also moving towards that. Many patients are demanding and would prefer to see a specialist directly nowadays.

Thus it is important that when you join medicine undergraduate degree, please be prepared to continue your education for another 10 years after graduation! In order for you to complete your postgraduate education, it will easily take another 10 years, assuming you pass all your exams in one try! So, don’t assume your education is only 5 years! MBBS do not mean anything now, in fact it is only considered as a diploma!

Getting into postgraduate training is also becoming increasing difficult. The number of places for Master’s programme is very much limited in local universities. The demand is greater than supply and of course don’ forget the quota system as well! Other than MRCP (UK) – internal medicine, MRCPCH (UK) – paediatric and MRCOG – Obstetric, you have to depend on local master’s programme for your speciality. Thus, you have a very limited option. With such a big number of doctors coming into the market now, I can assure you that getting a place for post graduate education is going to be a major problem in 2-3 years time! Be prepared.

My first Part of this topic attracted more than 600 people to visit my blog in a day. Today, I post my second part of my discussion for your reading.

1) Being a GP

As I have written before in my MMA articles, the future of GPs are bleak. If you think that you just want to complete your MBBS and open up a clinic, then I think you are misinformed badly. Many GPs are suffering nowadays. Many have even closed their shops due to severe competition. GPs, not only have to compete with their fellow GPs but also with private hospitals, government clinics, pharmacy and traditional medicine sellers. The scenario has changed as I have said in Part 1. You are also strictly regulated by the Private Healthcare and Facilities Act which was implemented from 2006 onwards. Many GPs are only earning a net profit of RM 10 000 a month which is ridiculous compared to the amount of work that you are doing. Imagine that you have to work from 9am to 10pm daily including Saturdays and Sundays, especially during your early days. That’s the reason why you notice less and fewer doctors resigning from the government sector to set up their clinic. GPs are now moving from urban areas to sub-urban and rural areas to open up their practises. There may be a better market for GPs in these areas compared to town areas.

2) Being a Consultant in a Private Hospital

Only in medicine I can earn RM 50 000/month when I work in private hospital? I had many friends and budding doctors who feel that medical specialist earns the highest in private sector compared to any other profession. Again, I would say that you are mistaken. Even though you may be right in terms of the earning capacity but what you are not aware is the fact that the private hospitals DO NOT pay us a salary!

Basically you are NOT employed by the private hospital. You are just running a clinic as a self-employed person in the hospital. Whatever you earn is the consultation/surgical fees that you are charging the patients. In fact, the hospital takes 10-15% of your consultation fee as their administrative fee. Furthermore you also need to pay a rental for the clinic space that you are renting! The rental can range from RM 4000 to RM 8000/month. Yes, if you are an interventionist/surgeon or have a lot of patients, you may earn as high as above but at the same time you can also earn very much less than expected depending on the number of patients that you see for that particular month. You may even end up earning less than RM 10 000/month at times! Again, with more and more private hospitals coming up, the competition will be greater and the income of each doctor in each hospital will definitely drop even further. Remember, if a patient’s hospital bill for an admission is RM 5000, only less than 25% of the bill is the consultation fee which belongs to you, of which the hospital will take another 10%!

Also, when you are in a private hospital you are all alone. There are no junior doctors to help you. You need to do all the procedures by yourself and must be available at all times to entertain any medical complaints from the patients (even in the middle of the night). It is not just a matter of running a clinic! So basically you can only charge a patient when you see a patient for consultation and that is your salary!

And also don’t forget, for you to reach the status of a subspecialists before going full-time private practise, it will take at least 12 years following undergraduate medical education, a total of 15-17 years !! By this time some of your fiends will be earning much more than you and driving bigger cars and going holidays all over the world. Many of my friends who went on to do IT, accountancy etc etc had become company managers and directors by the time I finish my subspeciality. They have started to enjoy their life when I was just beginning to think of earning money.

3) TV programmes : ER, CSI, House etc

Don’t get carried away by watching TV programmes like ER, CSI and House. Things do not work the way it is shown on the TV. I had one budding doctor who said that she wants to become a forensic pathologist. I am sure she was influenced by CSI. In Malaysia, the reality is, any forensic pathologist just sits in the mortuary the whole day. They hardly go down to the scene of the crime. Furthermore, if you do attend a court case, you will be tortured by the lawyer. BTW, don’t think we have all the high-end technology in our mortuary like what you see in CSI. In Malaysia, forensic pathologist doesn’t work in a police department. You are just another specialist in a government hospital forever, as you won’t be able to go private. Malaysian law do not accept a report by a private specialist.

4) Patient’s demand and increasing medico-legal issues

Many doctors are being sued nowadays. This happens in most developing or developed countries. Gone are the days where patients will forgive and forget. Even the government is asking all doctors in civil service to take their own indemnity insurance as the government may not be able to cope with the legal suits. The cost of insurance has gone up tremendously especially for surgeons and obstetrician. For Obstetrician, the yearly insurance stands at RM 40 000 – 50 000! So, don’t think that the public has high respect for you and thus they will not take any action against you. A small mistake can land you in court and your entire reputation will be affected, no matter how many life’s that you have saved.

I am sure I would have made a lot of you very depressed by now. Please do not do medicine for the reasons that I have mentioned above. You will regret it later. If you really have passion for medicine then by all means, go ahead. I give the same advice to all parents who seek my advice regarding medicine. But always remember, no matter how much passion you have for medicine, it is still a job for you to earn money for a living. Once you are married and have children, money will be the most important factor no matter what you think now.

The amount of money you are spending to do undergraduate medicine alone can easily be used to start-up a business! Most private medical colleges in Malaysia charges about RM50 000-90 000/year which comes to about RM 250 000 to 500 000 in total, not including accommodation and food. You can easily safe this money, do accountancy/engineering/designer etc etc and use it later to start your own business venture. Don’t you think it is a better option? To get back the investment that you have made for medicine will take another 20 years, not including the money that you need to spend for postgraduate education!

Let me tell you, the money now is not in professional field. If you are smart and only want to earn money, please try technical studies like architect, interior designer, accountancy etc. This is where the money is! If you are good, you can easily become a manager or director of a company by the age of 35.

Increasing numbers not only setting our medical field straight ahead to the limbo, it also impinges on the opportunity of the graduates who rightfully should be better trained in our public hospitals.

The problems we're all facing is political, profitable and lack of aspiration for changes by the senior.

Political - nothing much I have to say

Profitable - recognition of a medical school can mean big business to the investors. Big business means investors willing to use up some moolahs to push through the recognition. Adequacy of training is secondary. And if the medical school inadequately trained the grads, they are sure the consultants and senior doctors should trained those junior doctors, even if they are NOT being paid to do it, out of compassion, ethics and all those supposedly nice attributes of doctors.

Lack of aspiration by seniors/representative bodies - Well. If all the consultants/representative bodies in the country would have stand up (literally) and pushed through a major issue of too much doctors rather than be complacent that this problem is purely political, I guess the medical world has a good chance to be resuscitated before it turn vegetative.

Some junior doctors were at such palliative ground that the consultants feel it is better to let them off to the other department rather than be extended in the department for service. Eventually, they will be confirmed as a full registered doctors and it's mini 2012 whenever they give treatments.

Of course, I applauded some consultants who stood firm on their grounds, and even extended the unfit junior doctors even until 1 year and still counting. Perhaps at times, being guilty conscience can be worse than the lack of peace of mind.

Easier said than done, that I agree. Yes, it been said in casual coffeeshop discussion, farewell party, during ward rounds, during mortality reviews and even during sleep (I am guessing) but never formally on a proper formal platform to be taken serious on any account.

We're producing many, many, many doctors in great speed.
And you know what they say about speed.

Speed kills.


eelainee said...

another thing is when some friend or relatives know that you are doctor in so and so hospital, they will try the best to ask favor from you.. not for them, but for their friends or relatives...

Anonymous said...

Remember there's a Q&A session between MSU-IMS students and the DG?

"Will the Ministry of Health impose a freeze on new medical programs in Malaysia?"

He answered, "Yah, we'll freeze it. There's way too many medical schools nowadays.."

MOH has no authority on the establishment of medical school.

People who are supposed to govern medical education in this country should be those from the medical field, not some businessman, politicians, tom dick and harry or anyone else beyond the medical field.

What a pathetic system in Malaysia!

pilocarpine said...

@joeelaine: i think that is foreseable, we'll need to try our best, not stretch ourselves out too much. our lives afterall is interconnected in so many beautiful magical ways.

@anon: med education belongs to education ministry. I wont disagree on that, but MOH should really give a SERIOUS/STERN feedback on the chaos/blunder made so far.

renxo said...

I work in a private hospital as IT support. I know how much they earning, and yes, some doctors have to strive to get a good (veeeryy good) earnings. But for some, it's just okay to have enough to buy a BMW(s), have holidays once a while and happy faces wive(s) and children. These are doctors I saw passion and compassion in them. But they are also some doctors who are making millions in have a year (mostly surgeon, orthopedic, cardiologist) and they still can't get enough. Probably they need to save a trillion to buy some big mansion in the afterlife. And you know how they do this, they try to snatch the most fish in the pond before the fish swim away. What I mean is that the doctor will asked, "u have insurance? u have money. Now listen to me, u need to go for operation, n believe me, there's no other medication in this world that can cure you except you go for operative correction.. but it will cost u, but that's what you paying u'r insurance for.." hehe..

When I finished my SPM in 1998, I got 8A's and I'm in science stream. I could easily go for medicine studies. My parents were so mad at me when I change my UPU form behind their backs. They even have my school teachers to give me advice on taking medicine, but I was all against it. so I got an IT degree instead. Before I worked at this specialist hospital, I thought I've made the wrong decision on taking IT, but now, I'm more glad I did just that.

Plus.. some doctors are so overwhelmed by their income, or by the status of their job that they may think near godly.. that often they think that they are write all the time. And that make them look stupid sometime. For example, they tot a computer only cost 500 ringgit, and they tot if they order a printer today, they can get it by afternoon, or they tot that if a computer broke down, it can be fix in few minutes, regardless of whatever parts need to be replaced. and they tot a 250 ringgit laser printer toner is cheap, but still they don't want to pay for it, because.. it's expensive.. ;) confusing.. hehe.. think about it.

Tanuj Patmanathan said...

sad part is that parents and relatives are still pressuring their kids to pursue a medical degree. my own brother is currently completing his 2nd year in russia. My folks tried to push me for the same profession, but i knew something like this was going to happen, so i decided to go for forensic psychology, a field which not many people even know abt yet. What local hospitals Can do is reduce the time length of houseman ship, allow fresh doctors to start a practice, and keep monitoring their progress. if they fail to met a certain quota of patient satisfaction, shut the clinic down and make them undergo houseman-ship.

pilocarpine said...

@renxo:I believe I.T. has the similar predicament as medicine, just that I.T. is not being glamourized by the society.

@tanuj: u have to be in a field that you know you'll like.
reducing number of houseman will do, not the duration of housemanship.
shutting down a clinic can be very taxing for everyone, i personally don't think it is legit.

delirioustk said...

nice post. ^^
i think i got into medicine a little recklessly, and even in my final year, i find myself regretting that decision..its not that i thought medicine was like what you said - permanent job (ok, i did think of this!), lotsa money, fact, i think i really had passion for medicine in the beginning, but i lost it along the way. wonder if i can find it back?