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Where medicine has gone just awfully wrong
Published on: Saturday, March 25, 2017

By B. S. KO
I HAVE read with interest and sadness reports on the increasing number of house doctors who face problems during their training and the shocking numbers who have to extend or fail to complete their training and even abscond.

Without question, this very sad development in the training of medical graduates is a colossal waste that hurts not only the graduates and their parents but also the nation that’s struggling to provide quality healthcare services for all.

There have been calls for better treatment and compassion towards housemen to overcome the high rate of them leaving government service. Others have suggested that “nature should take its course” and those who do not make the grade be allowed to leave.

Medicine has always been an exacting science and art that keeps the bar higher to meet the demands of curing sometimes, relieving often and comforting always, the suffering humanity that confronts it day and night.

It has always demanded the best to enter medical schools, the hardest working to pass in examinations and the best to graduate. Any less would be unacceptable to the medical profession.

In our first medical schools – UM, UKM and USM – these standards were jealously guarded and enforced by local teachers and many overseas examiners. To allay the fears of those who think the students were not taught how to deal with suffering and be compassionate to patients, let me assure you all these were taught well to all the graduates of these three schools.

As a teacher of medical students since 1971, I can assure you that communication skills were taught since at least 1974, which is 42 years ago. And gradually these were taught in many other schools that followed by teachers from the three schools who readily filled the posts of lecturers in newer schools, carrying over the skills they learnt.

The proliferation of many medical schools since the late 1990s in our country and rapid recognition of numerous other schools overseas have produced a flood of Malaysian graduates who may not have the skills or rigorous standards we saw in the 80s. A big problem is also the severe shortage of good medical teachers and opening up opportunities for lucrative private practices have cut supplies of competent teachers so that newer schools are forced to seek medical teachers from overseas whose experience may not necessarily be what doctors in this country need.

The result is often that the newer Malaysian doctors trained from some countries and some new Malaysian schools are taught more theory than practical skills. These may be sometimes sufficient to scrape through exams but will be tested dearly in the more practice than theory of the fast-paced house officer years.

Medicine is an apprenticeship science and art and most teaching of medical schools in Malaysia is conducted in hospitals owned and run by the Health Ministry, where the vast majority of teachers of medical schools do not actually treat patients. Herein is the big gap between the good learning of theoretical medicine and hands-on practice of medicine that students need to learn from their lecturers. Facilities and opportunities for teaching of the much-needed practical skills in most MOH hospitals and clinics used by around 20 private medical schools in this country are limited, to say the least.

No amount of cramming and simulations will prepare the young, earnest future housemen for the shock of the real world of a Malaysian house officer in practice. Housemen are expected to see and manage patients in situations where all they learnt and much more by way of practice are brought to bear every day and night.

By the standards of the 1970s, where a house officer had to go on first call at least twice a week alone and cover up to 200 patients, today’s housemen have active, passive, shift, days off and infinitely more colleagues to help out.

So, technically, things should be better, you may think. But the root cause appears to be related to lower entry requirements, lower teaching skills required of teachers and lower emphasis on practical skills and attitudes.

I asked several house doctors who could not complete their houseman training (and were contemplating quitting) what they saw as the difference between them and Malaysian medical graduates who did their housemanship well.

Their answers were fairly consistent: They felt the UKM, UM and USM graduates were more skilled and knew all the procedures when they started their housemanship.

It is widely known that teaching, especially in medicine, must depend on teaching of knowledge, skills and attitudes (KAP). Diluting any of this for the sake of expediency has not done students, families, teachers and the nation any good. It can also contribute to harsh and unsuccessful efforts by those who supervise house officers to re-educate graduates who missed out during their crucial formative years due to other reasons.

As a teacher of medicine for over four decades, may I appeal to the ministries concerned that the whole process – entry of students into medicine, their training both locally and overseas and their acceptance for houseman posts – be thoroughly reviewed before the situation worsens?

B. S. KO

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