malaysian health system – how to excel !2

MALAYSIAN HEALTH MALAYSIAN HEALTH SYSTEM – HOW TO SYSTEM – HOW TO

EXCEL !EXCEL !DR FAUZIAH MOHD HASANDR FAUZIAH MOHD HASAN

MBBS (Tas, Australia)MBBS (Tas, Australia)

FRCOG (UK)FRCOG (UK)

ContentsContents• IntroductionIntroduction• Malaysian health system:Malaysian health system:

– Public and private Public and private – Strength and weaknessStrength and weakness– Career pathway – HO-> MO->Specialist-> Career pathway – HO-> MO->Specialist->

consultantconsultant– 1Care System1Care SystemHow to excel:How to excel:

- Individual desire to improve and make - Individual desire to improve and make changeschanges- medical education – ethicsmedical education – ethics- Government, Management, and politicians- Government, Management, and politicians- Society at large- Society at large

IntroductionIntroduction• Healthcare in Malaysia: radical Healthcare in Malaysia: radical

transformationtransformation• Widespread system of health care, public Widespread system of health care, public

and private sectors.and private sectors.• 5% social sector development budget 5% social sector development budget

>RM2B>RM2B• 4 years compulsory service, 2 years 4 years compulsory service, 2 years

housemanshiphousemanship• Still shortage of highly trained specialistsStill shortage of highly trained specialists• Promote Malaysia – health tourismPromote Malaysia – health tourism

Malaysian Health SystemMalaysian Health System

• Public Primary Health Care:Public Primary Health Care:

1)Klinik Desa1)Klinik Desa: :

- radius 5-10Km- radius 5-10Km

- run by Jururawat Masyarakat (JM)- run by Jururawat Masyarakat (JM)

- women and child health clinic- women and child health clinic

- refers to Klinik Kesihatan (KK)- refers to Klinik Kesihatan (KK)


2) 2) Klinik KesihatanKlinik Kesihatan: :

- one in small and major town- one in small and major town

- runs by Medical Assistants (MA)- runs by Medical Assistants (MA)

- has a Medical officer (MO), 1-2- has a Medical officer (MO), 1-2

- antenatal,general outpatient clinic- antenatal,general outpatient clinic

- converted to polyclinics – 8MO’s- converted to polyclinics – 8MO’s

- Family Medicine Specialists (FMS)- Family Medicine Specialists (FMS)

- MO: health edu, school visits, Mx - MO: health edu, school visits, Mx outbreaksoutbreaks

- cannot prescibe List A drugs.- cannot prescibe List A drugs.


•Public Health Officers – no Public Health Officers – no clinical work but work in heath clinical work but work in heath offices, administrative work – offices, administrative work – developing various programmes, developing various programmes, monitoring infective outbreaks monitoring infective outbreaks and controlling infective diseases and controlling infective diseases eg dengue, typhoid.eg dengue, typhoid.


•3) 1 Malaysia clinic:3) 1 Malaysia clinic:

- to cater for urban poor.- to cater for urban poor.

- run by MA 8am-10pm.- run by MA 8am-10pm.

- URTI’s, dressing, minor - URTI’s, dressing, minor ailments. ailments.

Public HospitalsPublic Hospitals• 1) District Hospitals:1) District Hospitals:

– Every district has oneEvery district has one– 2-7 MO, with and without specialists2-7 MO, with and without specialists– Has basic diagnostic capabilities eg Has basic diagnostic capabilities eg

blood investigations and X rayblood investigations and X ray– Bigger one has OTBigger one has OT– Refer to nearest General HospitalRefer to nearest General Hospital– One MO oncall – cover the whole One MO oncall – cover the whole

hospital, one man, woman show!!hospital, one man, woman show!!

Public HospitalsPublic Hospitals• 2) General Hospitals:2) General Hospitals:

– Every state has one or more.Every state has one or more.– Well equipped, some have subspeciality Well equipped, some have subspeciality

eg urology, neurology, cardiologyeg urology, neurology, cardiology– Well equipped with lab, imaging eg Well equipped with lab, imaging eg

CTScan, MRICTScan, MRI– Overcrowded, congested, 40-60 pt/wardOvercrowded, congested, 40-60 pt/ward– Train houseman and postgraduatesTrain houseman and postgraduates– Workload very high, stressfulWorkload very high, stressful

A&E A&E waiting waiting roomroom

Private sectorsPrivate sectors• 1) General Practitioners (GPs)1) General Practitioners (GPs)

– First private healthcare service providers in First private healthcare service providers in MalaysiaMalaysia

– Can do after 4 years compulsory serviceCan do after 4 years compulsory service– Simple primary care service to general publicSimple primary care service to general public– Highly respected, profitable business. No Highly respected, profitable business. No

regulations to monitor them. Allowed to regulations to monitor them. Allowed to dispense medication without pharmacist / dispense medication without pharmacist / trained nurse.trained nurse.

– Currently: stiff competition from other GPs, Currently: stiff competition from other GPs, private hospitals, government polyclinics and private hospitals, government polyclinics and 1Malaysia clinics. Less new GPs because:1Malaysia clinics. Less new GPs because:

GPs..GPs..

• i) Private Healthcare and i) Private Healthcare and Facilities Facilities

Act 1998 – implemented from Act 1998 – implemented from

20062006• ii) Income GPs decreasing – ii) Income GPs decreasing –

closure of clinicsclosure of clinics• iii)APC renewal without CME iii)APC renewal without CME points – poor outdated points – poor outdated knowledgeknowledge

..GPs..GPs

Future directions:Future directions:

• i) postgraduate degree in family i) postgraduate degree in family medicinemedicine

• ii) lose lisence to dispense ii) lose lisence to dispense medicationmedication

• iii) MOH encouraging GPs – Dip in iii) MOH encouraging GPs – Dip in Family MedFamily Med

• Academy of Family Physicians of Academy of Family Physicians of Malaysia has this programme since Malaysia has this programme since 2009.2009.

Private HospitalsPrivate Hospitals• Began to appear 1980Began to appear 1980• People go for better and faster People go for better and faster

specialist treatmentspecialist treatment• Run by bussinessman for a profit, Run by bussinessman for a profit,

few have charity armfew have charity arm• 3 big giants KPJ hospitals, Parkway 3 big giants KPJ hospitals, Parkway

(Khazanah owned) Pantai and (Khazanah owned) Pantai and Gleneagles hospitals and Columbia Gleneagles hospitals and Columbia Asia Hospitals (30% owned by EPF)Asia Hospitals (30% owned by EPF)

• Independently managed hospitals Independently managed hospitals like Fatimah, Assunta. like Fatimah, Assunta.

Private HospitalsPrivate Hospitals

• Do not pay consultant salary – self employedDo not pay consultant salary – self employed• Fees regulated by Private Healthcare and Fees regulated by Private Healthcare and

Facilities Act 1998.Facilities Act 1998.• 10-20% - administrative fee10-20% - administrative fee• No national healthcare financing systemNo national healthcare financing system• 3-5 years postgraduate experience3-5 years postgraduate experience• Single handed care, no HO/ MO…Single handed care, no HO/ MO…• Need commitment , hard work and sacrificeNeed commitment , hard work and sacrifice• Caused massive brain drain from govt sector, Caused massive brain drain from govt sector,

now stiff competition due to mushrooming of now stiff competition due to mushrooming of private hospitals.private hospitals.

Strength of Malaysian Strength of Malaysian Healthcare SystemHealthcare System

• 1.Ever improving over decades1.Ever improving over decades

• 2.Equitable access to healthcare for all2.Equitable access to healthcare for all

• 3.No interference to medical practice3.No interference to medical practice

• 4.Patient can consult and buy medication 4.Patient can consult and buy medication from whoever they trust from whoever they trust

• 5.Cost effective use of healthcare funds5.Cost effective use of healthcare funds

• 3.6% of GDP and 7% of total govt 3.6% of GDP and 7% of total govt expenditureexpenditure

StatisticsStatistics• Population : 27,728,700Population : 27,728,700

• Average annual population growth rate: Average annual population growth rate: 2%2%

• Infant mortality rate: 6.3% per 1000 live Infant mortality rate: 6.3% per 1000 live birthsbirths

• Maternal mortality rate: 0.3% per 1000 Maternal mortality rate: 0.3% per 1000 live birthslive births

• Perinatal mortality rate: 7.3% per 1000 Perinatal mortality rate: 7.3% per 1000 live birthslive births

• Live expectancy: Live expectancy:

Males: 71.70 Males: 71.70 Females: 76.46 yearsFemales: 76.46 years

Weakness of Malaysian Weakness of Malaysian Healthcare SystemHealthcare System1. The long waiting list – appt to see 1. The long waiting list – appt to see

consultant, outpatient dept, elective consultant, outpatient dept, elective surgery.surgery.(organizational, HR, management (organizational, HR, management problem)problem)

2. Competent, trained doctors, nurses, 2. Competent, trained doctors, nurses, para medicals. - mass production of para medicals. - mass production of doctors doctors in 2010 – 7500 housemen.in 2010 – 7500 housemen.nurses – lowered intake criteria – nurses – lowered intake criteria – mass production, seniors left for Saudi mass production, seniors left for Saudi Arabia, less supervision.Arabia, less supervision.

Weakness of Malaysian Weakness of Malaysian Healthcare SystemHealthcare System

3. Overemphasis on curative care, less on 3. Overemphasis on curative care, less on preventive, screening.preventive, screening.

4. Lack of control of charges in private 4. Lack of control of charges in private hospitals –rating of hospital, doctors fee – hospitals –rating of hospital, doctors fee – regulatedregulated

5. Lack of control of high tech medical 5. Lack of control of high tech medical equipment – business entity, potential equipment – business entity, potential hazards, costly.hazards, costly.

6. Lack of control in mushrooming of 6. Lack of control in mushrooming of laboratorieslaboratories

Housemanship..Housemanship..• 1a) Before 20001a) Before 2000

4 monthly rotations in 4 monthly rotations in Obstetrics & Obstetrics & Gynaecology, Medicine or Gynaecology, Medicine or Paediatric and Surgery or Paediatric and Surgery or Orthopaedic.Orthopaedic. After the 1 year After the 1 year training, transferred to rural or training, transferred to rural or semirural areas to serve in district semirural areas to serve in district hospitals or Klinik Kesihatans (KK) hospitals or Klinik Kesihatans (KK) (health clinics). Most of the time (health clinics). Most of the time wonderful experience but a little bit wonderful experience but a little bit scary due to lack of senior people to scary due to lack of senior people to consult or assist you.consult or assist you.

..Housemanship....Housemanship..• 1b) After 20001b) After 2000

Around the year 2000-2002, Junior Around the year 2000-2002, Junior medical officer postings was introduced medical officer postings was introduced after housemanship. ( 4after housemanship. ( 4thth and 5 and 5thth HO HO posting). 3 month posting in either posting). 3 month posting in either medicine/paediatric or surgery/ortho medicine/paediatric or surgery/ortho depending on which that you did not do depending on which that you did not do during the 1 year housemanship . After during the 1 year housemanship . After completing the 4completing the 4thth and 5 and 5thth postings, postings, posted to rural or district as a Medical posted to rural or district as a Medical Officer.Officer.

..Housemanship....Housemanship..

•1c) Since 20081c) Since 2008

Since 2008, housemanship Since 2008, housemanship training has been extended to training has been extended to 2 years. This means you will be 2 years. This means you will be completing all the major completing all the major postings before being postings before being transferred out.transferred out.

..Housemanship....Housemanship..RecentlyRecently: With the tremendous : With the tremendous increase in the number of doctors increase in the number of doctors produced, almost 6-8 HOs in each produced, almost 6-8 HOs in each ward of 40 patients. In fact, surgical ward of 40 patients. In fact, surgical department with 2 wards, department with 2 wards, sometimes has more than 40 HOs!! sometimes has more than 40 HOs!! The workload will definitely be The workload will definitely be lower, will lose out in training as lower, will lose out in training as HO.HO.

..Housemanship..HousemanshipShift DutyShift Duty: Working shift hour : Working shift hour means passing over the means passing over the management of the patient to management of the patient to another housemen every shift. another housemen every shift. This will definitely cause a lot of This will definitely cause a lot of problems in the continuity of care problems in the continuity of care of the patient. The responsibility of of the patient. The responsibility of the housemen will also reduce, the housemen will also reduce, making the doctor more making the doctor more complacent.complacent.

HO: Shift dutyHO: Shift duty• The housemen who is not interested in The housemen who is not interested in

being a doctor( many nowadays) , may being a doctor( many nowadays) , may just take his own sweet time to do all just take his own sweet time to do all his work so that he can pass over the his work so that he can pass over the problems to the next housemen who problems to the next housemen who takes over. This will go on and on untill takes over. This will go on and on untill the patient may not get the treatment the patient may not get the treatment that he needs. Politics will become the that he needs. Politics will become the main issue among the housemen. The main issue among the housemen. The hard-working ones will continue to hard-working ones will continue to suffer and definitely it will be more suffer and definitely it will be more difficult for the consultants to monitor difficult for the consultants to monitor these housemen as they will keep these housemen as they will keep changing every shift. changing every shift.

HO: Shift dutyHO: Shift duty

•The medical officers will begin to The medical officers will begin to complain as they will end up doing complain as they will end up doing all the work. Introducing shift hour all the work. Introducing shift hour work during housemanship will work during housemanship will also compromise the training of also compromise the training of the housemen. Less working hours the housemen. Less working hours with less exposure to with less exposure to emergencies.emergencies.

•Furthermore, working shift hours Furthermore, working shift hours means means NOTNOT entitled for “On Call” entitled for “On Call” allowance doing shift work.allowance doing shift work.

To Be A good DoctorTo Be A good Doctor

•What can I say is, if they committed, What can I say is, if they committed, make their own effort to learn/ask, be make their own effort to learn/ask, be nice to their nice to their colleague/staffnurse/JM/attendant in colleague/staffnurse/JM/attendant in the ward, follow orders that has been the ward, follow orders that has been ordered; they will be a good doctor. ordered; they will be a good doctor. BUT..if they are just standing there BUT..if they are just standing there like a consultant and quite, have to like a consultant and quite, have to ask then only they move..BIG ask then only they move..BIG problems!.problems!.

Rules and Regulation Rules and Regulation during Housemanship during Housemanship • A log book given for each posting. This log A log book given for each posting. This log

book needs to be signed off at the end of book needs to be signed off at the end of each posting by the HOD. HOD may extend each posting by the HOD. HOD may extend the training if he/she feels HO not the training if he/she feels HO not competent enough to be released. The competent enough to be released. The extension is for a minimum of 3 months but extension is for a minimum of 3 months but can go on as long as the HOD feels can go on as long as the HOD feels adequate. adequate.

• As a government servant, 25 days annual As a government servant, 25 days annual leave. As a HO, these 25 days will be leave. As a HO, these 25 days will be divided equally between the 3 postings in a divided equally between the 3 postings in a year. Any extra leaves including MCs, year. Any extra leaves including MCs, maternity leave and emergency leaves are maternity leave and emergency leaves are considered as an extension of considered as an extension of housemanship traininghousemanship training

Medical officerMedical officerDistrict/Rural postingsDistrict/Rural postings• After completion of housemanship, likely After completion of housemanship, likely

be transferred to rural clinics or district be transferred to rural clinics or district hospitals. With the recent influx of large hospitals. With the recent influx of large number of doctors, almost everyone will number of doctors, almost everyone will be transferred to rural areas, mainly be transferred to rural areas, mainly Sabah and Sarawak.Sabah and Sarawak.

• Health clinics (Klinik Kesihatan). Situated Health clinics (Klinik Kesihatan). Situated in rural and semirural areas. Most of the in rural and semirural areas. Most of the time there will be 1-2 MOs in each clinic. time there will be 1-2 MOs in each clinic. The major bulk of patients , antenatal and The major bulk of patients , antenatal and outpatient cases. Administrative work : outpatient cases. Administrative work : school visits, running various health school visits, running various health campaigns and public health talks. Help in campaigns and public health talks. Help in containing any outbreak. Primary containing any outbreak. Primary healthcare providers. Meetings to attend!healthcare providers. Meetings to attend!

Postgraduate studiesPostgraduate studies• Most postgraduate trainings are dependent Most postgraduate trainings are dependent

on Master’s programme conducted by the on Master’s programme conducted by the local universities. Once upon a time, we local universities. Once upon a time, we were totally dependent on UK-based exams were totally dependent on UK-based exams and training but unfortunately we lost it and training but unfortunately we lost it along the way. Currently, only MRCP (UK) – along the way. Currently, only MRCP (UK) – Internal Medicine, MRCPCH (UK) – Internal Medicine, MRCPCH (UK) – Paediatric and MRCOG (UK) can be done in Paediatric and MRCOG (UK) can be done in Malaysia. FRCS (for surgeons) used to be Malaysia. FRCS (for surgeons) used to be available to Malaysians but not anymore. available to Malaysians but not anymore. None of our hospitals are recognised as a None of our hospitals are recognised as a training centre for FRCS, which is now training centre for FRCS, which is now known as MRCS. Thus, for any surgical field known as MRCS. Thus, for any surgical field in Malaysia, you will need to do Master’s in Malaysia, you will need to do Master’s programme!programme!

Membership of Royal Membership of Royal CollegeCollege• Membership of the Royal College of Membership of the Royal College of

Physicians (UK) is a well-known exam all Physicians (UK) is a well-known exam all over the whole. It has a very strong over the whole. It has a very strong reputation as an entry exam for reputation as an entry exam for speciality training in UK as well as in speciality training in UK as well as in other parts of the world. It is conducted other parts of the world. It is conducted regularly, usually 3 times a year in regularly, usually 3 times a year in various countries. Malaysia is one of the various countries. Malaysia is one of the centres for the MRCP exams, all 3 parts.centres for the MRCP exams, all 3 parts.

• MRCPCH (UK)MRCPCH (UK)MRCPCH is similar to MRCP (UK) but MRCPCH is similar to MRCP (UK) but meant for those who wants to become a meant for those who wants to become a Paediatrician. It‘s examination structure Paediatrician. It‘s examination structure is similar to MRCP (UK).is similar to MRCP (UK).

..Membership of Royal ..Membership of Royal CollegeCollege• MRCOG (UK)MRCOG (UK)

MRCOG has 2 parts but the second part has both MRCOG has 2 parts but the second part has both written and clinical component. However, you need written and clinical component. However, you need to undergo training in O&G department for at least to undergo training in O&G department for at least 4 years before being allowed to sit for Part 2 4 years before being allowed to sit for Part 2 exams. One of the major issues in sitting for exams. One of the major issues in sitting for MRCOG is the fact that there are not many MRCOG is the fact that there are not many MRCOG holders in MOH to sign as a proposer for MRCOG holders in MOH to sign as a proposer for you!you!

• Master’s programmeMaster’s programme

Now, this is where a big problem is going to appear Now, this is where a big problem is going to appear soon. For all other fields, you are totally dependent soon. For all other fields, you are totally dependent on Master’s programme. This includes all surgical on Master’s programme. This includes all surgical fields. Master’s programme is a fixed 4 year fields. Master’s programme is a fixed 4 year programme.programme.

Master’s ProgrammeMaster’s Programme• There are 2 types of Master’s programme, the open and There are 2 types of Master’s programme, the open and

closed system. In the closed system, you will do the closed system. In the closed system, you will do the entire 4 years within the university, like in UKM Hospital, entire 4 years within the university, like in UKM Hospital, UH and USM Hospital. The open system may have UH and USM Hospital. The open system may have various programmes, like 2 years in MOH hospitals and various programmes, like 2 years in MOH hospitals and another 2 years in the Universities etc. You may even do another 2 years in the Universities etc. You may even do the entire 4 years in MOH hospitals for some of the the entire 4 years in MOH hospitals for some of the fields.fields.

• After completing your Master’s programme, you need to After completing your Master’s programme, you need to undergo another 6 months of gazettement process undergo another 6 months of gazettement process before being recognised as a specialist. Furthermore, before being recognised as a specialist. Furthermore, you will be bonded for 5-7 years for receiving scholarship you will be bonded for 5-7 years for receiving scholarship during the programme, which is compulsory!during the programme, which is compulsory!

• Generally, the subspecialist training is about 3 years Generally, the subspecialist training is about 3 years except for certain field like Cardiothoracic and Urology except for certain field like Cardiothoracic and Urology which may take 4 years. Again, whether you get a place which may take 4 years. Again, whether you get a place or not depends on availability of post and demand for or not depends on availability of post and demand for that particular field. For example, the waiting time for that particular field. For example, the waiting time for Gastroenterology training can even go as far as 1-2 Gastroenterology training can even go as far as 1-2 years.years.

SubspecialitySubspeciality

• Recently, to overcome this major problem, MOH has Recently, to overcome this major problem, MOH has taken another step backwards. You can only apply taken another step backwards. You can only apply for subspecialty training 1 year after you have been for subspecialty training 1 year after you have been gazetted as a specialist. For MRCP holders, this gazetted as a specialist. For MRCP holders, this means 2 and half years after passing MRCP (UK)!means 2 and half years after passing MRCP (UK)!

• Usually, the subspecialty training is divided into 2 Usually, the subspecialty training is divided into 2 parts, the first part (the first 2 years) will be done parts, the first part (the first 2 years) will be done locally and the 2locally and the 2ndnd part (remaining 1 year) will be part (remaining 1 year) will be done overseas. The MOH will provide a fully paid done overseas. The MOH will provide a fully paid scholarship for overseas training of 1 year but you scholarship for overseas training of 1 year but you will be bonded for 3 years. If you have received will be bonded for 3 years. If you have received undergraduate scholarship and Master’s scholarship, undergraduate scholarship and Master’s scholarship, you will be bonded a total of 20 years. Our Master’s you will be bonded a total of 20 years. Our Master’s degrees are degrees are NOT NOT recognised elsewhere.recognised elsewhere.

1 Care System..1 Care System..

•The 1 Care system will start by The 1 Care system will start by incorporating the GPs into incorporating the GPs into primary health care system. It primary health care system. It is a way for the government to is a way for the government to reduce their load in reduce their load in government clinics. Now, government clinics. Now, before every one gets excited before every one gets excited thinking that GPs are going to thinking that GPs are going to benefit, please check the benefit, please check the system in more detail.system in more detail.

..1Care System....1Care System..• Every employed person will have to contribute to Every employed person will have to contribute to

this scheme, similar like EPF. Certain percentage this scheme, similar like EPF. Certain percentage of your salary will be deducted monthly as a of your salary will be deducted monthly as a contribution to this NHFS. Basically, this scheme contribution to this NHFS. Basically, this scheme will allocate a certain amount of money for each will allocate a certain amount of money for each private citizens of Malaysia - it would be in a private citizens of Malaysia - it would be in a range of about RM4K per year. Every citizen need range of about RM4K per year. Every citizen need to register with a GP and can only seek treatment to register with a GP and can only seek treatment from that particular GP whether they like it or not. from that particular GP whether they like it or not. If you decide to choose someone else, you need If you decide to choose someone else, you need to pay on your own. Zoning will be implemented to pay on your own. Zoning will be implemented with only certain number of GPs will be included with only certain number of GPs will be included in each zone. in each zone.

..1Care System..1Care System• GPs must sign a contract with NHFS to become a GPs must sign a contract with NHFS to become a

panel clinic. Each of these GPs will be allocated panel clinic. Each of these GPs will be allocated about 1500-2000 patients. GPs with Primary Care about 1500-2000 patients. GPs with Primary Care Diploma or Family Physicians Specialist will be Diploma or Family Physicians Specialist will be given preference. Every GP will only be paid certain given preference. Every GP will only be paid certain amount of fee for each of their consultation and amount of fee for each of their consultation and the number of visits per year will be limited. Only the number of visits per year will be limited. Only certain medications listed as “standard drugs” certain medications listed as “standard drugs” under the scheme will be allowed to be prescribed under the scheme will be allowed to be prescribed and paid by the scheme as mentioned below ( so and paid by the scheme as mentioned below ( so the GPs may lose the profits from meds). Once the the GPs may lose the profits from meds). Once the citizen finishes his/her allocation, highly likely, they citizen finishes his/her allocation, highly likely, they have to go back to the government clinic. have to go back to the government clinic. However, maybe GPs may be forced to provide However, maybe GPs may be forced to provide free service for the remaining number of visits as free service for the remaining number of visits as part of social obligation to the community. Not part of social obligation to the community. Not sure where and how the government clinics are sure where and how the government clinics are going to be placed in this system.going to be placed in this system.

Corporatization of Government Corporatization of Government Hospitals..Hospitals..• Once the primary healthcare integration is Once the primary healthcare integration is

complete under the NHFS, the government complete under the NHFS, the government hospitals will be corporatised. For those who are hospitals will be corporatised. For those who are new in MOH, the corporatisation of government new in MOH, the corporatisation of government hospitals were supposed to be implemented in hospitals were supposed to be implemented in 1998/1999. Most of the new hospitals like 1998/1999. Most of the new hospitals like Selayang, Ampang, Sg Buloh, Sultan Selayang, Ampang, Sg Buloh, Sultan Ismail hospitals were supposed to be run by Ismail hospitals were supposed to be run by corporate bodies. Fortunately, due to the 1999 corporate bodies. Fortunately, due to the 1999 political crisis involving the sacking of political crisis involving the sacking of Anwar Ibrahim etc, the entire plan was Anwar Ibrahim etc, the entire plan was postponed. Soon, it will be revived under postponed. Soon, it will be revived under the 1Care system. Once corporatised, each the 1Care system. Once corporatised, each hospitals will be an autonomous hospital. Each hospitals will be an autonomous hospital. Each hospital will decide on how many doctors they will hospital will decide on how many doctors they will employ, how many housemen they will train and employ, how many housemen they will train and how many specialist they need. how many specialist they need.

..Corporatization of ..Corporatization of Government HospitalsGovernment Hospitals• There are not obliged to provide job to everyone. There are not obliged to provide job to everyone.

All graduates will need to apply to the individual All graduates will need to apply to the individual hospitals for a job. Incompetent ones may be hospitals for a job. Incompetent ones may be kicked out. However, it is a long way to go before kicked out. However, it is a long way to go before this happens,may be the corporatisation of this happens,may be the corporatisation of hospitals will only take place about 3-4 years hospitals will only take place about 3-4 years after the primary care integration, if everything after the primary care integration, if everything goes well. The entire restructuring exercise will goes well. The entire restructuring exercise will take about 15 years from 2014. Once everything take about 15 years from 2014. Once everything is complete, the NHFS will be paying for both is complete, the NHFS will be paying for both public and private sectors(with certain limit), by public and private sectors(with certain limit), by which time both may become one system. The which time both may become one system. The “semi-government” corporatised hospitals will “semi-government” corporatised hospitals will still be subsidised heavily by the government. still be subsidised heavily by the government. Personal insurance will be used to top up the Personal insurance will be used to top up the payment for private hospitals once the NHFS limit payment for private hospitals once the NHFS limit is achieved.is achieved.

Choice of care..Choice of care..

• There is choice with the present There is choice with the present system. With 1-Care this choice will system. With 1-Care this choice will not be there. The patient and public not be there. The patient and public pay upfront in the form of insurance pay upfront in the form of insurance or taxes. If they do not want the or taxes. If they do not want the doctors or the service that is doctors or the service that is allocated, they will have to pay again allocated, they will have to pay again for what they choose.for what they choose.

Achieving doctor : Achieving doctor : PopulationPopulation• With the current rate at which Malaysian doctors are With the current rate at which Malaysian doctors are

graduating from medical schools, both locally and graduating from medical schools, both locally and abroad, the country will reach its overall doctor abroad, the country will reach its overall doctor population target of one doctor for 600 population population target of one doctor for 600 population within three to four years, and a ratio of one doctor within three to four years, and a ratio of one doctor for about 400 population or less by 2020.There will for about 400 population or less by 2020.There will have to be 5,000 to 7,000 Medical Officer posts in have to be 5,000 to 7,000 Medical Officer posts in the public sector available annually within the next the public sector available annually within the next five years for the young doctors after completion of five years for the young doctors after completion of their housemenship training, and after that it will be their housemenship training, and after that it will be anybody’s guess.If there are insufficient posts, how anybody’s guess.If there are insufficient posts, how many can be absorbed by the private sector, which many can be absorbed by the private sector, which is already saturated in many areas?There will be no is already saturated in many areas?There will be no employment problems for doctors of good quality, employment problems for doctors of good quality, but the prospect of unemployment is a possibility for but the prospect of unemployment is a possibility for the mediocre, and possibly, some of the average the mediocre, and possibly, some of the average ones.”.ones.”.

Good Medical PracticeGood Medical Practice• The MMC has listed five basic ingredients of The MMC has listed five basic ingredients of

Good Medical Practice. They are professional Good Medical Practice. They are professional integrity, communication skills, ethical integrity, communication skills, ethical behaviour, treating patients with dignity, and behaviour, treating patients with dignity, and being a team player.being a team player.

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

• The statement of Sir William Osler, the father of The statement of Sir William Osler, the father of modern Medicine, is particularly relevant: modern Medicine, is particularly relevant: “Medicine is learned by the bedside and not in “Medicine is learned by the bedside and not in the classroomthe classroom

Adverse EventsAdverse Events

• Is Is Primum non cerePrimum non cere, ie, first do no harm, ie, first do no harm• It is now generally accepted that the It is now generally accepted that the

incidence of adverse events from incidence of adverse events from hospitalisations is about 10%, with single hospitalisations is about 10%, with single digit figures for mortality and morbidity.digit figures for mortality and morbidity.

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

Path to Excel…Path to Excel…

• Yesterday I was clever, I wanted to change Yesterday I was clever, I wanted to change the world, today I am wiser I will change the world, today I am wiser I will change myselfmyself

• Changing oneself for the better needs:Changing oneself for the better needs:– KnowledgeKnowledge– Vision and mission (dreams)Vision and mission (dreams)– SacrificeSacrifice– EnduranceEndurance– PassionPassion– Right attitude and Big heartRight attitude and Big heart

Reasons for entering Medical Reasons for entering Medical school!school!

• never thought medicine was this tough never thought medicine was this tough and depressingand depressing

• parents wanted me to become a doctorparents wanted me to become a doctor

• thought medicine can make a lot of moneythought medicine can make a lot of money

• I thought being a doctor is just sitting in a I thought being a doctor is just sitting in a clinic and see patients.clinic and see patients.

• got influenced by TV programmesgot influenced by TV programmes

• thought can cure the patients all the timethought can cure the patients all the time

Medical EducationMedical Education

• Different ways of imparting knowledge – Different ways of imparting knowledge – PBL, BST, TBL etc…outcome basedPBL, BST, TBL etc…outcome based

• Stress on medical ethics – why? Stress on medical ethics – why?

• The Tuskegee-Alabama incident, study The Tuskegee-Alabama incident, study from 1930-1970 African American not from 1930-1970 African American not treated for syphilis in order to study treated for syphilis in order to study the natural course of the disease.the natural course of the disease.

Medical EthicsMedical Ethics• Major scientific and medical Major scientific and medical

achievements, innovations – achievements, innovations – significant influences of human life significant influences of human life and health. Resulted in complicated and health. Resulted in complicated ethical, religious, social and legal ethical, religious, social and legal implications.implications.

• Main concern: needs progress but Main concern: needs progress but without deviations that threaten without deviations that threaten human dignity and best interesthuman dignity and best interest

Medical EthicsMedical Ethics• Have to deal with:Have to deal with:

– Flood of non ethical conduct by Flood of non ethical conduct by individuals and institutionindividuals and institution

– Effects of globalization of valuesEffects of globalization of values– Effects of big business on medical Effects of big business on medical

behaviourbehaviour

• Need regulation of medical and Need regulation of medical and research behavioursresearch behaviours

Reminders !..Reminders !.."Know that the life of this world is only play and amusement, pomp and mutual boasting among you, and rivalry in respect of wealth and children, as the likeness of vegetation after rain, thereof the growth is pleasing to the tiller; afterwards it dries up and you see it turning yellow; then it becomes straw. But in the Hereafter (there is) a severe torment (for the disbelievers, evil-doers), and (there is) Forgiveness from Allah and (His) Good Pleasure (for the believers, good-doers), whereas the life of this world is only a deceiving enjoyment." - [Al-Qur'aan, Surah Al-Hadid:20]

..Reminders !..Reminders !The Prophet (sallallahu alayhi wa sallam) said:

"The People will soon summon one another to attack you as people when eating invite others to share their food." Someone asked, "Will that be because of our small numbers at that time?" He replied, "No, you will be numerous at that time: but you will be froth and scum like that carried down by a torrent (of water), and Allah will take the fear of you from the breasts (hearts) of your enemy and cast Al-wahn into your hearts." Someone asked, "O Messenger of Allah, what is al-wahn?" He replied, "Love of the world and dislike of death." - [Abu Dawud]

CUCMSCUCMS

CUCMSCUCMS

The PhilosophyThe harnessing of human potentials in a comprehensive manner to produce holistic healthcare professionals who are intellectually, emotionally and spiritually-balanced is based on the principles of Islam and the obedience to the Almighty Allah.

CUCMSCUCMS

•Our VisionOur Vision

We aspire to be a distinctive We aspire to be a distinctive medical sciences institution of medical sciences institution of higher learning of international higher learning of international repute producing competent repute producing competent healthcare professionals.healthcare professionals.

CUCMSCUCMS

•Our MissionOur MissionTo be a distinctive medical To be a distinctive medical sciences institution of sciences institution of international repute, international repute, producing competent producing competent healthcare professionals who healthcare professionals who are intellectuality, are intellectuality, emotionally and spiritually- emotionally and spiritually- balancedbalanced

Improvement higher Improvement higher levels…levels…

•According to WHO, strategies to According to WHO, strategies to improve the performance of the improve the performance of the health workforce must initially health workforce must initially focus on existing staff because of focus on existing staff because of the time lag in training new health the time lag in training new health workers.”workers.”

suggested tactics to:suggested tactics to:

•Build education capacityBuild education capacity

•Harness the value of supervisionHarness the value of supervision

..Improvement higher ..Improvement higher levels..levels..• Leverage opportunities for “non-Leverage opportunities for “non-

clinical” education, for example, in clinical” education, for example, in the areas of public health, clinical the areas of public health, clinical research, risk management, and also research, risk management, and also training methods that address the training methods that address the new paradigms of care, e.g. from new paradigms of care, e.g. from acute tertiary hospital care to home-acute tertiary hospital care to home-based and team-driven care.based and team-driven care.

• Tactics that control the number of Tactics that control the number of fresh graduates entering the local fresh graduates entering the local workforceworkforce

• Continuous reevaluation of future Continuous reevaluation of future requirement for health workers.requirement for health workers.

……Improvement higher Improvement higher levelslevels• Controlling the number of Malaysians being admitted Controlling the number of Malaysians being admitted

and graduating from medical schools. This can be and graduating from medical schools. This can be achieved through:achieved through:– Creation of a body to oversee the quality of medical Creation of a body to oversee the quality of medical

education, the functions of which may be similar to the education, the functions of which may be similar to the Council on Medical Education in the United States.Council on Medical Education in the United States.

– Introduction of standards to improve the quality of Introduction of standards to improve the quality of medical education, e.g. requiring a basic university medical education, e.g. requiring a basic university degree before acceptance into a professional degree degree before acceptance into a professional degree program (as in some parts of the word), establishing program (as in some parts of the word), establishing minimum expectations in a medical curriculum, and a minimum expectations in a medical curriculum, and a minimum number of full-time medical faculty.minimum number of full-time medical faculty.22Following Following the Flexner Reportthe Flexner Report22 which advocated these changes which advocated these changes (and more) in similar circumstances to the present in (and more) in similar circumstances to the present in Malaysia, a large proportion of medical schools in the Malaysia, a large proportion of medical schools in the United States merged or closed, and the average United States merged or closed, and the average physician quality improved significantly.physician quality improved significantly.

– A standardized examination for all newly graduated A standardized examination for all newly graduated medical practitioners entering the workforce.medical practitioners entering the workforce.

– Review of requirements for admission and graduation.Review of requirements for admission and graduation.– Review of school recruitment practices.Review of school recruitment practices.

Right attitude!Right attitude!

• If they committed, make their own If they committed, make their own effort to learn/ask, be nice to their effort to learn/ask, be nice to their colleagues / staff nurses / JM / colleagues / staff nurses / JM / attendants in the ward, follow orders attendants in the ward, follow orders that has been ordered; they will be a that has been ordered; they will be a good doctor. BUT..if they are just good doctor. BUT..if they are just standing there like a consultant and standing there like a consultant and quite, have to ask then only they quite, have to ask then only they move..BIG problems!.move..BIG problems!.

Original Hippocratic OathOriginal Hippocratic Oath

Modern Oath..Modern Oath..• I swear to fulfill, to the best of my I swear to fulfill, to the best of my

ability and judgment, this covenant ability and judgment, this covenant

• I will respect the hard-won scientific I will respect the hard-won scientific gains of those physicians in whose gains of those physicians in whose steps I walk, and gladly share such steps I walk, and gladly share such knowledge as is mine with those who knowledge as is mine with those who are to follow.are to follow.

• I will apply, for the benefit of the sick, I will apply, for the benefit of the sick, all measures [that] are required, all measures [that] are required, avoiding those twin traps of avoiding those twin traps of overtreatment and overtreatment and therapeutic nihilismtherapeutic nihilism..

http://en.wikipedia.org/wiki/Therapeutic_nihilism

..Modern Oath....Modern Oath..

• I will remember that there is art to I will remember that there is art to medicine as well as science, and that medicine as well as science, and that warmth, sympathy, and warmth, sympathy, and understanding may outweigh the understanding may outweigh the surgeon's knife or the chemist's surgeon's knife or the chemist's drug.drug.

• I will not be ashamed to say "I know I will not be ashamed to say "I know not", nor will I fail to call in my not", nor will I fail to call in my colleagues when the skills of another colleagues when the skills of another are needed for a patient's recovery.are needed for a patient's recovery.


• I will respect the privacy of my I will respect the privacy of my patients, for their problems are not patients, for their problems are not disclosed to me that the world may disclosed to me that the world may know. Most especially must I tread with know. Most especially must I tread with care in matters of life and death. If it is care in matters of life and death. If it is given to me to save a life, all thanks. given to me to save a life, all thanks. But it may also be within my power to But it may also be within my power to take a life; this awesome responsibility take a life; this awesome responsibility must be faced with great humbleness must be faced with great humbleness and awareness of my own frailty. and awareness of my own frailty. Above all, I must not play at God.Above all, I must not play at God.


• I will remember that I do not treat a I will remember that I do not treat a fever chart, a cancerous growth, but fever chart, a cancerous growth, but a sick human being, whose illness a sick human being, whose illness may affect the person's family and may affect the person's family and economic stability. My responsibility economic stability. My responsibility includes these related problems, if I includes these related problems, if I am to care adequately for the sick.am to care adequately for the sick.

• I will prevent disease whenever I can, I will prevent disease whenever I can, for prevention is preferable to cure.for prevention is preferable to cure.

..Modern Oath..Modern Oath• I will remember that I remain a I will remember that I remain a

member of society with special member of society with special obligations to all my fellow human obligations to all my fellow human beings, those sound of mind and beings, those sound of mind and body as well as the infirm.body as well as the infirm.

• If I do not violate this oath, may I If I do not violate this oath, may I enjoy life and art, respected while I enjoy life and art, respected while I live and remembered with affection live and remembered with affection thereafter. May I always act so as to thereafter. May I always act so as to preserve the finest traditions of my preserve the finest traditions of my calling and may I long experience calling and may I long experience the joy of healing those who seek my the joy of healing those who seek my help.help.

THE OATH OF A MUSLIM THE OATH OF A MUSLIM PHYSICIAN..PHYSICIAN..

• In the name of Allah, Most Gracious, Most In the name of Allah, Most Gracious, Most Merciful.Merciful.Praise be to Allah, the Sustainer of His Creation, Praise be to Allah, the Sustainer of His Creation, the All-knowing.the All-knowing.Glory be to Him, the Eternal, the All-Pervading.Glory be to Him, the Eternal, the All-Pervading.O Allah, Thou art the only Healer,O Allah, Thou art the only Healer,I serve none but Thee, and, as the instrument ofI serve none but Thee, and, as the instrument ofThy Will, I commit myself to Thee.Thy Will, I commit myself to Thee.I render this Oath in Thy Holy Name and I I render this Oath in Thy Holy Name and I undertake:undertake:To be the instrument of Thy Will and Mercy, and, To be the instrument of Thy Will and Mercy, and, in all humbleness, to exercise justice, love and in all humbleness, to exercise justice, love and compassion for all Thy Creation;compassion for all Thy Creation;

To extend my hand of service to one and all,to the rich and to the poor, to friend and foe alike, regardless of race, religion or colour; To hold human life as precious and sacred, and to protect and honour it at all timesand under all circumstances in accordance with Thy Law; To do my utmost to alleviate pain and misery, and to comfort and counsel human beings in sickness and in anxiety;

..THE OATH OF A MUSLIM ..THE OATH OF A MUSLIM PHYSICIAN..PHYSICIAN..

To respect the confidence and guard the secrets of all my patients;To maintain the dignity of health care, and to honour the teachers, students, and members of my profession; To strive in the pursuit of knowledge in Thy name for the benefit of mankind,and to uphold human honour and dignity;

..THE OATH OF A MUSLIM ..THE OATH OF A MUSLIM PHYSICIAN..PHYSICIAN..

To acquire the courage to admit my mistakes, mend my ways and to forgive the wrongs of others; To be ever-conscious of my duty to Allah and His Messenger (S.A.W.), and to follow the precepts of lslam in private and in public. O Allah grant me the strength, patience and dedication to adhere to this oathat all times.

..THE OATH OF A MUSLIM ..THE OATH OF A MUSLIM PHYSICIANPHYSICIAN

Motto!Motto!

•To comfort always To comfort always but but

to cure sometimesto cure sometimes

•Thank you and best Thank you and best wishes to all….. wishes to all…..

malaysian health system – how to excel !2

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