A Doctor Too Many

Tan Kee Hian shared with me this highly relevant article in his mail today. The article touches on the flourishing medical education in Malaysia. It is very much a red-ocean scenario - 24 medical schools for a population of 26 million.

Out of his deep concern for Malaysia generally, and Sibu in particular, Kee Hian pointed out that:

It is a very good illustration of a Red Ocean with lots of copycats jumping on the bandwagon of medical schools. As the learned doctor-author pointed out, Malaysia has “. . . 24 medical schools for a population of 26 million!” It is also relevant to Sibu. I understand many people (parents, doctors, leaders, etc) would dearly like to start a medical school in Sibu. Does it make sense to have the 25th “vanilla” medical school located in Sibu? Perhaps yes, if we could create an uncontested space, a Blue-Ocean medical school that offers unique value to society, the students, and the investors. I provided some clues in my “Sibu in the Blue Ocean” Lecture.

This article by Dr. Hsu Dar Ren is pretty insightful and it is worthwhile for you to take your precious time to read through.

"A Doctor Too Many" appears in Malaysiainsider today.

Malaysia, a country with about 26 million inhabitants, boasts of 24 medical schools now.
Just a few years ago, the number was less than 10. In fact, when my eldest son entered medical school 10 years back, I could count the medical schools with my fingers. Now even with my toes and my fingers, I can no longer. Some of the names are so new that I, as a doctor, did not even know they existed until I did some research for this article.
The list is below:
Public universities:
* University of Malaya, Faculty of Medicine
* Universiti Kebangsaan Malaysia, Faculty of Medicine
* Universiti Sains Malaysia, School of Medical Sciences
* Universiti Putra Malaysia, Faculty of Medicine and Health Sciences
* Universiti Malaysia Sabah, School of Medicine
* Universiti Malaysia Sarawak, Faculty of Medicine and Health Sciences
* International Islamic University Malaysia, Kulliyyah of Medicine
* Universiti Teknologi Mara, Faculty of Medicine
* Universiti Sains Islam Malaysia, Faculty of Medicine & Health Sciences
* Universiti Darul Iman, Faculty of Medicine
Private Universities and Colleges
* UCSI University, Faculty of Medical Sciences — School of Medicine
* Monash University Malaysia, School of Medicine and Health Sciences
* International Medical University, Faculty of Medicine
* AIMST University, Faculty of Medicine and Health Sciences
* Allianze College Of Medical Sciences, Faculty of Medicine
* Management and Science University, Faculty of Medicine
* Cyberjaya University College of Medical Sciences, Faculty of Medicine
* Royal College of Medicine Perak, School of Medicine
* Melaka Manipal Medical College, School of Medicine
* Penang Medical College, School of Medicine
* MAHSA University College, Faculty of Medicine
* Newcastle University Medicine Malaysia (NuMED)
* Taylor’s University College, School of Medicine
* Utar
These are the medical schools in Malaysia. These schools, when fully functional, will produce about 4,000 doctors a year. There will be thousands more Malaysian doctors being produced overseas, since many Malaysians are studying medicine in the UK, Australia, New Zealand, India, Indonesia, Russia, Taiwan and even Ukraine.
The sudden mushrooming of medical schools is apparently due to shortages of doctors in the public sectors. This is because most doctors in government service resign after their compulsory services and opt for the supposedly greener pasture in the private sector.
In most other countries, the logical thing to do to counter this brain drain of doctors to the private sector is to find out why doctors are resigning from government service, and then try to address the woes of the doctors, and hopefully, keep them in service. I call this common logic.
The Malaysian solution, like in many other instances, does not take common logic into account but rather uses the sledgehammer approach. After all, we do have Malaysian logic, which is different from common logic practised in most other countries. For example, if we cannot have spacecraft of our own, we can still produce astronauts by sending Malaysians into space, hitchhiking on other countries’ spacecraft.
In most other countries, the common logic will be to try to improve the working conditions in public sector so that doctors will stay back. But Malaysian logic is sledgehammer logic, and is very different.
If the doctors do not want to stay in government service, then Malaysia shall flood the market with doctors, so goes the Malaysian logic. Never mind that setting up of medical schools and training doctors are expensive businesses. We have petroleum and huge amount of development funds.
By building more buildings and buying expensive medical equipment to equip these medical schools, billions will have to be spent and, of course, in the Malaysian context, everyone will be happy, down from the planners, the contractors, the parents and all others involved, since the perception is that projects in Malaysia inevitably will have some leakages and wastages, and many people are very happy with these leakages and wastages.
Never mind that we may have the hardware but we may not have enough qualified people to man these medical schools.
The Malaysian logic seems to be like this: If enough doctors are produced, the market will be saturated with doctors, and thus, doctors will have nowhere to go but to stay in government service.
Well, the people may be clapping hands and rejoicing that, with more doctors than are needed, medical costs will come down.
Unfortunately, things do not function like this in medical education. Experience in some countries tells us that some doctors in private practice, when faced with too few patients, will charge higher and do more investigations, some of which may not be needed. So instead of medical cost going down, it will go up.
In any advanced nation, the setting up of a medical school requires a lot of planning and is not done on an ad hoc basis. Planning must include where to source for experienced and qualified teachers; where to build new or source for existing teaching hospitals, which are big enough for the placement of these medical students to do training.
Planning such as facilities, equipment, classrooms, curriculum. In the west, it takes many years of training for a medical school to be set up; whereas in Malaysia, we see more than 10 in the last five years.
In Malaysia, due to the sudden “exponential” increase in medical schools, we have medical schools pinching staff from each other, even the mediocre ones. With that number of qualified teachers only, it is unavoidable that many teachers may not have the experience and qualification to be medical lecturers.
The early birds (medical schools) are more fortunate. Their students are placed in bigger hospitals like the General Hospitals of Kuala Lumpur or Penang. Now, some of the medical schools just opened have to send their students to smaller district hospitals to do their training. The smaller hospitals are often manned by more junior doctors who are not qualified to be medical teachers, and these hospitals have only very basic facilities and equipment.
This is just the beginning of the problems. For a doctor, graduating from a medical school is the beginning of a life long journey, and the basic medical degree is more like a license to start to really learn how to manage and treat patients.
The most important year after a doctor graduates is the houseman-ship. If a doctor does not have proper houseman training, then he would face a lot of problems later on. He or she may know all the medical knowledge in the world (just for argument’s sake, since knowledge of medicine is so vast that no one can know everything), but without the proper houseman training, he or she will not get the hand-on experience so crucial and important to doctors.
A doctor without proper houseman training is not unlike a person who has only ever raced in arcade games, suddenly being asked to race in a real life race. He would not have the hands on experience to do well. A doctor without proper houseman training would be like a person given a license to kill, and a disaster waiting to happen.
Now, with 4,000 doctors being produced in a year, where do we find so many houseman positions for these young doctors?
Even now, with some of the medical schools just starting and not yet producing doctors, and the number of doctors being produced is much less than the 4,000, the wards in some of the bigger hospitals are filled with so many housemen that, in some wards, there are not enough patients for these housemen to learn management skills.
About a year back, I was told, in HKL some of the units have more than 20 housemen. Recently one doctor told me that in some units, it may have even more than that. I was aghast. Since with that many housemen in a single unit, and so few senior officers to guide them and so few patients for them to learn from, how are they going to learn the skill of doctoring?
When there is not enough training for these housemen, what do you think our policy planners do? In the typical Malaysian style, they increase the length of houseman-ship from a year to 2, hoping that the longer time will help to give better exposure to these doctors.
Compared to Australia, New Zealand, and United Kingdom, houseman-ship is still one year only. By increasing the length of the houseman-ship, it is a tacit admission that our one-year houseman training is not as good as the above mentioned countries.
A poorly trained houseman will become a mediocre medical officer, and since now most of the specialists are trained internally, it will be a matter of time before future specialists may not be as well trained as presently.
Many parents do not know about the actual situation and still encourage their children to take up medicine. They are not told of the actual situation. The day will come when there are simply so many doctors that none are adequately trained. There will come a day when a doctor graduating from a medical school cannot even be placed in a houseman position.
And that day is actually very near.