Malaysian government doctors working in public hospitals are bounded to the duites of "on calls". Its not an option, not overtime but a mandatory duty for doctors with no exceptions. Now on calls would begin after office hours till the next morning. But it usually starts after the doctors have finished their day shift, continue with the oncall, then resume the next day shift. In short, doctors who are on call work 36 hours. If the day is hectic, busy with numerous complicated cases, they usually don't get a wink of sleep. Eventually, the following day, these doctors are tired, exhausted, weak and fatigued which would eventually affect their performance. Doctors on call rates depends on which hospital they work in, and in which department. If the hospital is catering for a large population and have limited amount of doctors, on call rates can increase. Basically, on calls occur 6-9 times a month, including weekends and public holidays. Which means having either just 1 on 3 days rest of normal working days in between.

Many doctors dread on calls. Despite doing it for many years, on calsl would always stress up anyone. The anticipation of working alone, at night with no sleep never bring joy to anyone. However, in Malaysia, doctors still do it for the sake of service. As for our director general of ministry of health, the working hours and doing it for 8 times a month is more than fair. Its a doctor's duty in view of lack of doctors. Mainly because they leave for greener pastures to avoid having this lifestyle and working environment.

However Malaysia is heading to become a developed country. And being developed doesn't mean having tall towers, a F1 circuit, a beautiful airport or an abundant amount of shopping malls. Its just a facade.  Taking care of public servants is also a requirement to indicate how developed we are. This is to ensure that these public service doctors are happy and are capable of providing excellent service. Which in the end reflects upon the status of a developed country.

Doctors are human, and are prone to mistakes. Even during normal working hours. Imagine after 24 hours without sleep! I remember a consultant once commenting after a patient was amazed to see the Medical Officer working non stop for 30 hours straight. He said “we are trained to do it”. Yup, trained to work post call with spinal reflex decisions and doing procedures without using much of our brains. “Zombies” were what the post call doctors were labeled. Monotonous shell of a drone, working on autopilot. However, such conditions may result in wrong decision making, wrong management and sub par performance/treatments.

Below are examples of why the developed country have moved away from making doctors work more than 24 hours. They have made researches and have used past cases to drive their point that tired and fatigued doctors can make very devastating mistakes to their patients. But in Malaysia, such a risk is acceptable, as even our own leaders and policy makers agree that our on call hours are ideal. Malaysian healthcare workers, especially govt doctors, are doomed to be stuck and a very, very under developed system.

*** surprising, Malaysian labour laws do not allow workers to work more than 8 hours a day. I wonder why it does not apply to doctors ***

Samples of court cases pointing out doctor fatigue causing medicolegal cases:

Case 1: Brotherson v Royal Perth Hospital (Australia)¹²

Robert Brotherson was a 12-year-old boy who underwent open heart surgery in 1978 for congenital heart disease. His postoperative course was complicated by hepatic dysfunction and renal failure requiring peritoneal dialysis. While on dialysis, he developed glucose intolerance which was treated with an insulin infusion.

Eight days after his initial surgery, Robert's condition improved, and dialysis was ceased at about 0600. During the medical hand-over between 1800 and 1900 that evening, a consultant decision was made to reduce the frequency of blood sugar monitoring. The decision was based on blood sugar levels (13.1 mmol/L at midnight and 9.05 mmol/L at 0700), and the desire to give Robert an opportunity to sleep. A further blood sugar level of 4.2 mmol/L had been measured at 1612, but not recorded in the notes until the following day. As a result of this omission, the significance of the downward trend in blood sugar level may not have been fully appreciated. At 0550 the following morning Robert had a hypoglycaemic fit resulting in permanent brain damage.

In 1995, when Robert was 29 years old, the District Court of Western Australia awarded damages of $2.75 million against Royal Perth Hospital. After a trial which lasted four weeks, Judge French observed that it was difficult to avoid the conclusion that the long shifts the staff worked, with an overwhelming workload, had contributed to their oversight.

Case 2: The Libby Zion case (USA)¹³

Libby Zion was an 18-year-old woman who died in a New York hospital in March 1984. In January 1984, Ms Zion had begun psychiatric treatment for stress, and was taking phenelzine up to the day before her admission. She was admitted by an emergency department junior resident with a tentative diagnosis of "viral syndrome with hysterical symptoms". At the time of her admission at 0200, both the emergency department resident and the medical intern had been on duty for 18 hours.

At 0330 Ms Zion received pethidine 25 mg intramuscularly for agitation and shivering. Between 0400 and 0430 she became increasingly agitated, confused and began thrashing around in bed. The medical intern, attending another patient, was twice notified about the patient. He first gave a telephone order for physical restraint, then another for haloperidol 1 mg intramuscularly. At 0630 Ms Zion was found to have an axillary temperature of 42¡C, for which the intern ordered cold compresses and a cooling blanket. Shortly afterwards she had a respiratory arrest and could not be resuscitated.

The postmortem findings were bilateral bronchopneumonia with presumptive evidence of cocaine use. Her father, an attorney and a writer for the New York Times, claimed that his daughter had received inadequate care from overworked and undersupervised medical staff. He successfully lobbied for a grand jury investigation into his daughter's death. The grand jury returned no criminal indictments against the hospital or its physicians, but found much at fault with resident training and staffing. As a result of these findings, New York State implemented legislation which limits a doctor's shift in emergency services to a maximum of 12 consecutive hours.

Case 3: Johnstone v Bloomsbury Health Authority (UK)¹⁴

An obstetric senior house officer was employed in 1988 by University College Hospital in London to work a basic 40-hour week with an additional 48 hours per week "on-call" (working overtime while residing in the hospital). He was subsequently required to work 32 hours over one weekend, with only 30 minutes' sleep. On another weekend he worked for 49 continuous hours, taking over 60 calls, and was able to sleep for only seven hours.

In 1989, Dr Johnstone took the Bloomsbury Health Authority to court, successfully arguing that he had sustained personal injury as a result of his work schedule. In upholding the damages awarded, the court of appeal found that the health authority could not lawfully require the doctor to work so much overtime in a manner which constituted a threat to his health. In this case, the court rejected the argument that "if you cannot stand the heat in the kitchen, you should get out, or not go in". It noted that it was "a matter of grave public concern that junior doctors should be required to work such long hours without proper rest that not only their own health may be put at risk but that of their patients as well".

Case 4: Wilsher v Essex Health Authority (UK)¹⁵

Martin Wilsher was born in December 1978, nearly three months premature. At birth he was described as a "very floppy blue baby". He was initially intubated, but was able to be extubated after eight minutes and was admitted to the Special Care Baby Unit on supplemental oxygen via a face mask. In the Special Care Baby Unit, a junior resident doctor mistakenly inserted a catheter into an umbilical vein for arterial blood gas sampling. The error was subsequently missed by both a senior registrar and a consultant radiologist. The resident and registrar involved were either working continuously or had been "on call" (working overtime) every second night and weekend. When the catheter was changed by the senior registrar after 24 hours, it was again placed into an umbilical vein instead of the artery. Due to being supersaturated with oxygen for approximately 32 hours, the baby developed retrolental fibroplasia, resulting in near-total blindness.

The court of appeal dismissed an application by the health authority contesting the damages awarded in the subsequent action by the child's parents. The judge concluded that "a health authority which so conducts its hospital that it fails to provide doctors of sufficient skill and experience to give the treatment offered at the hospital may be directly liable in negligence to the patient... I can see no reason why, in principle, the health authority should not be so liable if its organisation is at fault".

Why developed countries stay developed.

No Such Thing as a Typical Day

Many emergency room doctors would say there's never an average workday at an ER. Workdays will depend on the specialty of the emergency room physician, how busy the emergency room is and the time of day. Since most emergency rooms are open 24 hours a day, 7 days a week, ER doctors must work night shifts as well as day shifts. The typical shift length for an ER doctor is about 10 to 12 hours, although a resident ER doctor can sometimes work 24 hours straight. These 24-hour shifts feature much of the same type of care as the day and night shifts, except that the care is continuously given by the same doctor. It used to be that after working 24 hours straight, the ER doctor would then go straight into his next regular 12-hour shift. However, regulations in 2003 put a cap on doctors working more than a 30-hour shift. Recommendations from the Institute of Medicine suggest limiting shifts to no more than 16 hours.

Malaysia has a loooooonng way to go to become developed. Long way....

The 1Malaysia clinic is an effort by the Malaysian government to provide a better health-care service to the public, especially in rural and highly populated areas. At current time, there is a total of 44 clinics throughout Malaysia. However, an issue brought forward by MMA (Malaysian Medical Association) President Dr Quek, has raised a very valid and pertinent point. These clinics are not manned by doctors. In fact, they are managed by nurses and medical assistants (MA). In view of doctor shortage nationwide (I wonder why?), this is as far as medical service can be provided in these small widespread clinics. The validity of the argument is debatable.

In normality, light illnesses such at the common cough and cold can be identified by medical assistants and nurses such as their functions during triage at an emergency department. However, management of any illness will be brought forth to a medical doctor in order to assure that proper and appropriate measures/management are  provided to the relevant illnesses. This has always been the mantra of medical health and treatment. The setback of such installments of MAs and nurses in these 1Malaysia clinics is their inability to identify severe illnesses which may initially present with mild symptoms. At times, they could quickly progress acutely and may eventually cause death. Therefore, in our EDs, cases are triaged into green (mild), yellow (moderate) and red (severe) zones. Most in green zone are discharged with medications but some are placed under observation and at times admission in view of a doctors suspicions of an underlying menace that may surface later with great intensity.

For example, with regards to paediatric cases, a true case that happened in my ED, a toddler was seen by MAs during triage for cough and cold. At the time, the child appears active and cheerful and was subsequently slotted into the greenzone with a waiting time of more than 1 hour. During that waiting period, the child quickly became lethargic, weak, had a seizure and eventually collapsed on the mother's lap. He was then quickly resuscitated and intubated but despite vigorous CPR, the child succumbed to his illness. The paediatrics team were puzzled and after the child's autopsy, reports mentioned of dehydration and lumbar puncture results revealed he suffered from Meningitis. Although reports from the triage mentioned of an active and cheerful child, but signs such as cold peripheries, capillary refill time, poor skin turgor, dry oral mucosa and neck stiffness could have been picked up by a medical doctor. Although this may be an isolated incident, it is a situation that opened the eyes of our Paediatric team and immediate recommendations were made to have a secondary doctor to double check paediatric cases in triage to prevent the recurrence of such a case.

As for 1Malaysia clinics, although they provide basic medical necessities, the decision for referrals or emergency medicine may not be as efficient and could prove fatal for certain medical situations. Doctor's are needed at these clinics but with the acute shortage, even in government hospitals (who are doing 36 hours on-call 6-8 x per week), the standard modality of medical treatment could be compromised. The initiation of 1Malaysia clinics is commendable, but any sort of actions in providing better health-care quality should be thought thoroughly from all angles. In time, maybe, doctors would be incorporated into these 1Malaysia clinics but until the government overcomes the doctor shortage (not by forcing them to work extra but to provide interesting incentives), 1Malaysia clinic may be short-lived.

The plight for doctors continue on StandUp. I've been away to settle things regarding my Masters Programme of Paediatrics and certain family issues. Unfortunately, in the process, I have left this blog hanging in the wind. Now with a little time on my hand, I will contribute further articles and writings for the betterment of doctors (especially govt doctors) and for the common knowledge of how medicine works in Malaysia. The new year has approached and mind you, nothing much has changed in the medical field. But of course housemanship prolonged to 2 years with a compulsory govt service which was extended to 4 years. Despite all that, more wish to be doctors and more wish to leave doctoring. The usual on going "brain drain" problem which will never be resolved in Malaysia.

Happy 2010!!

StdUp

Choose medicine.

Choose nights, choose PRs and scrotal exams, choose being bleeped when you’re taking a shit, choose bare below the elbows, choose and book, choose being so hungry you enjoy hospital food, choose never seeing your friends again, choose not washing your hands for a change, choose dehydration, a f***ing big cannula, Quality Street over Roses, MRSA, choose scrubs (watching it or wearing them). Choose cyclizine the morning after the mess party, choose Adele the Australian physio, choose sitting in the mess watching mind-numbing, spirit-crushing game shows, stuffing junk food into your mouth praying that you’re bleep won’t go off. Choose MI over PE because someone’s got to make a diagnosis. Choose bd, tds, qds, those f***ing T’s with the dots on them.

Don’t choose life, choose medicine.

(for the medical students)

From MMR

In The Star on 3rd June 2009. At least someone up there still cares:

Government doctors still not being paid their due

THE Malaysian Medical Association (MMA) would like to refer to the letter “Deal for government docs reasonable” (The Star, May 12) by the PSD which stated that the initial salary of government Medical Officers was the highest compared with those of other schemes of service in the public sector. The MMA acknowledges that there has been a significant increase in the salaries of government doctors over the past few years, and we would like to thank the PSD for having given due consideration to our requests to improve the remuneration of such doctors. However, we would like to clarify a few points made in that letter. Firstly, with regards to the on-call allowance, we would like to point out that the RM150 per night is only for medical officers doing “active” on-call duty, i.e. working 16 hours per day beyond their normal working hours. These are usually the medical officers in the Medical Unit, Surgical Unit, etc. Medical officers working in less “critical” clinical departments like Pathology or Radiology are only eligible to claim RM50 or RM90 per night while on call depending on the number of hours spent at the hospital after office hours. There are also some medical officers such as those working at the health clinics who do not have any on-call allowances. Secondly, paying RM80 per hour for locum work is a very good initiative by the Health Ministry. Unfortunately not all medical officers are given the opportunity to do this, as the extended clinic hours (5pm to 9pm) only involve 16 polyclinics out of more than 800 government clinics in the country. The locum work is mostly done by the doctors working at a particular polyclinic and doctors working at other polyclinics (which do not have locum services) in the same district do not get any chance at all. Thirdly, the statement that in 2010, newly appointed medical officers would be receiving a salary of RM6,000 per month as they would be promoted from UD41 grade to UD44 grade upon completion of two years’ housemanship and upon confirmation in service is exaggerated and misleading. The actual UD44 salary at P1T1 is RM3,028.90 with fixed allowances of RM1,450.00 (including critical allowance of RM750, housing allowance of RM400, elaun khidmat awam of RM300 and COLA RM100 to RM300 depending on the location). Although a doctor may earn up to RM6,000 by doing a lot of active calls or working many hours doing locum, this would not be the salary of the majority of the first year medical officers. The MMA has repeatedly requested the Government to introduce a separate service scheme for government doctors from that of other civil servants, as a doctor’s undergraduate training is longer at between five and six years, compared with other professionals. Our working hours are long and protracted and there is a period of five years of compulsory government service which is not a requirement for other professionals in the civil service.

DATO’ DR KHOO KAH LIN, President, MMA.

This has been, and will always be our vow as Malaysian government doctors. We don't use the Hippocrates oath here. Its in Bahasa Malaysia.... feel free to translate.

> "IKRAR WARGA KESIHATAN
>
> Kami
> Warga kesihatan
> Tidak akan mengeluh
> Walau bekerja berhempas pulas
> 36 jam tanpa henti
> bagaikan seorang anjing
> walaupun menteri kami menidakkannya
> kerana beliau
> bukan warga kami.
>
> Kami
> Tidak akan bersungut
> Pabila muka kami terpercik darah,
> Nanah,
> mahupun air ketuban hijau.
>
> Kami
> Tetap membedah siasat
> mayat reput dan berulat
> demi keadilan si mati
> Walau keluarga menunggu di rumah mayat
> dengan pisau dan parang
> dan ahli politik.
>
> kami
> warga kesihatan
> tidak akan mengeluh
> menghadap kaki berkulat
> mengutip ulat langau daripada kudis
> mengorek najis daripada dubur manusia yang sembelit
> serta menghendap faraj berdarah,
> berlendir,
> bernanah hijau,
> mahupun mengorek lidi yang disumbat
> untuk menggugur janin.
>
> kami
> tidak akan bermogok
> walau kami dicemuh manusia yang tidak mengerti,
> juga di berita dan akhbar
> serta oleh orang yang sepatutnya
> membela nasib kami.
>
> Kami
> Akan sentiasa ikhlas merawat
> Walaupun ada ketika
> pesakit kami
> Lebih sihat daripada kami sendiri.
>
> Kami
> Akan sentiasa rela bergaduh
> Dengan ibu bapa
> Yang sanggup melihat bayinya terencat akal
> Daripada menerima rawatan
>
> (dan mereka akhirnya menyalahkan kami
> Kerana mental anak mereka kini terjejas
> sebab kedegilan mereka sendiri.)
>
> Kami akan sentiasa
> Menjaga ibu bapa yang tidak dipeduli anak
> Anak-anak yang tidak peduli ibu bapa
> Dan pesakit-pesakit mental yang tiada harapan sembuh
> sebab lambat rawatan
> kerana ibu bapa malu sekiranya anak mereka
> dilabel mental
> dan akhirnya mereka sendiri meminta
> anak-anak mereka ini
> dibuang jauh-jauh.
>
> Kami
> Akan sentiasa ikhlas
> Walau kami
> Tidak berpeluang makan dan minum
> Rehat dan mandi
> Dan bersembahyang lima waktu
> Demi kepentingan kerja."

Vow created by an anonymouse medical officer. Thanks a million.

Yet again, doctors are put in the limelight, not for their courageous efforts in saving lives, or their efforts to provide their best service despite a pathetic lifestyle and “ridonculous” (from Bolt) government salary, but instead accused for reading a paper or appearing to lag and laze in the hospital. It’s typical of Malaysian media and gossip to only highlight the negative of doctors compared to the massive amount of good that they do. Only of course if it’s politically motivated.

This, as yet again, has proven for a fact that being a Malaysian government doctor may as well be the DUMBEST but noblest job in the world. Getting slammed by the media and by a public figure has done so much to further “impress” the public upon the fragile integrity and image of Malaysian government doctors. In short, Malaysian government doctors are underpaid, overworked and now scrutinized for every slip up without much support for their own welfare. Its either Malaysian government doctors, are ignorant, oblivious, too passionate or just so clueless about their own well being and rights. Can anyone tell me who has an occupation that forces them to work 36 hours a day? And on weekends too? (And if any of u are claiming that a new ruling of house officers having the day off after a 24 hour call by MOH recently; I’m sorry to say that the order is not carried out in most of our govt hospitals).

Doctors are human too. Whether the doctors who were lazing around on the job in HKL were truly factual or were misinterpreted by certain individuals, only God knows. Although it’s the emergency department, not all doctors there are posted there or are on duty. I’m a paediatrics doctor. I see children only. And when I come down to emergency department to see a child patient and linger there to wait for their results, I may flip my phone, call someone for a referral or flip thru some case files. Probably sitting on my ASS. But if a so called public figure would have seen me doing that, with “20” adult patients waiting in line in the emergency dept, his assumption would clearly state I was lazy and not intuitive. DO NOT ASSUME!! One of many lessons taught to doctors but not to idiots. There are emergency doctors there on 8 hour shift duties. They are considered the “jack of all trades” of doctors who can deal with any emergency and are mostly running on their toes with constant energy (as of the Energizer bunny) just to cope with the amount of emergency cases. Despite the increase of emergency cases, since the rich can no longer afford the private sector due to economical depreciation, these doctors still manage to carry out their duties, even though being understaffed. My salute to them.

Doctors at time do procrastinate. But I can assure that most Malaysian government doctors work their ASS OFF, whether it is to provide their best service, to save a life that can’t be saved, or to study for another 4 years (making a total of 10 years studying from undergraduate) to pursue their specialization in order to work their ASS OFF some more to give their best service. And no, the pay increment is not much. Ask a government specialist; with all the PTK and such.

So, the next time a doctor saves a life, intubates a premature baby, repairs an open fracture, conducts CPR and revive a dead, runs like a headless chicken for group and crossmatch blood, cries with a relative when a patient dies, protects an assault patient from gang rivals, delivers a baby of a complicated pregnancy, gets stuck in op theatre for 8 hours for a kidney transplant, or even muster a SMILE to a patient after working 35 hours non stop….

WRITE THAT IN THE F*CKING PAPERS!!!

Nuff said…..

“CUT MALAYSIAN DOCTORS SOME SLACK”

The Malaysian media really loves gore.... whether its their explicit enjoyment of flesh and blood or their particularly detailed report or incidences. Either way, whoever the relative's of the victim would be put in despair for reading the article.

Boy killed in gory accident

MUAR: A 15-year-old boy on a motorcycle was killed in a gory accident, his head crushed and left hand severed. He is believed to have hit a dog, fallen and run over by a car.

Muhammad Syahiddin Ibrahim, from Parit Jawa here, was riding his brother’s bike when the incident happened near Kampung Parit Besar at about 1.30am yesterday.

Villagers who heard a crash rushed to the scene and were shocked to see a headless body and a hand lying on the road, and a car in a drain several meters away.

They also saw a dead dog about 100m from the body and believed that the boy could have hit the dog, fallen onto the road and got run over by the car.

The villagers thought the boy’s head had gone missing, but police at the scene to investigate found that the head had been crushed and the teeth scattered on the road.

The driver of the car, from Bakri, suffered some injuries and was warded at the Sultanah Fatimah Specialist Hospital.

The victim’s father, Ibrahim Saipan, said he was shocked when he received calls about his son’s accident at about 3am.

His son, a Form Three student of SM Raja Muda, was to be sleeping at home but had left the house without telling anyone, he said.

Nonetheless, recently I attended a seminar by one of our reknown hand a micro surgeon's seminar. He was explaining on his miracle surgery which involved a femur to femur reconnection of an amputated leg. Before explaining further, he showed us the video of the victim involved in the MVA!! What??!! How??!! u may ask...even we were stumped...apparently, some of the passerbys had a camcorder and recorded the whole incident,  from when the initial accident occured, to people helping the victim, then WHAM!! a truck rolled over the left leg amputating it entirely!! blood, flesh, peices of meat and muscle all over the tarmac (is that gory enuff for ya?).... and of course the amputated leg lying a few yards away.... then after the victim was brought to the hospital and recovering after the surgery.. this "good smaritan" gave the victim a copy of the video. He might have said :" Hey, I caught your accident on video, and it was soooo cooooooll!!!" My god. If I ever were in an accident, I hope to God that no one is recording it!! especially if its gory!!

I knew that someone would actually support the punishment by KKM in my previous article:

"I think the ‘punishement’ is fair. Imagine that O&G MO........ (by poor doctor in MMR)"

My rebuke:

“poor doctor’s” comments is as typical as our director’s point of view. It is the doctor’s (HO’s) fault for not following through their logbooks and confirming an APC for practise. It is their fault for being careless and with their “takde ape ape” attitude, that causes their demise. “no one to blame but yourself.

Basically, “poor doctor” clearly is thinking “in the box”. A qualified surgeon who is competent in TURP or gastrectomy, but does not have a proper Malaysian APC (suggestively he graduated and further studied in Congo and returned to Malaysia), is technically “incompetent” in view of his “paper qualification”. No papers, no go (Nazi attitude). Anyways, its true enough that a license is pertinent in medical practice. The issue at hand is how these doctors ended up where they were and how the bureaucratic red tape has made their situation worse rather than giving ways or methods for resolution. Remember, these doctors underwent housemanship the same time and and handed up their logbooks to the office together, but subsequently got lost without their knowledge. Why were they ignorant as “poor doctor” may ask? Its because they were neck deep with work and were dedicated in achieving a pinnacle in their career by further studying. Their HODs can vouch on their efforts and hard work. However, they seem to have overlooked to check the office (who ensured them that they will do everything) to ensure that all paper works have been submitted.

Whether these doctors are functioning within the law of Malaysian medicine, it is totally a subjective matter. If they are convicted of malpractice, they may be labeled as Murderers as “poor doctor” suggested. But in the true eyes of practice and doctoring, these doctors cared more for their patients rather than their own bureaucratic well being.

A story; my sister in law is a lawyer, she also has so called “logbooks” to fill out. Once completed, they hand it up and the Malaysian Justice Dept will process the papers followed by “2 support letters” and subsequently “called to the bar” once the registration has completed. Not much effort was done by my sis as updates and progress of her registration were sent via mail to her by the justice dept as they believe that lawyers are very busy people.

But I guess doctors in Malaysia are treated differently. Therefore they have to be vigilant in every sense of the way; while working with patients, bearing with consultants, handling “takde ape ape” HOs and the bureaucratic crap of MMC and KKM. Nobody watches their back here in Malaysia. “pseudomallei” has given very valuable advise for new doctors in Malaysia.

“poor doctor” sounds like the typical KKM doctor.(Specialist or consultant maybe?). One that we have too much of and would never change the system for the betterment. Everything “by the book”. (r u Ismail Merican? )

My plea: “Give these doctors a break for God’s sake….they really need it”

I have a lousy weekend ahead. In fact, I’ve been having many lousy weekends. Thanks to being on call. Yup… the usual drag of working in a hospital for 36 hours. Why does it produce a lousy weekend? Well, if u’ve worked for a solid 5 days a week (with 1 – 2 on calls in between), u don’t have the weekend to look forward to especially if ur on call on Saturday. And nope, usually u don’t get the next day off as u would need to do the weekend morning rounds the next day which usually ends by 2-3pm (on a Sunday). And then ur off to work again on Monday. So it actually feels like uve worked for 2 weeks straight. And to top it off, u might get another Saturday which then makes it feel like 3 weeks straight. No wonder doctors are a bunch of grumpy a$%holes. Even I know that I’m grumpy at times.

But to make matters worse, married to another doctor whose on call schedule is as crappy as mine, we end up not seeing each other as often as a stewardess and a pilot. As of this weekend, I’m on call on Saturday (cant see my wife), she’s on call on Sunday (cant see my wife), and then I’m on call again on Monday (EOD). So technically, I wont see my wife from Saturday till Tuesday afternoon. And the one I pity the most is my son, who will only get to spend time with one of us during the weekend. I guess its tough to be a Malaysian govt doctor, and worse of all would be the children of Malaysian Govt doctors whose parents are so busy with work, patients, on calls and so on. So much for family outings and family quality time.

Once a paediatrics consultant confided in me when her daughter was prepped to go overseas for studies in engineering. She claims that her daughter refuses to do medicine as both parents are doctors and are barely around for anything much. All of a sudden, my fierce consultant looked at me with tears in her eyes a said “I was a bad mother, a very bad mother”. But hey, her kid turned out ok, just not close to the parents. I guess that’s not important for doctors. Well, as I said before in my posts. Being a doctor is a noble job. Being a doctor in Malaysia is the dumbest job in the world. If u had a lifestyle (or life even) before medicine, u can kiss it goodbye once u start serving this country.

PS: All this for a solid cool RM 3500 a month. I love this job!!!! Should get Mike Rowe (of Dirty Jobs on Discovery Channel) to come and do a stint of doctoring work in a Malaysian Govt Hospital. I’m sure it would be a highlight in his documentary. And I’m still doing it……

Oh, by the ways… HAPPY CHINESE NEW YEAR!!!

Here's an update to the log book incident. Apparently, a decision has been made by KKM (Ministry of Health) and our beloved Dr Ismail Merican. 4 unfortunate doctors in my hospital have fallen victim to the "late logbook" incident and have received the punishment as I have dictated before. But to add more salt to the wound, KKM has released an order that the 4 fellow doctor's APC are not fully licensed and are subsequently not allowed to do clinical practice. Its funny, these doctors have served for 5 years without any incident, one of them have a part one in MRCOG and another has part one in MRCS. And now, they are going to be clerks. Or doing statistics or whatever KKM would give them. For a country that claims not to have enough doctors, they sure as hell take red tape seriously. That's justice for ya.....

Malaysian government doctors are late bloomers. Yes, it took me 5 years of working in this line to actually realize it and to eventually succumb to the cruel reality. It actual fact, no matter how many of u may deny it, life is none other than a "rat race". (I'm sure some can picture Mr Bean in the movie similarly entitled Rat Race). Once children become school goers, their life has entered the never ending race for high achievement. Heck, some as young as 4 years old are sent to pre schools where they start teaching these toddlers hi fi subjects and send them home with homework. Once in school, its the race for excellent grades, to ensure the excellent university (most likely overseas for Malaysians) and subsequently to pursue the excellent career. Now in Malaysia, if ur a straight A student, then ur destined to be doctor. Nothing else. Read the news papers - " Straight A student for SPM did not receive scholarship to pursue medicine", "Straight A student dies in freak car accident - aspired to be a doctor", "Daughter of padi field worker got straight As, acquired a spot for medicine"...and the list goes on. Its blasphemy for those with all As not to do medicine. Anyways, as to late bloomers, those doing medicine will undergo a grueling 5 years medical course. Not to mention some universities having pre medical subjects (core sciences) for 1 or 2 years, thus making studying medicine a total of 6-7 years. By that time, those doing other fields may have a head start in working and in their careers 3-4 years before a med student graduates. "So what?" some may say. "Once doctors start work, their salary are high". Maybe, but no longer in keeping with current economic turmoil and inflation. And in the government service (Ministry of Health), a doctors salary climbs at a snails pace. I've worked for 5 years and my current salary is RM3300 a month. Plus another RM 900 for sleepless on calls (paediatrics). Which makes a total of RM 4200 a month. It may look big, but its just keeping my head above the water for now. Now many of my colleagues have reached a basic salary of RM 10,000 a month. Of course after working for 8 years, me only 5. Some even RM 15,000. Of course, they have been dwelling in the private sector. To them, the sum above is AVERAGE. So with that, they are able to buy a teres house costing RM 380,000 or above (in the Petaling Jaya area), and a non Proton car. With all that baggage, they still have extra to spare for insurance and other luxuries such as vacations. Ok, as for me, I just bought a house (apartment) costing RM 250,000 - monthly loan of RM2000, and a Proton Persona - monthly loan RM 607. Then my maid for RM500 a month. Then my kids insurance for RM 500 a month. All in all, my expenditures are RM 3607, which leaves a balance of RM 593. My wife earns RM 2700. She's a doctor too but of 4 years. She has her own car loan and parents to support. Now, my private colleagues have moved in to their respective houses, renovated and furnished them beautifully. I just bought mine and will only move in mid of 2009. Still staying with my parents. In short, I felt left behind in the "rat race". All said and done, my friends have progressed ahead in life whilst I'm just beginning to explore into it. Furthermore, now in a Master's programme, I'm now a doctor cum student. Which makes the feeling even worse. To my surprise, I'm not the only one suffering this slow paced feeling. My wife's specialist in Urology, (whos a qualified surgeon, now in his 4th year of Urolgy sub specialty), does not own a single property. He has yet to acummulate the finances to attempt to buy a property in Selangor. He's still renting with his doctor wife. Many of u may yell at me now and suggest private practise, or even to stop whining and get on with the job. But I have just one problem - I wanna serve. And the best place to do it is in a government hospital. I guess u can't get everything in life, and being a late bloomer in the "rat race" may well as be the folley of medicine. Or is it a sacrifice? I'm not too sure anymore, as doctors sacrifice so much already.

I've got a story to tell. Nope, it aint a Christmas carol or tale. Its the usual misfortune of doctors to work in a unforgivable place such as the government of Malaysia, particularly, the Ministry of Health (MOH). In a way, I knew this doctor since housemanship days. She was hardworking, intelligent and constantly works without a single whine (such as myself). She completed her housemanship and progressed onwards to become a Medical Officer. Now, for those who are not aware, housemanship takes about 18 months to do but for the first 12 months, you undergo 3 major postings of 4 months each with a log book filled up at the end. The major postings may include Medical, Surgery, Obst and Gyn, Paediatrics or Orthopaedics. So at the end of 12 months, 3 logbooks must be handed up to the department and subsequently confirmed by the Malaysian Medical Council (MMC) and MOH for the Anual Practise Certificate (APC), thus rendering a doctor "safe" to practise.

Now, the story begins when this doctor mentioned fulfilled the criterias of passing up all her logbooks and proceeded forward and became a Medical Officer (MO). She was a good MO. She was in Medical, then went off to Nephrology whereby she was loved by her staff and her consultant. She was a nephrologist prodigy in the making. She remained there for almost 4 years and plans were made to further her studies.

However, on one fateful day, she received a letter notifying that her 3rd logbook was never received 4 years ago!! To her surprise, and after inquiring the department of her hospital, the logbook never reached MMC or MOH, thus meaning that the logbook had gone missing in the hospital itself after being handed up. Unhappily but undeterred, my friend made an appeal, and MOH/MMC requested thst she hand up the last 3rd logbook. So off she goes collecting signatures again with a new logbook and finally hands it up once completed.

You think it ends there? Not yet. She then hands up the new logbook to Putrajaya MOH and was finally at ease. So she thinks. She then received another letter with regards to the late completion of her logbook and to face disciplinary action for her delay. Nothing much was thought at first, especially with a her consultant and HOD of nephrologist backing her up.

Then the dreaded letter arrived. Her punishment:

1. Her 4 years of service will not be recognized.

2. She will lose seniority and therefore will gain rank and pay slower than her juniors

3. Since her service is no longer recognized, applying for Masters is even more difficult as Masters require at least 3 years working experience

4. There will be a black mark in her professional record which will affect promotions and applying for Master.

She just stood quiet, silent, when she got the news. All the above had to be explained to her as of to a little child. Shock I guess. Pity.

Doctors save lives, but not many would want to save ours.

Nuff said.

This was another response to the letter from Concerned Citizen. This was printed in The Star: 

Docs just want to be appreciated

I WISH to comment on “Stop whining, government docs,” by Concerned Citizen (The Star, Aug 12).

First of all, I would like to clarify that when we are on-call, we are doing “active call”, meaning that we have to be in the hospital for 24 hours.

This is unlike pharmacists who can stay and sleep at home when they are on-call as

they only need to come to the hospital should any problem arise.

Other healthcare personnel work according to shifts either in the morning, afternoon or at night. Therefore, they are not considered on-call and should not be paid on-call allowance.

When on-call, doctors are in the hospital 24 hours attending emergencies sometimes

even sacrificing meals and

sleep.

Most of the time the surgical doctors will be operating in the wee hours with only two to three hours of sleep if they are lucky and they have to continue the next day operating on the elective list for another 10 hours.

Mind you, we do not even have half a day off after being on-call the previous day.

The writer said that a fresh houseman commands a basic salary of RM2,458.39. I’m not sure where he got the figure but I've been in the government service for seven years and my basic salary still hasn't reached that figure.

Furthermore, the on-call allowances of RM150 on weekdays and RM170 on weekends are applicable for medical officers and not for housemen as stated by the writer.

We have accepted that on-call is part of our job scope.

We are not whining or complaining. We are used to working on public holidays. We are used to sleeping in the hospital while others are celebrating Hari Raya, Chinese New Year, Deepavali and Christmas with their love ones.

Our children are already used to staying at home during school holidays while their classmates enjoy family trips. Our children are also used to seeing their father or mother at home only 15 days a month because of on-call duties.

These are the sacrifices that we have made for the sake of our patients.

We are not complaining. We just wish that people appreciate us for what we do. It takes a doctor to understand another doctor’s plight.

A CARING DOCTOR,

Petaling Jaya.

In response to this remark, we replied with this:

We are replying to the letter from Concerned Citizen from Taiping entitled “Stop Whining, government doctors” issued on 12th August 2008. It seems that Concerned Citizen is very well versed with the fresh houseman (HO) basic salary and allowances. The fresh housemans nowadays get better pay than the senior medical officers 4-5 years ago. Currently the total sum of salary and allowances received by a senior medical officer (MO) and a fresh houseman is almost the same.

With regards to on call duty, in UK, doctors cannot work more than 16 hours non stop as it is impartial to the labour laws. A circular was formed by their Ministry of Health in UK to ensure that doctors do not exceed the legal working hours. They recommend doctors to rest after a 16 hour shift as judgement and managements of patients could be compromised due to lack of sleep/rest. However such labour laws do not apply here for Malaysian government doctors. It's bewildering that such a critically detailed occupation like medicine where lives of patients hang in the balance of precise medical decisions are given to the hands of doctors who have worked long 24 hour shifts. Its likely that mismanagement may occur as doctors are human and are prone to errors when physically and mentally exhausted.

In Malaysia, after being on call for 24 hours (I.E.: from 8 am to 8 am the next day), the doctors resume normal work in the wards immediately till 5pm. In short, the doctors work non stop for a span of 36 hours. There’s a shortage of doctors in the ward, thus the post call (after 24 hours on call) doctor is still needed in the hospital to continue on with his/her duties despite how busy it was the night before. These doctors attend a variety of cases during the call; emergency operations, CPR, intubation, child abuse case, premature babies, gun shot/stab wounds, drowning, head injuries, motor vehicle accidents, caesareans for fetal distress ..etc. Things that would keep anyone awake. This grueling on call duty would only earn us a measly RM150 a night (for MOs), which basically means RM10 an hour.

Concerned Citizen also mentioned that doctors (in his article Housemens) earn another RM 1000 – RM 2000 (totalling RM 5000 a month) a month for on calls. This would mean the poor chap has to do 10 to 20 calls per month as HOs earn RM 100 per on call. This poor doctor has to do on call every alternate day of his/her life (every other day) which basically means he/she has no life, as he/she would practically live, eat and sleep in the hospital. (We sleep after getting home from a call to recover. Most people do that. Its a natural body response.)

Basically, a senior MOs basic pay would comprise of RM 2600. Allowances would equate to another RM 1000, and on calls would provide another RM 1000 (if he/she were to do six on calls per month with RM 150 per day and weekend rounds), totalling to RM 4600. This is after 5 years of service in the government sector (MOH). Concerned Citizen should have checked his facts right before lashing out at government doctors.

On call pharmacists in the hospital usually do not need to stay in and do not need to attend to emergency cases in the wee hours of the night. If their services are required, the hospital will contact them via phone or page. Furthermore, if they were not paid for their overtime, they too are neglected in the sense of equal pay for equal service given. Pharmacists may be underpaid as well (which may explain why they too jump to the private sector).

Yes, fresh graduates of other discipline  may earn less than new doctors but our pay remains on a plateu for donkey number of years unless we specialize and progress through the ranks and by going through PTK in the government. If a doctor remains as an MO for years (chronic MO), then don't expect their pay to exceed RM 6000 in the government. As the example above, an MO of 5 years only earns a total of RM 4600 a month.

We are merely asking for a suitable on call payment for our efforts in view of the rising costs in Malaysia. If the government can afford to pay RM80 an hour for doctors in health clinics who attend the usual cough and cold cases, then they should consider increasing the on call allowances for MOs in the hospital settings, thus preventing doctors from leaving the government for greener pastures in the private sector. (MOs in private hospitals earn RM8000 basic salary).

I wonder if Concerned Citizen is aware of how taxing an on call could be. Imagine doing 8 – 10 calls per month for the past 4 to 5 years. A lot of doctors become exhausted with this lifestyle. 2 to 3 weekends in a month are spent doing on calls or doing morning rounds. It is considered as the main reason why doctors leave the government service/hospital settings to try and obtain a more comfortable lifestyle.

Please don't regard this as whining from the government doctors. Some of us have stayed on for years to serve the public and have furthered specialized to provide a better service. However, in view of Malaysia being a developed country by 2020, we were hoping that the working condition and salary of doctors would improve and that we would not be the minority of professionals who suffer in silence. Its a gruelling job, but somebody has to do it.