Sunday, June 22, 2008

Mismanagement, Mismanagement, Mismanagement!

....for twenty two years, Malaysia was under the stringent care of a medical doctor whose previous administrative experience was that of Klinik Maha in Alor Setar, Kedah.

Mismanagement, Mismanagement, Mismanagement!

An Ailing Malaysian
A graduate from Universiti Malaysia Sarawak (UNIMAS) shocked me recently with her pathetic knowledge in pharmacology. She was placed in charge of a patient with a fractured hip bone. The elderly man from Sandakan had been under her care for days already. I reviewed the patient and identified multiple acts of blatant neglect and implicit murder. The docile patient was simultaneously on three non-steroidal anti-inflammatory drugs – Celebrex, Arcoxia and Voltaren. As a result, his kidney function was deteriorating, a phenomena totally oblivious to the house officer concerned. He was probably having a slow upper gastrointestinal bleeding as well, for his red cell count was falling slowly but steadily.

As a house officer, she was to be in constant knowing of the patient’s latest condition and medications. She was not, obviously. In addition, a house officer is supposed to be working under the supervision of medical officers. This too, was not happening obviously. Her medical officers were either just as apathetic or equally unfamiliar with drugs and their adverse effects. The last question that begs an immediate answer will put to shame all ye pharmacist apologists. Drug charts are reviewed each day by the hospital pharmacists for approval and dispensing, so why did the wise and esteemed pharmacists dispense the medications knowing it is a case of overzealous polypharmacy? Perhaps they too, were as well-read as the house officer.

When confronted, the house officer became defensive and insisted that Arcoxia and Voltaren were not in the same group as Celebrex. In fact, she was even unable to provide me with the corresponding scientific names of all the drugs she was prescribing to the patient.

I can accept a doctor’s being fresh and uninformed. I can’t however, accept a doctor’s being clueless and arrogant. She incurred my wrath for more reasons than her outright ignorance. She downplayed my concerns and was unwilling to learn from her mistakes. In short, she was unteachable.

I ended up wasting thirty minutes of my youth trying to educate this young Malaysian Chinese lady in basic clinical pharmacology. I should have been paid by UNIMAS for doing the job of its lecturers.

I have acquired a notorious reputation of sorts among the junior doctors. They know they’re in for a fiery tongue lashing session when I discover a patient under their care is neglected and unacceptably mismanaged.

It’s really annoying when patients are mismanaged in the wards. It’s not as though I have never committed blunders of my own. Everyone screws up every once in a while but mostly inadvertently. Then there are those who are total screw-ups in life and are seemingly determined to make others meet the same fate.

From my own limited observation on which I have no evidence or random surveys to quote from, I find that patient mismanagement falls mostly into three categories: investigations, fluids and drugs. I can write endlessly about the mismanagement of patients but I don’t see how it can be edifying to anybody.

This is not to be another case write-up overflowing with incomprehensible verbose medical jargon.

An Ailing Malaysia
Rather, I wish to draw parallel of the daily bungling of an ill person to the half a century mismanagement of a nation. After all, for twenty two years, Malaysia was under the stringent care of a medical doctor whose previous administrative experience was that of Klinik Maha in Alor Setar, Kedah.

Malaysia is currently very, very ill. If the world had an Intensive Care Unit (ICU) for ailing nations, Malaysia is an ideal candidate for admission because despite being in a debilitated condition, there are chances that Malaysia can be restored to viability and stability. We can blame the Abdullah administration all we want but truth be told, he inherited a nation that was messed up by his predecessors for almost half a century.

Political analysts have write theses after theses about how Malaysia became as ill as she is today. The problem list is long but can be generally summarized to three main areas of mismanagement: Wealth, Human Resource and Time.

At risk of sounding like an overplayed, outdated Vanilla Ice track, it really isn’t too far fetched to reiterate that Malaysia is a land blessed with abundant wealth.

Malaysia has almost everything mother earth has to offer except for real snow, chubby pandas and an intelligent deputy prime minister. Malaysia has the resources to provide almost anything for her citizens – delicious multicultural delicacies, natural places of interests and potent C4 explosives.

Had the richness of the nation been fully utilized prudently and honestly, Malaysia can today be more generous than Cuba, more flamboyant than Brunei and more peaceful than Switzerland.

Yet the solemn fact is that the fat of the land has been squandered and stashed away in the private Swiss bank accounts of those who call themselves ambassadors of the nation and defenders of race, religion and culture.

We have ended up therefore instead with trunk roads littered with potholes and hospital mortuaries stocked with fallen motorcyclists, even as our limestone mountains are indiscriminately chiseled away on a daily basis.

Our oil reserves have almost run out after decades of drilling with bountiful profits reaped in the process, but still we have districts without schools, schools without teachers, teachers without money and now, money without value.

It is not too late for Malaysia to undo the wastages of her wealth on white elephant mega projects and salvage the residual assets of our land. UMNO has proven itself incapable of keeping its hands out of the cookie jar. Perhaps Anwar Ibrahim, Lim Kit Siang and PAS can do better job?

Human Resource
A Singapore-based hospital came to Sabah recently on a small-scaled roadshow. The institution is in the process of expanding its services and is thus somewhat short on manpower. The Human Resources team came on a recruiting tour, hoping to employ medical officers and registrars with the prospect of further training and sub-specialization. The employment terms and conditions were moderately attractive although the salary scheme will not make one rich in view of Singapore’s high living cost.

Yet the team of headhunters emphasized one crucial characteristic that has hitherto been sorely absent from our Malaysian civil service. It is none other than the factor of and emphasis on meritocracy in consideration for future remuneration and promotion. All this while, the Malaysian Ministry of Health proclaims that our doctors are leaving solely because of monetary reasons.

I must admit that I am extremely tempted to send in my curriculum vitae to a foreign institution. I am not alone, apparently.

What the Malaysian Ministry of Health is trying hard to oust and discard, their counterpart at the south of the peninsular border is waiting impatiently to receive.

In the Singaporean hospital’s own admission, up to 40% of doctors in the Lion City are Malaysians.

Some quarters estimate that between one to two million Malaysians are currently serving a foreign country. Every family I know seems to have a relative or a child working overseas. Therefore, a Malaysian diaspora in the scale of a million or two isn’t really incredulous.

Only God knows how many talented and skilled Malaysians have left the country since BN’s discriminative policies came into effect. It’ is not entirely an issue of race or ethnicity. It is very much the question of political affiliation and personal ideals as well. Great thinkers like Azly Rahman and M Bakri Musa are Malays by the most rigid definitions yet they have chosen to serve a foreign land in spite of the promises of a privileged life back here in Tanah Melayu. Enlightened individuals with enormous talent can never gel with an authoritarian regime that tolerates no dissenting view.

Indeed, we have lost doctors and engineers, economists and artists, thinkers and writers and even P. Waytha Moothy and Sufiah Yusof.

In short, the Malaysian government since 1957 has failed to safeguard our collective resources as well as resourceful individuals.

Only time will tell whether a Pakatan Rakyat administration will adopt a new stance in employment and promotion - the axiom that human resource is the greatest asset to any corporation. After all, such a working principle has worked well for our southern neighbours thus far.

Time and tide waits for no man. Time and tide waits for no country too, especially one that doesn’t appreciate the value of time and the consequences of wasting time.

The Malaysian government and the civil servants it employs are experts in time wasting.

Our civil servants did not acquire their fame for unproductivity for nothing. On second thoughts, perhaps I’m contradicting myself. Maybe they did after all - by doing nothing.

Every half hour or so, is a protracted coffee break in the typical bureaucratic office. The culture of ‘minum teh’ is too entrenched in the system. In fact, the one who does not participate in this orgy of sluggishness might end up alienated and ostracized for being pretentiously diligent. The working ethics might have improved a little over the years but mostly, an administrative officer in civil service is more likely to have Solitaire on one’s computer screen than a window of backlogged records and documentation.

Every other day meanwhile, there seems to be a reason to organize a lunch function of sorts. It’s either the welcoming of a new department head or the farewell to a retiring director. It’s either the officiating of a Toilet Cleanliness week or the formal closing ceremony to the Service-with-a-Smile campaign. If 100 personnel attend these two-hour functions every other day of the week, it’s a loss of 100x2x3 = 600 working hours each week, or the loss of 2 months productivity per week.

Every other week or so thereof is an inescapably lame workshop or nonsensical seminar. These are programs that supposedly improve the skills, knowledge and public relations of our bureaucratic staff. More often than not however, they are delivered by untalented souls who would otherwise not find employment in the private sector. The mother of all these courses is none other than the Induksi and Biro Tatanegara Program (BTN) that serve only to brainwash any dissenting views and convert opposing voices into all-hail-UMNO-and-BN zombies. Each Induksi session lasts two and a half weeks.

Do the maths and one will arrive at a horrifying figure of unpardonably wasted time. Suddenly it all makes sense why our general hospitals never to seem to have enough nurses, medical assistants, dentists, pharmacists and doctors. They are all busy feasting away in a hotel ballroom listening to speakers spreading pro-UMNO propaganda.

Most people will welcome a paid holiday to while their lives away. I’d rather earn my keep and make the most of my time treating ill people just as I was trained to, so thank you very much.

A Priceless Trinity

Like the Father, Son and Holy Ghost unified in their Holy Trinity, Wealth, Human Resource and Time is essentially one and the same.

Time is money and human resource equals wealth.

Is that a concept too complex and beyond the understanding of our pea-brain politicians? Or are they as recalcitrant as the obstinate house officer from UNIMAS, the arcetypal of 'bodoh, sombong?


danial said...

i agree with you that the attitude of the current batches of housemen is very worrying. the quality of care in my hospital too is deteriorating fst because of these people, especially those who are trained in other countries.

reading your post reminds me of how on last friday, two junior doctors questioned me on my judgement. but as a busy doctor in outpatient clinic, i simply asked them to come down from their air-conditioned, comfortable NICU and see the toxic baby in my room and manage her. he mumbled quietly and agree to admit the baby.

to be arrogant and stupid is simply unacceptable

Kong said...

The doctor clueless about pharmacology tells us one thing: Our assumption that only the cream of Malaysian Chinese gets to get into local public university doing difficult course like medicine is merely mirage. There are incompetent Malaysian Chinese, just like there are incompetent Malays.

Anonymous said...

Very well said. Congrats.

About the houseman part, Malaysian housemans graduated from overseas(eg Australia, US) are not any better than the ones graduated from local U. In my humble experience.

Not only lacking in terms of knowledge, attitude is a problem. They have one thing in common, they like to tell LIES. I don't understand why.

Sigh... While Singapore is luring all the capable and experienced doctors from Malaysia, Malaysia is left with only a handful of them plus with all the lying,dont know, dont care doctors.

What a loss.

Gan said...

I dread to think what will be the outcome of our health care in years to come ....

Jed Yoong said...

;) dun waste ur talent here. ;)
singapore will reward u. or at least u have a decent chance.
here u have to fit in and be mediocre, kill some patients like in ur example and then be recognised.
God bless.

kong: it has nothing to do with the chinese. the syllabus has been DUMBED DOWN so that everybody can pass and be a doctor......wooo hooo

Kong said...

Jed, I beg to differ.

It's simply impossible for any thumb downed syllabus to cause that simple mistake. And that beg the question: why are those simple mistake being made?

So I am more inclined to agree with what anonymous said, it's the attitude. May be the doctor/pharmacist didn't bother to learn their stuff in university. Or may be they do possess those knowledge but has the 'don't care' attitude.

nckeat88 said...

I got your point, you are trying to humiliate the local graduate especially the Chinese that they are actually not smart as you are.

I also presumed that one shouldn't treat the medical profession as noble profession. One should instead sell themselve to the highest bidder.

Let me tell you the truth I saw equal numbers of morons from the UK, Ireland or even Australia who also do not have a clue of what is medicine about. Some of them don't even know how to calculate EDD from the LMP. Spme of them don't even know what a CTG lokks like. You got bad and GOOD HOs from local and foreign universities.

Product of the System said...


It baffles me how you came to the conclusion that my intention was to humiliate the local medical graduates. Perhaps you did not ready my previous posts.

Anyway, i am myself a local graduate, and still working locally.

Details are sometimes included for the sake of clarity and completion with no hidden motives.

Thanks for reading.

nckeat88 said...

Sincere apology from me for the harsh words. Anyway I am always annoyed by the people who is trying to worship doctors from overseas. They think that those from the Harvard or Oxford are the only real doctors.

The problem of deterioration of HO quality is partly due to the ever increasing intake of the local medical students which the number not matched by the teaching faculty and facilities. The other main reason is the commercialization of medical education which 'Anyone which money can become doctor' and gov will absord them (as long as they got money).

Many forgot the pledge that they want to serve the rakyat when they choose the profession of doctor. But when they become doctor, they sell the soul to the highest bidder. For them it is ok to serve the rich master but abondon your poor kampong folks and keep on blaming the poor health system but fail to contribute.

Another POTS said...

Dear POTS,

Things that really puzzled me, how could a HO prescribe Celebrex and Arcoxia? These two drugs are specialist items. Also Sufiah Yusof is not a Malaysian!

Hi&Lo said...

Sabahans deserve to be screwed for being parochial.

They are too complacent and comfortable to want a better life for their future generations.

Am talking abt the middle-class Sabahans. They know what are the wrongs and good at criticising. But come to the crunch they have no guts.

Worst, when you act upon their complaints and grouses, they get jealous of your cleverness.

Product of the System said...

Another POTS,
Puzzling heh?

But it's not impossible or far fetched here in Sabah.

There are ways and means to get a 'specialist item' if one knows how.

Pharmacists are pretty lenient when drugs are prescribed from the wards because they assume that all medications were ordered by the specialists and countersigned as such.

Anyway, the HO most probably did not prescribe the drugs on her own, but under the order of a specialist who was not in touch with the patient's cocktail of drugs. It's neglect on the specialist's side but it still doesn't absolve the HO of her ignorance.

Anonymous said...

Dear Dr. POTS,

Good writings and revelations on the Malaysian System especially in your field. Hope you are not a racist that you dont want to be. Fair to others and fair to yourself.

Kong said...

nckeat88 said..."Anyone which money can become doctor' and gov will absord them (as long as they got money)."

Try getting into an Australian or UK medical schools and see whether that will work. Unless you donate a couple of million to their school, you will be surprised that they also insist on good academic results. Plus interviews to access your characters.

Of course, some unsuitable candidates do get in occasionally, just like the Malaysian Chinese lady doctor mentioned by POTS who got into the 'hard-to-get-in' local university.

Kong said...

There is another possibilities as to why those glaring mistake wasn't rectified: Fear of speaking up.

The way we are taught from young and the environment we live in does not rewards those who speak up & do the right thing. Even judge are reluctant to speak the truth, what more young HO? Why rock the boat? Keep quiet and everything will be fine. There are simply too many 'yes' people around. It's good we have people like POTS speaking his mind. Agree or disagree does not matter. What matter is we can openly debate any issue as long as it has some logic behind the arguments.

nckeat88 said...

Anyone can become doc and this is true. As long as you got money (as low as 120k which you can get easily from personal loan) you can get into a Russian or Indon Medical school regardless of your result (even if you were from Art stream because they got premedic course for a year to qualify anybody into medical school. These doctors got the same salary scale (and guaranteed a job by Malaysian gov) as those local or UK/Aust graduates. Even for local private medical schools, the primary criteria is money (except the amount is higher in range of 250 to 400k).

If you don't believe me, call those ad in the newspaper. They are willing to help you get admitted to medical school as long as you got money. They can even take forecast SPM result (Art stream) as admission criteria.

Anonymous said...

This in response to hi&lo

Sabahans, Screwed ??? Parochialness??

wow, a touch of sentiment on a personal level aye? are you the screwed or the the screwer? clever. clap clap. but please don't generalize and offer your judgement as "deserving" and call it cleverness.

oh, and hc, welcome back and thanks for staying on

Kong said...

Yes, you are right, anyone can become a doctor. You can probably buy a doctor certificate from some disreputable corners of the world without even having to attend any lecture.

But on the other hand, you can't do that with some reputable countries in the world. Not unless it runs into the million. So you should not make sweeping statement that would degrade the doctor profession as a whole.

nckeat88 said...

I think one shouldn't make sweeping statement that those from developed nations are all good.

Recently I got a HO from UK (United Kingdom not UK Malaysia), when I ask him to comment on a chest Xray, he commended that the CXR is good, NO CREPITATION. So tell me how to teach this kind of HO.

Kong said...

2 different things you are talking about.

I disagree with your statement that anyone with money can become a doctor by getting into medical school anywhere in the world. You can do so in some countries but not in most advanced countries (not unless you paid million or establish a chair or something).

But I did not say all doctors produced by these advanced countries will be good doctor. Entirely different things.

Of course, we will probably start another debate as to what constitute a 'good doctor'. Granted that Mother Teresa is not strictly a doctor but she has all the qualities of being a great doctor and she came from a Albania (I think there are many people who doesn't even know where that is). On the other hand, the notorious Dr. Josef Mengele is German. May be these are not good example but what I meant to say is, good & bad doctor can be produced anywhere in the world. Yes, even locally trained doctors can be excellent or terrible.

Alan said...

If there is a leak somewhere, the logical thing to do is to patch it up so that its content does not continue to leak through.

Paradoxically, in this country, the "logical" thing to do is to dig a bigger hole so that its content deplete at a faster rate.

This may not be entirely attributale to the stupidity of the administration. I would say that things are as it is in Malaysia because there are insincere politicians (traitors of the country) who intentionally allow the leak (brain drain) to continue so that the country will be deprived of intellectuals who are deemed to have the potential to subvert their selfish political agenda.

These people rather manage a group of obedient, less intellectual, third-class mentality folks than to be challenged by a group of rebellious, intellectual, first-class mentality folks (ie. RPK, Farish Noor, etc.)

What's happening is a loss to the country but it's a gain to these selfish politicians.

Kong said...

Agree with you , Alan. Next step is to change some voters' mentality that:

1. Your single vote can make a difference so go out to vote. Many just couldn't be bothered with the usual excuse "It's useless".

2. It's o.k. to not vote for your your usual past party. Old folks old habit dies hard.

CK said...

i think POTS story of a Malaysian Chinese doc screwed up case is by no means a way to degrade the local grads or race-specific whatsoever.
i'm against any worshipper of overseas graduates, being fully aware, most of the times, it's the indvidual that matters.
however, the local education system was being designed and manipulated in such a way that mediocrity rules.
speaking of non-bumis grads churned out from local uni, we (cos I am one of them) are not the same anymore. it used to be thought that any non-bumis who gain entry into local uni are of good quality etc but it's not entirely true. with the quota etc, now the non-bumi undergrads are not working hard enough to strive for the best (not being sarcastic but it's true) cox a so-so effort is enough to put them on the top of the crop. so, by giving leniency to bumi students, the non-bumi students indeed lowering down their std as well and this definitely doesn't augur well with the whole scenario. it will go lower and lower....

Dr. Johari said...

"The way we are taught from young and the environment we live in does not rewards those who speak up & do the right thing. Even judge are reluctant to speak the truth, what more young HO? Why rock the boat? Keep quiet and everything will be fine."

I agree with Kong, I had an experiance where I can't manage to complete my delivery obsrvation during my student. It is off course my mistake and I agree if my lectures dare to fail me. But at least I was not lying at tht time like most of my friends did.

Anonymous said...

Is this conversation still alive? It seems like most replies are from ppl in the medical proffesion.. Malaysian doctors? If you are there, how's working in malaysia like?