Doctors Prescribe, Pharmacists Dispense, Patients Suffer

...the difference between a drug and a poison is the dose. A toxin used in the right amount for the right condition is an elixir. A medication used in the wrong dosage and for the wrong indication is lethal poison....


Doctors Prescribe, Pharmacists Dispense, Patients Suffer.

Real Life Scenario

Madam Ong is a 52-year-old lady with a twelve-year-history of hypertension and diabetes. She complained of generalised lethargy, lower limb weakness, swelling and pain. She brought along her cocktail of medications for my scrutiny. Her regular medications included the oral antidiabetics metformin and glicazide and the antihypertensives amlodipine and irbesatan. Madam Ong also had a few episodes of joint pains three months ago for which she had seen two other different doctors. The first doctor suspected rheumatoid arthritis and started her on a short course of the potent steroid prednisolone. Thereafter, she developed increasing lower limb swelling for which a third doctor prescribed the powerful diuretic frusemide.

Madam Ong was not on regular follow-up for hypertension and diabetes. Additionally, she has been re-filling her supply of steroids and diuretics at a pharmacy nearby with the purpose of saving up on the consultation charges.

I took a more complete medical history and performed a thorough physical examination. I concluded that this lady’s health was in a complete mess.

She was under sound management by the family physician until the day she defaulted follow up and was started on prednisolone by a doctor who was unaware she was diabetic. The steroid probably helped in relieving her arthritic pains though the suspicion of rheumatoid arthritis was never proven serologically.
However, it also worsened her sugar and blood pressure control and weakened her immune system.

Her legs swelled up because of the fluid retentive properties of the steroids. In addition, early signs of cellulitis were showing up around her legs due to a weakened immune function. The diuretic prescribed by the third doctor helped a little with the swollen limbs but she became weak from the side effects of diuretics.

Madam Ong’s problems escalated when she decided to forgo her doctors’ opinion altogether and decided to self-medicate simply by collecting all her medications from the pharmacist who supplied them indiscriminately. Unknowingly, the pharmacist had added to the lady’s problems in spite of the wealth of knowledge the pharmacist must have possessed.

The above scenario is a fairly common scene in the Malaysian healthcare. We see here an anthology of errors initiated by doctors, propagated by the patient’s health seeking behavior and perpetuated by a pharmacist.

Noteworthy but Untimely Move

The Ministry of Health is set to draw a dividing line between the physician’s role and the pharmacist’s, restricting physicians to prescribing and according dispensing rights solely to the pharmacists.

Such a move virtually has its effects only upon doctors in the private practice and particularly the general practitioner who relies on prescription sales for much of one’s revenue.

Doctors prescribe and pharmacists dispense. It’s the international role of each profession and very much the standard practice in most developed countries.

The Ministry of Health however, has failed to take into account the local circumstances in mooting this inaugural move in Malaysian healthcare. The logic and motive behind the Ministry of Health’s proposal is in fact laudable, but only if the Malaysian healthcare scenario is more organized and well-planned.



Spiraling Healthcare Costs
In the United Kingdom, all costs are borne by the National Healthcare Services. In the United States, despite all the negativity painted by Michael Moore’s Sicko, most fees are paid for by health insurance without which one cannot seek treatment. In these countries and many European nations, there is hardly any out-of-pocket monetary exchange between patients and their clinicians.

This however is not the case for Malaysia. Most patients who visit a private clinic are self-paying clients. The costs of consultation and medications are real and immediately tangible to patients. A visit to the general clinic for a simple upper respiratory tract infection may set one back by as much as RM 50.00 inclusive of consultation and medication. Most clinics these days are charging reasonable sums between RM 5 to RM 15 for consultation. Some are even omitting consultation charges altogether in view of the rising costs of basic healthcare. The introduction of the MOH’s ‘original seal’ to prevent forgery of drugs contributed much to this.

There is no denial that most clinics rely on the sales of medications in order to remain financially viable. From my personal experience, the charges for medications by private clinics are not necessarily higher than pharmacies. In fact, since each practitioner has a stockpile of one’s own preferred drugs, the cost price of the medications can be much lower than that obtained by the pharmacists who need to stockpile a wide variety of drugs. It is therefore a misconception that pharmacies will provide medications to patients at a much lower cost all the time for all medications.

Retracting dispensing privileges from the private clinics will only force practitioners to charge higher consultation fees in order to sustain viability of their practices. In the end, the patients end up paying a greater cost for the same quality of healthcare and medications. Inevitably, much of the increase in healthcare costs will also be passed on panel companies who will then be paying two professionals for the healthcare of their employees.

In this season of spiraling inflation, this proposal by the Ministry of Health is ill-time and poorly conceived.

Unequal Distribution of Medical and Pharmacy Services
As it already is, private general practice clinics are mushrooming at an uncontrolled rate. A block of shoplots in Kuala Lumpur may house up to five clinics. Does Malaysia have a corresponding number of pharmacists to match the proliferating medical clinics? If and when clinics are disallowed to dispense medications, the market scenario will become one that heavily favors pharmacists. The struggling family physician suddenly loses a significant portion of his revenue while the pharmacist receives a durian runtuh overnight.

The situation is worst in the less affluent areas and rural districts where the humble family physician may be the solitary doctor within a 50km radius and no pharmacy outlets at all. For example, there are no pharmacies in Kota Marudu, Sabah and only one in the town of Kudat. Patients seeking treatment in these places will get a consultation but no have no avenue to collect their prescription if doctors lose their dispensing privileges.

The absence and dearth of 24-hour pharmacies is also a pertinent issue. At present, many clinics operate around the clock to provide immediate treatment for patients with minor systemic upset. These clinics play an important role in reducing the crowd size and the long waiting hours at the emergency departments of general hospitals.

Without a corresponding number of 24-hour pharmacies to dispense urgent medications, the role of 24-hour clinics will be obtunded. The MOH’s plans of implementing its doctors-prescribe-pharmacists-dispense policy will merely backfire and result in the denial of services to patients.

A Bigger Problem Is The System Itself
The increasing number of medical centers around the country is not necessarily in the patients’ best interests or an indicator of improved healthcare provision. Most clinics and medical centers serve an overlapping population of patients. A person may be under a few different clinics simultaneously for his chronic multiple medical problems, resulting in a scattered, interrupted medical record. One doctor may not be informed of the interventions and medications undertaken by the patient at another practice. The concept of continuous care and a long term doctor-patient relationship is practically improbable.

This is unlike the system in the United Kingdom where each family physician is allotted a certain cohort of patients for long term care. The doctor remains in full knowledge over his patients’ progress, making general practice one that is rewarding and meaningful.

The trouble-ridden Malaysian healthcare system prevents optimal clinical practice especially for doctors in the private sector.

Until the Ministry of Heath puts in place a more systematic and organized approach to healthcare, patients will still be denied optimal medical services despite a clear division between the roles of doctors and pharmacists. The process of prescribing and dispensing is but one step in the cascade of events that may result in harm being done to the patient. Role separation between the doctor and the pharmacist will not eliminate drug-related malpractice and negligence, as I have illustrated in the real clinical scenario above.

Loss of Clinical Autonomy
Private practitioners in Malaysia are at present enjoying a reasonable sense of autonomy over the health of their patients. In many ways, the freedom of clinicians to make decisions with adequate knowledge of the patient’s needs and circumstances is a plus point in clinical practice.

Involving the pharmacists in the daily management of every patient removes a great part of the doctor’s control over the clinical circumstances of the patient. He may prescribe one drug only to be overruled by the dispensing pharmacist later. The clinician has privy to much information about the patient’s circumstances that are available only in the patient’s medical records. It is based on this information that a clinician makes decisions on the final choices of medications for the patient.

A dispensing pharmacist does not have access to such priceless clinical history and may very well make ill-informed decisions in the patient’s medications. Once again, my introductory scenario demonstrates how pharmacists can help perpetuate a patient’s mismanagement.

Selective Implementation of Rules
Rules in any game should be fair and just and implemented on both parties. If doctors are to be prohibited from dispensing, shouldn’t pharmacists too be forbidden from diagnosing, examining, investigating and prescribing?

Yet this is exactly what takes place everyday in a typical pharmacy.

I have seen with my own eyes (not that I can see with someone else’s eyes anyway) pharmacists giving a medical consultation, performing a physical examination and thereafter recommending medications to walk-in customers. It is also not uncommon to find pharmacies collaborating with biochemical laboratories to conduct blood tests especially those in the form of seemingly value-for money ‘packages’. These would usually include a barrage of unnecessary tests comprising tumor markers, rheumatoid factor and thyroid function tests for an otherwise well and asymptomatic patient.

Pharmacists intrude into the physicians’ territory when they begin to do all this and more.

Doctors may occasionally make mistakes due to their supposedly inferior knowledge of drugs despite the fact that they are trained in clinical pharmacology.

In the same vein, pharmacists may have studied the basic features of disease entities and clinical biochemistry but they are nonetheless not of sufficient competency to diagnose, examine, investigate and treat patients. Pharmacists are not adequately trained to take a complete and thorough medical history or to recognize the subtle clinical signs so imperative in the art of differential diagnosis.

In more ways than one and increasingly so, pharmacists are overtaking the role of a clinical doctor. Patients have reported buying antibiotics and prescription drugs over the pharmacy counter without prior consultation with a physician.

If the MOH is sincere to reduce adverse pharmacological reactions due to supposedly inept medical doctors, then it should also clamp down on pharmacists playing doctor everyday in their pharmaceutical premises. Patients will receive better healthcare services only when each team member abides by and operate within their jurisdiction.

The move to restrict doctors to prescribing only while conveniently ignoring the shortcomings and excesses among the pharmacy profession is biased and favors the pharmacists’ interests.

The Root Problem is Quality
A significant issue in Malaysian healthcare is that of the quality of our medical personnel. This includes doctors, dentists, nurses and pharmacists, therapists, amongst others. A substantial number of our doctors are locally trained and educated. If current trends are extrapolated to the future, the number of local medical graduates is bound to rise exponentially alongside the unrestrained establishment of new medical schools.

The quality and competency of current and future medical graduates produced locally is an imperative point to consider. Competent doctors with a sound knowledge of pharmacology will go a long way in improving patient care and minimizing incidence of adverse drug reactions. The very fact that the MOH resorts to the drastic step in prohibiting doctors from dispensing medications indicates that it must be aware of the high prevalence of drug-related clinical errors.

Much of patient safety revolves around the competency of Malaysian doctors in making the right diagnosis and prescribing the right medications. Retracting dispensing rights from clinicians therefore, will not solve the underlying problem. Our doctors might still be issuing the right medications but for the wrong diagnosis. In the end, a dispensing pharmacists will still end up supplying the patient with a medication of the right dosage, right frequency but for the wrong indication.

Patient safety therefore begins with the production of competent medical graduates. The problem lies in the fact the same universities producing medical doctors are usually the same institutions producing pharmacists. It is really not surprising, since the basic sciences of both disciplines are quite similar. Therefore, if the doctors produced by our local institutions are apparently not up to par, can we expect the pharmacy graduates who learnt under the same teachers to be much better in their own right?

Among other remedial measures, my personal opinion is that the medical syllabus of our local universities is in desperate need for a radical review. There is a pressing need for a greater emphasis on basic and clinical pharmacology. At the same time, the excessive weightage accorded to paraclinical subjects like public health and behavioral medicine need to be trimmed down to its rightful size. Lastly, genuine meritocracy in terms of student intake, as opposed to ‘meritocracy in the Malaysian mould’, will drastically improve the final products of our local institutions.

The MOH’s Own Backyard Needs Cleaning
Healthcare provision in Malaysia has undergone radical waves of change during the Chua Soi Lek era. The most sweeping changes seem to affect the private sector much more than anything else. The Private Healthcare Facilities and Services Act typifies MOH’s obsession with regulating private medical practice as though all doctors are under MOH’s ownership and leash.

An analyst new to Malaysian healthcare might be forgiven for having the impression that the Malaysian Ministry of Health is currently on a witch hunt in order to make private practice unappealing and unfeasible in order to reduce the number of government doctors resigning from the civil service.

Regardless of MOH’s genuine motives, it must be borne in mind that private healthcare facilities only serve an estimated twenty percent of the total patient load in the whole country. The major provider of affordable healthcare is still the Ministry of Health and probably always will be. Targeting private healthcare providers therefore, will only create changes to a small portion of the population. Overhauling the public healthcare services conversely, will improve the lot of the remaining eighty percent of the population.

At present, the healthcare services provided by the Malaysian Ministry of Health is admittedly among the most accessible in the world. The quality of MOH’s services however, leaves much to be desired. Instead of conceiving ways and means to make the private sector increasingly unappealing to the frustrated government doctor, the MOH needs to plug the brain drain by making the ministry a more rewarding organization to work in.

The MOH needs to clean up its own messy backyard before encroaching into the private practitioners’.

An indepth analysis of MOH’s deficiencies I’m afraid, is not possible in this article.

MOH’s “To Do List”
The prescribing-dispensing issue should hardly be MOH’s priorities at the moment.

I can effortlessly think of a list of issues for the MOH to tackle apart from retracting the right of clinicians to dispense drugs.

Private laboratories are conducting endless unnecessary tests upon patients and usually at high financial cost despite their so-called attractive packages. In the process, patients are parting with their hard-earned money for investigations that bring little benefit to their overall well being. Mildly ‘abnormal’ results with little clinical significance result in undue anxiety to patients. More often than not, such tests will result in further unnecessary investigations. The MOH needs to regulate the activities of these increasingly brazen and devious laboratories.

Medical assistants trained and produced by the MOH’s own grounds are running loose and roaming into territories that are far beyond their expertise. It is not uncommon to find patients who were on long term follow up under a medical assistant for supposedly minor ailments like refractory gastritis and chronic sorethroat. A few patients with such symptoms turned up having advanced cancer of the stomach and esophagus instead. The medical assistants who for years were treating them with antacids and multiple courses of antibiotics failed to notice the warning signs and red flags of an occult malignancy. They were not trained in the art of diagnosis and clinical examination but were performing the tasks and duties of a doctor. There is no doubt that the role of the medical assistant is indispensable in the MOH. Just as a surgeon would not interfere with the role of an oncologist, medical assistants too must be aware of the limits of their expertise. MOH will do well to remember the case of the medical assistant caught running a full-fledge surgical clinic in Shah Alam in late 2006.

Adulterated drugs with genuine risks of lethal effects are paddled openly in road side stalls and night markets. They are extremely popular among folks from all strata of society who rarely admit to the use of such toxins to their physicians. It is possible and highly probable that many unexplained deaths taking place each day are in some way related to the rampant use of such preparations.

Non-medical personnel are performing risky and potentially lethal procedures daily without the fear of being nabbed by the authorities. These are mostly aesthetic procedures. Mole removals, botulinum toxin injections and even blepharoplasty are carried out brazenly by unskilled personnel and usually in the least sterile conditions. It makes a mockery of the plastic surgeon’s years of training but above all, proves that the MOH is indeed barking up the wrong tree in its obsession to retract the dispensing privileges of medical practitioners.

Closing Points
In summary, a patient’s health is affected by many factors – a doctor’s aptitude is merely one step in a torrent of events. The health seeking behaviors of patients play an imperative role in the final outcome of one’s own health. Most harm to patients can only occur as a result of unidentified minor errors in the management flowchart of a patient. If allowed to accumulate, such errors converge as a snowball that threatens the long term outcome of an ill person.

There are a multitude of other clinical errors apart from prescribing and dispensing, some of which are not at all committed by trained medical staff. The MOH must get its priorities right by first overhauling an increasingly overloaded public healthcare service.

Lastly, the difference between a drug and a poison is the dose. A toxin used in the right amount for the right condition is an elixir. A medication used in the wrong dosage and for the wrong indication is lethal poison.

Read more!

Labor Day, Laboring Day.

We’re all laboring in our own ways, and in more ways than one.

All over the world, we see the poorest of folks having the most number of children. From the suburbs of Brazil to the plains of the African continent, from the dumpsites of Philipines to the streets of India, from the hills of Ranau to the paddy fields of Kedah, we see....



Labor Day, Laboring Day.

It’s May 1st 2008. The year passes by pretty fast doesn’t it?

Anyway it’s Labor Day, which I assume is a day to celebrate all those who work and labor to make a living. The laboring population is no longer restricted rigidly to labourers – those sweat-bathed, sun-soaked, mud-splattered men (and women) in construction sites all over Malaysia and the world.

We’re all laboring in our own ways, and in more ways than one.

Some are at the very lowest of the Maslow’s hierarchy of needs, the stage of mere survival. If ever a survey is undertaken to estimate the percentage of the Malaysian population still struggling to make ends meet each month, I believe the final results will be nothing less than shocking, if they are not manipulated, twisted and re-manipulated by the authorities. Such a survey will ultimately require a huge, randomized sample population, dedicated and trained manpower and sincere, unbiased statisticians.

Alternatively, one can just got the nearest ATM machine, rummage through the available dustbins, collect the ATM receipts and calculate the average leftover savings of the working Malaysian citizen.

Some of us with so-called stable careers are at Maslow’s stage of security. We might be saving hard for that elusive property to call home or for that non-local car that wouldn’t break down every month. Most of us I think, are working and saving for our future and that of our families. It’s not the ideal state of existence, especially when we read and hear of the extravagant lifestyles of the Hollywood stars drunken with excessive self indulgence. Then again, most of us are objectively better off than a great part of the population – the hungry, barefooted, elderly folks of Paitan, Sabah for example.

Over in Peninsular Malaysia, the Malaysian Trade Union Congress (MTUC) has been lobbying for a minimum wage for all workers. It’s been a dreadfully long time and goes without saying that the capitalistic Barisan Nasional government has been turning a deaf ear to the MTUC until recently. The shrewd and perhaps opportunistic opposition parties meanwhile have been lending the MTUC their voice on the streets but hitherto, no tangible efforts to make minimum wages a reality for laboring folks.

I am no expert in human resources and economics. Even so, I find the argument for a minimum wage for everyone littered with ifs, ands, and buts.

There is no denial that many workers across a wide range of jobs and fields are struggling to pay their bills and feed their children. With the exponential rise in fuel prices, inflation is bound to get worse. Basic necessities, groceries, foodstuff, and household items will consume a great portion of the average household expenditure. Savings will be scarced for these laboring folks, if at all.

Still, life is always filled with irony and wonders of wonders.

The couple that earns RM 6000 of combined income per month has only two children and one dog. A thousand kilometers away, the couple who commands RM 50 per day harvesting palm oil in the interiors of Pahang is raising a brood of five children plus one on the way in the wife’s uterus. Despite their financial constraints, the labourer husband has his wife go into labor every other year until menopausal age or when the Labor Party is finally recognized in Malaysia, whichever is sooner.

Some communities do not believe in contraception. Some even consider family planning a deadly sin. Copulating for pleasure and not for reproduction equals damnation in the burning brimstones of hell. God does not speak vocally or vehemently very often, but I wonder what God will say when he sees men and women who reproduce without the basic financial ability to raise the child in a world that requires money to survive.

If indeed family planning and contraception is a sin of any degree, then bringing a child into a world indiscriminately without a will to provide for the baby is a sin a thousand times the severity of contraception.

All over the world, we see the poorest of folks having the most number of children. From the suburbs of Brazil to the plains of the African continent, the dumpsites of Philipines to the streets of India, from the hills of Ranau to the paddy fields of Kedah, we see the most religious and uneducated and impoverished folks beating the Syrian hamster in a race to be fruitful and multiply.

It is even more frustrating in Malaysia when these reproductive folks emerge later on demanding their special privileges and rightful crutches supposedly accorded to their apparently deprived children under the Malaysian constitution.

Does poverty bring with it a certain spirit of fecundity?

Perhaps it is the other way around.

Perhaps a body of fertility without a corresponding mind of sensibility invites a life of poverty and destitution.

Some nice and sweet folks ooh and ahh and declare that marriages and children are made in heaven.

True beyond a doubt.

So are rain, storm and thunder. Humans wear raincoats and umbrellas to shelter themselves from rain. There is no reason then why humans should be prohibited from using condoms if they have no plans of receiving that gift from heaven called children just yet.

A great part of the blame is upon religious figureheads for all these nonsense – the Pope, the mullahs, the priests and the imams. It’s bad enough these arrogant mortals are engaged in an intense competition to populate the earth with believers of their faith. It’s worse when they fail to see the perpetual hurt and lasting damage their narrow-minded, selfish ambitions are inflicting upon pious and susceptible simple minded folks. Lastly, it is the worst when the hatred-filled religionists employ children of impoverished families as suicide bombers and jihadists.

My point is this - a minimum wage is not the golden answer to a labor population grappling with spiraling inflation. No minimum wage will ever be sufficient until these hardworking men learn to direct their amorous energy elsewhere or utilize it with a pinch of foresight.

There are of course other factors to consider in alleviating the burden of inflation upon the laboring population. Unscrupulous traders, corrupted politicians, market monopolies, imprudent spending, diesel smuggling, unproductive farming and exploitive employers are topics more suited for commenting by economists and analysts.

As to MTUC’s demands for minimum wage, I say give the workers a minimum wage by all means. Make it a fair and decent one please.

While they’re at that, throw in some contraceptive devices too.


Read more!

The Young Sabahan (1)

The youth of Sabah are not any more or less teachable than the Malay bumiputras of Peninsular Malaysia. They are no less talented or skilful. They are perhaps, lesser beings in the eyes of UMNO and Barisan Nasional.

The one best method to condemn a community to eternal ignorance is by neglecting and forgetting it. In this respect, the youngsters of Sabah have been neglected for much too long.


The Young Sabahan (1)

The locum clinic I work for placed a 3X4 cm in the local Borneo Post recently. It was looking to hire a new clinic nurse to replace one who had left earlier in the month after eight years of tenure.

A total of 531 applicants from all over Sabah sent in their applications and resumẻ of sorts.

It’s not unlike an American Idol contest. The applicants were mostly young, jobless locals from the distant districts of Sabah. They had to undergo a grilling interview. The reward was less lucrative than the million-dollar record deals of a singing competition though. At the end of it all, only one will get the job – a pretty mundane and unenviable job.

Hilda is an eighteen-year-old Bajau lady from Kota Belud, about 200 kilometres from Kota Kinabalu city. The fifth of seven siblings, she had just completed secondary school, attaining a decent pass in the SPM examinations. Her life had come to a defining junction upon completion of her secondary education. Her family is unable to support Hilda for any further education. Heck, even making ends meet in this season of inflation is a struggle. She has come of age and was obliged to contribute to the family income. After eight months of being unemployed and unproductive, Hilda was under increasing pressure to do something about her life.

Opportunities and development are limited in Kota Belud.

It is never easy abandoning the comfort and confines of the familiar family nest. She is not keen to, but her options are limited. She can leave home and fend for herself in the foreign environment of Kota Kinabalu city, sending home her leftover cash, if any. Alternatively, she can resume her village life in Kota Belud, get married at a tender age and start a baby factory of her own, attaining grandmotherhood by the age of forty not unlike her own mother.

The first choice was unattractive and daunting, but was nevertheless more viable than specializing in copulation and reproduction.

Hilda was finally employed not because she was better, prettier or more impressive than the other hundreds of applicants. She was not fluent in English, far from it in fact, despite her documented ‘A’ in her SPM English. She did not write any better than the others or speak more confidently. Hilda was hired because she was willing to take up the job at the lowest offer.

For the next one year, Hilda will be working eight-hour shifts each day with one day off after three consecutive overnight shifts at the clinic. Registering patients, mixing and packing medications, phone calls and billings will be her tasks of the day. At the end of each month, Hilda will be paid RM 440.00. It runs up to about a RM 14 per day or RM 1.80 per hour – figure much lower than the standard market wages.

Without any form of self-transportation, Hilda needs to stay near the clinic. She rents a room in a flat no larger than half a badminton court. The flat houses thirteen other job-seeking young Sabahans. Hilda shares her room with another young lady. She pays RM 110 each month for her room slightly smaller than a Proton Perdana. Hilda is left with RM 330 for the next 30 days.

As comparison, my grandmother’s Indonesian helper commands a salary of RM 500 per month, with food and lodging privileges.

Stories like Hilda’s are a dime a dozen in Sabah. She is a bumiputera just like the Muslim Malays of Peninsular Malaysia.

Despite years of trumpeted, keris-wielding, battle cries of bumiputra-ism, the fruits of the New Economic Policy have eluded her for half a century.

Development is scarce in the districts of Sabah not because of the lack of funds or the absence of potential. Massive corruption at federal, state and district levels have swindled the locals of their pooled taxes. The unbelievable gambling debts of former Sabah chief minister Osu Sukam amounted to almost seven million ringgit. It a small testimony of how rich Sabah can be if its monies were entrusted in the proper hands.

National education has failed Hilda and the million other local Sabahans. Malaysian education is accessible to most folks, but at what price? Most schools away from the city of Kota Kinabalu are pillars of shame. With limited facilities, insufficient teaching staff and less than ideal environments of learning, national education becomes a farce in these district schools, not that it is any less a mockery throughout the country anyway. As in most national schools, the air is pungent with forced indoctrination and pro-government propaganda. Unlike their counterparts from the more urban areas, the young minds in the districts of Sabah do not access to alternative worldviews. Libraries are a rare sight, if and when they are available, the variety of reading material is limited. Internet is a foreign word - the people I’m writing about right now are not reading this web page right now and probably never will.

Like the many before her, Hilda complied with the teachings and contents of her education syllabus. It is written in her text books and declared by her teachers that the current Malaysian government is the best one can ask for, a government that was legitimately elected via a free, fair and just democratic process and one that safeguards the wellbeing and interests of Malaysian citizens regardless of race, religion and culture.

Life in her kampung was simple, quiet and tranquil. It could have been her be-all, end-all, her destiny forevermore if not for the fact that everyone needs to grow up and earn a living one day. As it turns out, life and survival in the real world requires more than an SPM certificate. She had trusted her teachers, her books and her school but evidently, her trust is misplaced. Sabah and Malaysia is a pretty different place that the one she had read about in her textbooks and the images she sees on her television screen. If our national school textbooks were kosher and to be believed, Malaysia is the utopia in every idealist’s dream. The reality of course, is that Malaysia is capitalist to the core supplemented with elements of communism, apartheid and Talibanism.

An erroneous and homogenous worldview in an unquestioning mind is precisely what UMNO desires from the rural population of Sabah. From Ranau to Kota Marudu, Tawau to Sandakan, Kudat to Tenom, keeping young minds in the dark about the realities of life will ensure continuous Malay supremacy in land where Malays are the minority.

Sabah has lost a generation or two to UMNO’s political hegemony.

The youth of Sabah are not any more or less teachable than the Malay bumiputras of Peninsular Malaysia. They are no less talented or skilful. They are perhaps, lesser beings in the eyes of UMNO and Barisan Nasional.

The one best method to condemn a community to eternal ignorance is by neglecting and forgetting it. In this respect, the youngsters of Sabah have been neglected for much too long.

Contrast their fate and deal in life with that of their Malay counterparts in Semenanjung Malaysia. The Malays have endless vocation institutions, double scholarships, training programs and re-training programs. Don’t Sabah’s youth deserve the same, or something similar at the very least?

I’m not one who spares the rod and spoil the child. I believe that man (and woman) should be taught to fish and not spoonfed indiscriminately. In the process of learning fishing, which I assure you might sometimes take a while, one still needs to hand them some fish every now and then.

I’ve worked in Sabah long enough to know that most young Sabahans are not typically those who will end up as ungrateful Mat Rempits and flamboyant Mat Minahs when given an opportunity to improve themselves.

They deserve a bigger role in life than merely providing cheap labor to the capitalists among us.

Hilda has no long term plans for now. She will not be sending any money back home anytime soon either. With her own survival hanging on a delicate balancing act, she will remain as one of the many faceless young Sabahans for the moment, if not forever.

Read more!

House Officers: A Rose By Any Other Name....

We can call these medical graduates housemen, interns or by the acronym H.O. One lady surgeon even calls them slaves. The fact is, house officers are indispensable in Malaysian healthcare.

The day house officers in government hospitals go on strike is the day Malaysian healthcare collapses and comes to a total halt.

There is...a dire need for a system that places an emphasis on accountability and meritocracy. The lying house officer must be brought to book, the incompetent house officer sent back to his books, and the outstanding house officer written in the good books.


House Officers: The Backbone of Malaysian Health

Hypocalcemia in Pregnancy

It was 3am in the morning. A lady at 32-weeks of pregnancy came to the hospital complaining of numbness and very mild weakness over her right hand that was limited to a few fingers. The first house officer who attended to her, Dr. Gua, had no definite diagnosis in mind. She took the routine blood investigations anyhow which included a calcium level. Her calcium level came back as 1.9 which was low. Alarmed and concerned, Dr Gua referred the patient to her obstetric medical officer who was similarly troubled. She too had no inkling of the underlying cause and in turn referred the patient to a fellow medical officer from the department of internal medicine. The trainee physician arrived dutifully in a short while, attended to the patient, asked a few questions and ordered a truckload of blood investigations. The barrage of blood tests included a thyroid function test, liver function test, serum phosphate, serum magnesium, renal function test, serum and urine cortisol amongst others. She was worried over the unexplained severely low calcium level and decided to admit the patient for intravenous calcium gluconate.

Once in the ward, a second house officer reviewed the patient. Dr. Ahmad read through the notes and asked some basic questions. He too, was increasingly worried, but for different reasons.

Here’s why.

The initial blood was taken with a tourniquet that was applied for a pretty long time. Such a method of blood sampling may result in an artificially low calcium level due to physiological changes around the area where the tourniquet was applied. In other words, the pregnant mother did not have low calcium to begin with. Intravenous calcium gluconate is dangerous and could have killed her instantly.

The story does not end here though.

Dr. Ahmad repeated the blood sampling without a tourniquet. The result of the second calcium level was 2.2, which was acceptable in pregnancy due to physiological changes in the blood constituents. His medical officer however, did not think so and again referred to the medical team for further advice. It was decided that the plan to give intravenous calcium gluconate should go on. The mother was started on calcium tablets thereafter. Dr. Ahmad remained unconvinced and suspicious of his superiors’ management throughout. He complied nevertheless.

In retrospect, the pregnant mother presented with symptoms very typical of carpal tunnel syndrome. It was the right timing at 3am, the exact symptoms and in the ideal patient. There was no need for any blood investigations or any possibilities of an impending stroke whatsoever.

House officers and the Quality of Malaysian Healthcare

The public healthcare of Malaysia will rise and fall with the services of the house officers. I do not know about the rest of the world but this is fact for Malaysia.

The first personnel to attend to a newly admitted patient in the ward is usually the house officer. The ill patient who suddenly takes a turn for the worse is usually referred to the house officer on-call. Blood investigations, applications for radiological procedures, referral letters and discharges, and basic clinical procedures are all carried out by the house officers.

Without house officers, much work will not be carried out or would have to fall upon the shoulders of the medical officers.

We can call these medical graduates housemen, interns or by the acronym H.O. One lady surgeon even calls them slaves. The fact is, house officers are indispensable in Malaysian healthcare.

The day house officers in government hospitals go on strike is the day Malaysian healthcare collapses and comes to a total halt.

The Malaysian Medical Association (MMA), when they are not boozing away in the MMA house, has been fighting for the rights and welfare of house officers for decades now. I say aye to more rights and welfare and renumeration for house officers, yet I also know pretty well that we have a very variable and colorful population of house officers in the civil service. Not all of them deserve their basic salary of RM 2137.70 much less their much acclaimed right to greater benefits, higher allowances, more oncall claims and automatic promotion to a U44 grade officer.

I only have the experience to compare Malaysian graduates from local universities to Malaysians who graduated from foreign institutions.

Truth be told, despite all that they say about the low standards of our medical schools, the majority of our local medical graduates fit in fairly well into the local healthcare system. Fitting in is not synonymous with competency and excellence but most of our local graduates nonetheless are able to function in a system they are familiar with.

Granted a chance to work with foreign graduates in a foreign land, I just might be singing a very different tune. However, I am not even for a moment under the delusion that other nations naturally produce more ethical and more knowledgeable medical graduates.

I do know however that in most developed nations, there is a prevailing sense of responsibility and a emphasis on a culture of accountability.

That is something that is sorely lacking in our healthcare services.

The ‘Don’t Know’ House Officer

All doctors do not know something to certain extent. In fact, all doctors will not know anything about something if you prod them hard enough. Personally, I studied pharmacology rigorously like a mad man in medical school and naturally, I take pride in knowing something about drugs and toxins. If someone asked me something about the histological variants of ovarian tumors however, I will reply with nothing less than a stupid blank stare and declare with no shame that gynaecology is not my forte.

There are many house officers who however, seem to know nothing about all things. It’s really anyone’s guess whether this has always been the trend even in the good old days of Tanah Melayu or whether such a dunno tak tau culture is the result of half a century of race-based intake into local medical schools. The NEP policies have given rise to a complacent lifestyle among both Malay and non-Malays students. Why study hard when one has been having things served on a silver platter one’s whole life? Why study hard when one can pass an exam because the marking standards have been lowered to cater to the ‘special children’ with special rights?

House officers from foreign universities are not naturally better though.

The most reasonable and objective statement is to evaluate each house officer as an individual and not from the university one graduates from. We have a great number of lousy, undeserving students entering local universities both public and private institutions and they are not restricted to any particular race. We also have an abundance of mentally-challenged personalities graduating from India, Ukraine, Ireland, Indonesia and China. No doctor should be identified or stigmatized by the university one graduated from. The final competency of any medical student is really all about the person’s own initiative.

Unlike graduates from computer science and social arts and food technology, medical graduates upon completion of their studies are never ready to get up and work. A ‘don’t know anything’ house officer is terrible, but not beyond help. A conducive training environment made up of willing teachers, understanding superiors, supportive nurses and adequate facilities will make a world of a difference.

The ‘Don’t Know, Don’t Care’ House Officer

A forty-something man was admitted for hemorrhagic stroke. After a few days in the ward, he developed pneumonia and required mechanical ventilation. The house officer on-call whom I’ll just name Dr. Chong was entrusted with the task of sampling the patient’s arterial blood gases. He did so, but did not know how to interpret the results. Even so, he did not seek help. At 8 a.m six hours later, the patient died. Postmortem, the notes were reviewed and the results of the blood gases taken before the patient’s death were nothing less than shocking. It showed severe combined respiratory and metabolic acidosis.

Dr Chong is the kind of house officer I categorize as the ‘don’t know, don’t care’ type. These are characters that never fail to baffle me. I wonder what these clowns are doing in the profession of medicine in the first place.

They don’t know, not because they have cerebral palsy or severe mental retardation.

They don’t care, not because it’s not their business, but because they are callous, indifferent or simply uninterested. They appear to hold firm to the belief that ignorance is bliss. No matter what is happening, what instructions were given and how these house officers are reprimanded, their response is always along the policies of ‘don’t know, don’t care’.

“Doctor, patient is in pain…” – Don’t know, don’t care.

“Doctor, patient’s potassium is only 2.6…” – Don’t know, don’t care.

“Doctor, how is my surgery going to be like tomorrow?” – Don’t know, don’t care.

“Doctor, I am having a cough and a fever…” – Don’t know, don’t care.

These house officers are beyond help. As the person battling at the frontline, they do not seem to realize that the things they do and do not do at a certain time can make a big difference to a patient’s outcome. Perhaps they are not truly beyond salvation. Perhaps when one of their own family members die or fall ill, they might turn over a new leave and change for the better.

The ‘Don’t Know, Don’t Care, Bullshit Non-stop’ House Officer

These are the most dangerous and perhaps the most difficult to see through. Some people are born to talk, and then there are those that are born to bullshit. They are not necessarily smart. In fact, those who knew them well and long enough might even suspect them of having mild dyslexia. They are not caring, far from it in fact.

They are however very capable of putting up a face as though they are sweet, empathic and all that’s noble in a doctor’s holy heart.

They slither out of troubles and crises, and I use the word ‘slither’ because these doctors are serpents. Deceitful and cunning, eloquent and loud, these doctors will do anything to save themselves from trouble.

Outright lies, dubious documentation and clinical sandiwara are their practice of the day.

I’m reminded of someone I’ll call Dr. Marvin each time I come across such deceitful doctors.

Dr. Marvin was a graduate from a local private university in Melaka. He’d disappear for hours to have his cigarette session. When confronted about his disappearance from the ward, he would feigned that wide-eyed innocent look, stare you back in the eye like Shrek’s Puss in Boots and exclaimed regretfully that he came across some frail old osteoporotic lady on his way back from the busy clinic who required his assistance climbing the stairs to the second floor. When he failed to turn up for work or oncalls, he would swear on his mother’s grave that his father had a heart attack at home at 6 am in the morning. His father must be a very blessed person, because the senior Marlin has had twelve supposed heart attacks in the preceding two weeks and is still mysteriously alive with no symptoms of heart failure.

Unsurprisingly, these are the house officers most liked and favored by their superiors.

Unlike the don’t know, don’t care house officer, the ‘don’t know, don’t care, bullshit non-stop’ house officer are truly beyond redemption.

The ‘Know Something, Can’t Do Anything’ House Officer

House officers have for far too long been erroneously labeled as being a homogenous group. They might be the lowest in the hierarchy of the administration but they are never all equal and same. Similarly, just because one is a medical officer, specialist or consultant does not mean that the person possesses greater knowledge and more astute clinical acumen.

A young lady at 18 weeks of pregnancy was admitted to the High Dependency Unit for “UTI sepsis”. She was experiencing high fever with shortness of breath. Urine tests showed an ongoing urinary tract infection (UTI). She was treated with antibiotics and hydrated vigorously. Upon completion of the antibiotics, she was swollen all over the body. Her feet were both so puffed up that she couldn’t even wear her own sandals. Fluids were accumulating in her lungs, her abdominal cavity and even around her genitalia.

The consultant obstetrician came and ordered for a full workout to exclude tuberculosis and HIV.

The specialist in turn thought the source of the infection was from her genitalia. The so-called specialist refused to listen to the house officer’s objection and ordered an emergency surgery to incise and drain the ‘labia majora abscess’.

The medical officer complied.

The patient complied too and went under the knife.

There was no abscess.

In the midst of all this stupidity and narrow-mindedness was a house officer name Dr. Mel. Unknown to and unlike the consultant and his team of esteemed specialists and honorable residents, Dr. Mel had sat down and taken a full medical history and performed a complete and thorough physical examination. Dr. Mel had done something none of the obstetricians did. He listened to the young mother’s heart and detected a murmur. Dr. Mel put it all together and opined that the patient’s fever was because of infective endocarditis that had set upon a heart that was defective to begin with. The ongoing generalised edema was the result of heart failure.

He was sure that the obstetricians were wrong. He was sure that the patient had no supposed ‘labia majora abscess’. He was sure that sending the patient for surgery was a dumb and lousy idea. His hands were tight though. In a feudalistic system however, who will listen to a lowly house officer?

His conscience got the better of him in the end. Dr. Mel secretly arranged an echocardiogram for the patient. It showed a mitral valve prolapse with calcified valve leaflets. He restricted the patient’s fluid intake to 500 cc per day. Within a week, the patient was fit to go home. The last I heard, both mother and child were safe.

Summary

No doctors can fully rid themselves of the humbling title of house officer.

At best, every doctor is an ex-house officer whether one is now a consultant, a specialist or a private practitioner. Not all competent house officer ends up as a specialist and similarly, not all specialist was once a competent house office.

The specialist of one discipline may very well be as competent and knowledgeable as a house officer in another discipline. The obstetrician will fumble around when faced with an orthopaedic patient.

Thus, there is no need for arrogance and unnecessary show-off.

There is however, a dire need for a system that places an emphasis on accountability and meritocracy. The lying house officer must be brought to book, the incompetent house officer sent back to his books, and the outstanding house officer written in the good books.

This article was about house officers – their quality and qualities, their ethics regardless of ethnicity.

The contents of this article can easily be extrapolated to medical officers and specialists and consultants in fact.

After all, the consultants of today were the house officers of yesteryears.

For example, the ‘don’t know, don’t care, bullshit non-stop’ HO of 1980 is a neurosurgeon today.

Sigh…..











Read more!

Dr. Rikki

Not a word came from him. Not a movement did he make. The fringes of his blood-stained white coat fluttered in a mini-frenzy as the squeaking, jaded ceiling fans blew his way. Against the sun, his tiny frame casted a long and forceful shadow.


Dr. Rikki

Marked furrows were forming between his tired-looking eyes, his expression slowly transforming into a frown. The teeny hazel eyes strained against the scorching afternoon sun, consigning eventually into a vague squint. In the cramped and crowded medical ward, a neck and white coat was not exactly the ideal outfit. Sweat trickled slowly down his temples, coalescing finally into a pool that drenched his short-sleeved turquoise shirt. His black neck tie was oversized in proportion to his tiny frame, hanging a few inches after his rusted belt buckle.

I stood an arm’s length away, keeping mum, observing this senior doctor in deep, concerted attention. There was no smile upon his pimple-scarred face. He had sparse graying hair that was otherwise trimmed neatly to an inch’s length. This great man must be at least forty years old but it was also possible that years of striving and struggling to be the knowledgeable man he is today have aged him beyond his time.

Scrawny and thin, his hands stayed put in the side pockets of his black pants hanging a distance above his ankle, revealing a pair of holed black socks wretched from years of repetitive wear, wash and tear. There was no definite expression upon this overworked and underpaid Dusun doctor. His bent and hunched posture bore evidence to the years he must have spent silently and lonesomely burning the midnight oil in the noble hope of serving his community one day.

This was a day like any other. A young lady laid in her bed, breathless and exhausted from whatever was rocking her frail, ailing physical body. At the end of her bed stood the pensive doctor, deep in thought and away in a restricted zone of his own.

Not a word came from him. Not a movement did he make. The fringes of his blood-stained white coat fluttered in a mini-frenzy as the squeaking, jaded ceiling fans blew his way. Against the sun, his tiny frame casted a long and forceful shadow.

It is true then, what we medical students were taught in medical school. So much information could be gathered from a mere general inspection of a patient lying before us without the need of touching, pricking or prodding a distressed soul. I wondered what was going through his mind. If only I could get a sneak peak at the long list of probable diagnoses he was conceiving all by himself.

A few other doctors gathered nearby, around the patient, beside her but not at the bed’s end. They were young and well-built, both cheerful and nerdy, talkative and restless. How unbecoming of these junior doctors to be distracted and uninterested even as their consultant physician remained focused and unrelenting over the pitiable young lady.

The consultant brushed aside an irritating sweat droplet that had made its way into his left eye.

It was then that I saw his name: Dr. Rikki, a name that I will remember forevermore. The sound of cymbals and drum roll played ceremoniously in the back of my mind. Behold Dr. Rikki – the first consultant physician of this house officer’s budding career.

It was then that Dr. Sam broke the mellowed ambience. He was one of the three younger doctors surrounding the patient.

“So what do you think Dr. Rikki? Do you think the sodium level in this patient is normal?”

?????

Now, wait a minute. Did that medical officer just posed a daring challenge to his consultant specialist, in a very rude manner nonetheless?

Dr. Rikki remained silent, his authority and wisdom under siege from a subordinate unaware of his rightful position.

“Dr. Rikki, if you don’t know the normal sodium levels, you can refer to the reference figures attached with the blood results,” Dr. Sam persisted, handling Dr. Rikki the patient’s charts.

I almost fell back to the ground in shock. Like a fool, I’ve been looking up to the wrong figure among the crowd. I have mistaken a fellow house officer for a consultant specialist.

The drumroll in my mind ceased abruptly, the cymbals came to a crashing halt.

Dr. Rikki (not his true name) remained interesting and enigmatic though, but mostly for very different reasons. As I worked with him or rather worked him out, I discovered a wealth of incredulous enlightenment, if I were right to deem it as such.

Dr. Rikki was indeed forty something years old. An indigenous local Sabahan, he was sent on MARA scholarship to Indonesia to study medicine, in spite of the fact that he never did apply for medicine or was ever interested in medicine in the first place. He went anyhow, and stayed a duration exceeding twenty years. He failed his first medical school, attempted to return but was pushed by MARA to complete his medical degree in another Indonesian medical school. It was then that he fell in love and married an Indonesian Chinese. The couple would go on to have four children – in Indonesia. As the responsibilities of fatherhood mounted, the then MARA scholar Rikki took an extended break from medical school to raise his brood. A man’s gotta do what a man’s gotta do, even if it was at the expense of Malaysian taxpayers’ money. He remained under MARA scholarship until the day he finally graduated with a medical degree from Indonesia – fifteen years later. He did not immediately return to Sabah though. The newly bestowed Dr. Rikki stayed behind in Indonesia for another few years. Only God Almighty will know what he was doing there.

Over the next few months of working with Dr. Rikki, it was obvious that he was pursuing all things but medicine all those years in Indonesia.

He made ridiculous clinical errors that will go down in hospital records as urban legends.

He discharged a patient with intravenous medications. The bent old lady came back to me with two boxes of bottles and drips but no tablets or pills.

He sent a patient with active tuberculosis home with all the goodies of vitamins, iron and double calcium supplements, but no anti-TB medication.

He started a drip regime for a patient in sepsis: three pints of normal saline and two pints of ceftazidime. What was he thinking, a life-long prevention of melliodosis infection?

A stroke patient was started on tube feeding. Most doctors will start slow say, at 500mls/day. Dr. Rikki started slow too, at 2mls/day.

His English was incredible, in a very absurd manner. Like advance kindergarten teachers, we taught him how to spell A-O-R-T-A and A-S-T-H-M-A, dictating each alphabet to him. Our blood pressure was rising faster the price of oil per barrel in USD.

When a lactating mother assured us she was breastfeeding well, Dr. Rikki scribbled in the notes: Mother says breast is well.

We all need amusement in our daily work, but not when it’s dangerously funny. I thank Dr. Rikki for all that and more.

I do not have any idea where Dr. Rikki is now. It would be interesting to know though. He’s definitely not in the hospital anymore. Rumors are that he left to pursue farming in Papar. Others say he was sent back to medical school (again!).

I may sound judgmental and holier-than-thou in writing the truth about him. Seriously, I don’t blame him for being slow, I blame him for wasting my father’s taxes and for being unwilling to improve and learn on the job despite the repeated chances.

What’s my point in writing this article?

Amongst others, some of which are stating the obvious:

• First impressions are deceiving. I felt like a fool after that first meeting in the ward.

• The BN government has wasted enough of our money handling out scholarships by ethnicity.

• Sabahans won’t necessarily treat Sabahans better. So stop this crap about work permits for Peninsular Malaysians when Filipinos are entering the state in sampan-loads every day.

• Tertiary education is not in the best interest of every person. Some are better off owning a farm in Papar, to sell papayas and become rich.

• Our Ministry of Health is full of hot air each time it speaks about quality control. Dr. Rikki worked for 18 months before the Ministry decided to take remedial action. If he saw just three patients per day, he would have endangered the lives of 3X30X18 = 1620 patients. Any one of them could have been your father and my grandmother.

• Possessing a medical degree is not reflective of anyone’s grey matter. It is true that empty vessels make the most noise, but not always. It is also true that diam-diam ubi berisi, but not always too.

Read more!

SKT 79, so how now?

Sincerity and good manners are relevant only to patients, not to a healthcare system riddled with pride, prejudice, racism and cronyism.

How does one react and behave when the future you’ve been working for is suddenly snatched from you?


SKT 79: so how now?

I checked my SKT today or rather, my friend checked it for me.

Hopeful but not overly, prepared but not for the worst, it was still much of a surprise that I only managed a mere 79 points for my SKT of 2007.

Still doubtful that I was given such a low mark, I rechecked it myself at the office. The young girl in green tudung was friendly and cooperative. Despite the time being very close to lunch hour, she brought out a thick, dog-eared record book. I scanned through the pages, found my name and took a long look at the points.

True enough, just as I had suspected.

I did not get 79 points.

My friend had reported it wrongly.

It was a 78.

The SKT is an acronym for Sasaran Kerja Tahunan. It is an annual evaluation exercise whereby heads of departments or specialists-in-charge grade their subordinates based on a few pre-set criteria on a scale from 0-100. It is very much a subjective and arbitrary means of assessing a doctor’s overall work performance over the preceding one year. More often than not, the final tallied points are hardly reflective of the individual’s capabilities and commitment to one’s job. The lazy doctor who disappears from the ward five times a day and sleeps throughout his on-call may very well end up with the same mark as one who goes the extra mile for one’s patients. Ass-licking and ball-carrying go a long way, to put in as bluntly as possible.

The main significance of the SKT is mostly for doctors who plan to apply for specialty training through the master’s programs conducted by our local universities. In view of recent changes in the external exams for the surgical fields, most doctors have little choice but to pursue their specialty training via the master’s program. A minimum SKT of 85 for three consecutive years is a basic criterion before one is eligible to apply for specialty training in a local master’s program. For the bumiputra doctors, an alternative specialty training program is available through Skim Latihan Akademik Bumiputra (SLAB). For non-bumiputras, we are essentially left at the mercy of our superiors to determine our future, or the lack of it, with one quick stroke of the pen.

Realising the weightage that the SKT plays in one's career, some department heads have set policies that no doctor's SKT should ever be lower than the magic number of 85. As such, every Hisham, Chan and Komaladevi will receive a commendable score regardless of one's actual work performance. It defeats the whole purpose of an annual assessment so I really wonder why anyone should even bother to work hard when ass-kissing will propel one to the top.

With an SKT of 78, my chances for a placement in the local master’s program is essentially nil.

Zilch. Zero. None. Non-existent.

What should I do now?

I can go on the whole night whining like a loser about how the macha who boozed and snoozed on the job got a better mark because he boozed and snoozed with the macha specialist who graded him. I can go on exposing the wrongs committed by this same specialist who graded me, how I stayed behind till the wee hours of the morning cleaning up the mess he created to a bleeding patient. I can write on and on because I’m writing the truth but I won’t.

I need to think think hard and ponder deep.

I need to weigh my options at this juncture.

Righteous anger is still anger. Bitter truth is still bitterness.

“My peace I give to you, peace not as the world give but peace that comes from heaven” – Jesus Christ

I do not think it is easy for anyone to sit down calmly and endure injustice flung into one’s face.

Sincerity and good manners are relevant only to patients, not to a healthcare system riddled with pride, prejudice, racism and cronyism.

How does one react and behave when the future you’ve been working for is suddenly snatched from you?

Shrug…It was never mine to begin with anyway.

I’ll weigh my options.

At this point, I can:
• Sit down and shut up. I can choose to wait for another year or two and hope someone fair and just will accord me the minimal points I need to apply for masters. By the time I am eligible to apply for a masters course, the SLAB products who were once my juniors will be my lecturers. Then again, life is not a race, or so they say…

• Get on my knees and appeal to the kind-hearted boss to re-evaluate me. I’d have to put on a gay smile, speak some niceties, do tip-toe dance or two and hope it’ll soften his callous soul. Think I should do that?

• Join the masters program as a private candidate. Pay RM 20,000 to learn under SLAB lecturers only to be left without a job upon graduation. Not a bad option in fact.

• Forgo my ambition of ever specializing, serve out my compulsory government service and open up a general practice somewhere in Kota Marudu.

• Quit medicine altogether and join a pharmaceutical company or a direct sales scheme.

• Pack my bags and leave for a foreign land and join the fight in a survival of the fittest.

• Commit suicide and hope the racist leaders of Malaysia will learn their lesson. Fat chance that’s gonna happen.

Still thinking. Still pondering.

It’s not easy. It never was.

“My peace I give to you, peace not as the world give but peace that comes from heaven” – Jesus Christ

Guide me Jesus.

Amen.

Read more!

SLAI or SLY?

A popular Malaysian blogger, Ong Kian Ming (soon to be Dr. Ong Kian Ming) who writes regularly for Malaysiakini and educationmalaysia.blogspot.com enquired about the SLAB/SLAI programs. This was my reply to him, which i will share with you all.

SLAB/SLAI: A World Of A Difference


Dear Kian Ming,

Sorry for the late reply.

The link that you attached was not accessible.

Nevertheless, the SLAI program is something recent. UM did not have such a program, at least not when I left UM in 2005. In theory, the SLAI and SLAB programs are both equal and identical.

In practice however, there are marked differences between the two.

A reasonable analogy will be like how the Ministry of Higher Education claims to practise meritocracy in theory but puts in place a very devious mechanism to ensure the continued dominance of the bumiputra Malays.

By its name, it may appear that SLAB is a program that caters to all bumiputras – both Muslims and non-Muslims, Malay and non-Malay bumiputras. A close friend of mine, a Kadazan bumiputra once met up with a senior professor of Universiti Malaya to enquire about her eligibility for the SLAB program and how she can go about applying for the scheme. The senior professor of Public Health, who was also the then Deputy Dean of the Medical Faculty gave a very nebulous answer but essentially told this friend of mine that non-Muslim bumiputras are basically not eligible for the trainee lecturers’ program. I was there personally so my eye-witness account is essentially all I can offer you as solid evidence that the SLAB program itself is a mere smokescreen to ensure Malay supremacy among the academic ranks.

The SLAI program is really something else. It stands for Skim Latihan Akademic IPTA (Institut Pengajian Tinggi Awam). There are no ethnic criteria attached to it but in view that the bumiputras already have SLAB to cater to them, you are very correct to assume that SLAI is therefore in existence to cater for the non-bumiputras.

If at all the SLAI and SLAB programs can ever be comparable to each other, I can only say that both does not emphasize on meritocracy. The few non-bumiputras I know who are currently in the SLAI program were not among the top students in their classes. Apart from that, the terms and conditions after one successfully completes one’s studies under the SLAB/SLAI programs are similar.

This is perhaps where their similarity ends. On closer scrutiny , one can see great discriminative practices between the two programs.

I am only covering the medical fraternity as I do not want to make any misleading statements that may not be true for other fields of knowledge.

For starters, the SLAI program for non-bumiputras or rather non-Malays, are open to all specialties in theory but greatly constrictive in practice. Competitive disciplines and specialties in high demand are very much closed to non-Malays. These include opthalmology, otorhinolaryngology, orthopaedics, general surgery, anaesthesiology, radiology, obstetrics and gynaecology. Non-Malays keen to pursue SLAI training will have to contend with non-clinical fields like the basic sciences (physiology, biochemistry, anatomy), public health, or less competitive clinical disciplines like internal medicine. This is in stark contrast to the overwhelming presence of bumiputra Malays in the SLAB programs for the aforementioned hugely popular surgical disciplines.

The number of successful SLAI candidates pale in comparison to the number of SLAB trainees. If you are interested, you can view the individual departments’ academic staff and compare the number of SLAB to SLAI lecturers currently in the Faculty of Medicine, University of Malaya. This is the link. Assuming the website is updated (it is not!), there are only three non-bumis currently pursuing an academic program under SLAI. The ratio of SLAI:SLAB candidates is therefore easily 1:10. As such, I can’t see how anyone can portray the SLAI program as equal and equivalent to SLAB.

The process of applying for SLAI is also more rigid and stringent. Conversely, there have been many instances where the bumiputra doctors who never even applied for a SLAB placement were simply given an offer to pursue SLAB. More often than not in fact, the bumiputra Malays are given the luxury to take their pick from a few disciplines. One Malay colleague of mine wsa invited to choose between internal medicine, orthopaedics and obstetrics and gynaecology! Such privileges are of course not accorded to the SLAI candidates, who must decide on what they want to pursue when applying for the training program.

As with most other government schemes in Malaysia, the process of entering these academic programs is littered with political elements. Once again, I’m using Universiti Malaya as an example. There is an uncanny overwhelming presence of royalties among the SLAB lecturers and trainee lecturers. We can see this clearly in the departments of orthopaedics, otorhinolaryngology and ophthalmology. The number of academics with preceding Tengku-s is really a cause for suspicion. In addition, there is a great element of family business as well. The daughter and son-in-law of UM’s ex-vice chancellor, Professor Annuar Zaini are both in the SLAB programs of paediatrics and general surgery respectively. As far as the academic records are concerned, they were both merely average students while they were pursuing their basic degrees in UM. A father and daughter team is also currently in the Department of Social and Preventive Medicine. There is nothing improper about any father-daughter team except for the fact that the Professor himself was also the person who processed his daughter's application papers. It is not unlike the corrupt practices of late Zakaria Mat Deros. Sons and daughters of Datuks and other UMNO cronies are also abundant in the SLAB program. The SLAB program is thus one that is lacking in transparency.

I am not sure if there is any solid method to substantiate these allegations except through my personal daily observations and ground knowledge.

A great number of SLAB graduates are currently holding influential positions within the faculty. Generally, their privileges extend beyond the completion of the SLAB program. Some have been promoted to head of departments and professorships, bypassing more experienced and competent lecturers. Most of these SLAB graduates went on to pursue further training overseas on a university scholarship, at the expense of other non-bumi lecturers that joined the academic ranks by merit. This is also the major factor behind the resignation of many non-Malay academics from the university. It remains to be seen whether the privileges of further training and education will be accorded to the SLAI candidates.

My personal opinion about the SLAI program is that it is in reality a sly move by the Higher Education Ministry to appear meritocratic while resuming their racist means of managing Malaysian tertiary education.

I hope I have shed some light on your enquiries about the SLAB/SLAI programs.

Regards.

Read more!

Times I Screwed Up (2)

Like a frozen scene captured on film, the ambience of the moment remains as vivid today as it was then. A crumpled photo of a golden-haired, bearded Jesus lay on the floor, his hands clasped in prayer with loving eyes towards heaven. Tan’s wife had been holding the photo just a while earlier. From the corner of my eye, Tan’s wife stood a metre or two away watching us anxiously in our futile efforts of bringing a dead man back to life. To the medical personnel, he was just another patient. To her, that was her companion in health and sickness, love and war, life and beyond. Tears streamed down her flushed face, each droplet refracted into an array of mini-lucent colors by the golden Sabbath sun rays. Her weeping was tangible but inaudible, silenced within the helter skelter of chaos. Even as Tan laid there in



I Remember


“Can you please come now? I’m really sorry. But I really don’t know what to do. Tan is desaturating with low GCS.”

Like a horror dream, the phone call jolted me from sleep. I rummaged and stared at my clock. It was 5.00 am on a Sunday morning. It took me a while to absorb the reality of the situation. Did my colleague Yati really call to ask for help?My handphone confirmed the phone call. If Yati had indeed called me, then Tan was indeed in distress.

He shouldn’t be, though. There was no reason for him to be in distress, not at all.

Fifty-something year-old Tan was admitted two weeks before that. A Sino-Kadazan from Keningau, his name was fully Chinese yet he spoke no Mandarin or any Chinese dialect. Like most Sino-Kadazans, he was Chinese only by name but not by culture or language. Like most Sabah folks too, he was especially trusting and simple-minded.

Tan was a survivor. He was first admitted three years prior to this for a massive heart attack. From the medical records, his heart stopped beating for almost ten minutes. Most patients do not survive asystole and usually even if they do, it is not without severe significant brain damage. Miraculously, Tan survived that life-threatening episode and his heart started beating at a normal rate and rhythm again. He did not escape unscathed. He suffered a stroke during the resuscitative process which left him paralysed on the left side of his body.

Even so, Tan made a gradual and almost complete recovery to regain function of his body. Within a year of the heart attack and stroke, he was back in his estate, tapping rubber nonchalantly in the company of his wife. He was a little sluggish in his movements but he got by nonetheless. Where help was needed, his loyal lady saw to his needs. Life went on for the ageing couple. They had children who were working in the city but were contented in the humble nest they had built back in Keningau.

Everything was fine and quiet and blissful until Tan fell while working in his estate one rainy dawn.

He was admitted for surgical management of a broken left hip bone. We traced his records and were amazed that he pulled through a massive cardiac event with minimal functional impairment. The medical and anaesthetic teams reviewed him and cleared him for surgery.

Yati and I were both house officers back then. She was a graduate from Universiti Islam Antarabangsa (UIA) with wealthy parents well-connected to both UMNO and Anwar’s PKR. We had worked well in our previous postings and had cooperated effectively in the management of most of our patients. She was the first to attend to Tan when he was admitted.

Tan came to my attention when he first complained of difficulty in passing urine. I asked a few questions and looked at his charts. He was also constipated and nauseous. He was on morphine for pain relief. The culprit was immediately obvious. I struck off the morphine from his charts, put him on laxatives and assured him that the urinary retention and constipation will soon come to pass. I was reluctant to insert a urinary catheter despite the insistence of the staff nurses. As far as the staff nurses were concerned, all they want is one less complaining patient. From a doctor’s point of view, everything is about the possible risks against benefits to the patients. In Tan’s case, the underlying reason for his problems was obvious and there was no reason to put him on a urinary catheter.

I left for the clinics. I returned two hours later.

Unknown to me, in my absence, the staff nurses had persuaded another house officer to put Tan on a urinary catheter. I was less than amused but did not pursue the matter further.

Tan was scheduled for surgery soon. An outbreak of a fungal infection over the planned surgical site however prevented us from performing surgery until the infection has cleared.

One week later, the skin infection showed little signs of imminent recovery. Unsurprisingly, Tan developed a urinary infection due to the indwelling catheter. I started antibiotics and tried to remove the catheter but it was stuck, simply stuck. The balloon that held the catheter in place would not deflate. It was adamant and unrelenting despite all our measures. We referred to the urology team for assistance. The urology medical officer, a UKM graduate took three days to come to attend to Tan. Under ultrasound guidance, he punctured the balloon of the urinary catheter and successfully removed it. It only took fifteen minutes.

Tan was fine again, or so I thought.

The night before Yati’s call, I had checked on Tan, just six hours prior to her SOS call. Tan was well and cheerful and even bade me good night. His wife had just given him a new hair cut. The ward was too stuffy, warm and humid that Tan had opted for an army crew cut. He looked younger and definitely much neater in his new crop. He looked like a bald version of Phua Chu Kang, only a little greyer and wrinkled.

I will never forget the scene that greeted me that morning when I reached the ward. Tan was barely conscious. In fact, he was barely breathing. He was running a fever of 42 degrees. His oxygen saturation was only 86% on high flow oxygen. Apart from the oxygen supplement, little else was done for him since the time he deteriorated. In her panic of the sudden and unexpected downturn of Tan, Yati had somehow forgotten basic resuscitative measures. It didn’t help that the orthopaedic registrar on-call was incompetent and irresponsible.

Personally, I was outraged and furious but that was not the time for a blame game. Amidst the need to rush and the urge to yell, a list of probable diagnoses raced through my mind. Tan’s blood pressure was low - it could have been another heart attack. He was breathing but not responding – it could have been a stroke – an infarct or a bleed or something like that. It may be a deep vein thrombosis with migration to the lungs. It could be a fat embolism from his long bone fracture. It could have been respiratory failure from orthostatic pneumonia, if that was possible.

We inserted lines and tubes and a new urinary catheter. That was when the truth surfaced. No urine flowed into the catheter or rather, it was not urine. It was pus, frank pus – thick, foul-smelling, green-colored fluid.

It was not a heart attack or stroke or any embolism. It was a simple urinary tract infection that had set in from the catheter. Despite his apparent general wellness, Tan had been increasingly ill all these while with pus forming in his urine, his bladder and up to his kidneys converging finally as pyelonephritis and full blown sepsis. By now, all our efforts were in vain, like a chase after the wind.

We commenced CPR soon after. Like a frozen scene captured on film, the ambience of the moment remains as vivid today as it was then. A crumpled photo of a golden-haired, bearded Jesus lay on the floor, his hands clasped in prayer with loving eyes towards heaven. Tan’s wife had been holding the photo just a while earlier. From the corner of my eye, Tan’s wife stood a metre or two away watching us anxiously in our futile efforts of bringing a dead man back to life. To the medical personnel, he was just another patient. To her, that was her companion in health and sickness, love and war, life and beyond. Tears streamed down her flushed face, each droplet refracted into an array of mini-lucent colors by the golden Sabbath sun rays. Her weeping was tangible but inaudible, silenced within the helter skelter of chaos. Even as Tan laid there in lifeless bliss and heavenly awareness, my thoughts were tumultuous with troubling images of an elderly lady wandering alone in a wide and misty rubber estate. Beneath my apparent energy and vigor, I was in fact very numbed and sore within and without.

Lying there was a patient who once conquered a stroke and a massive heart attack. He was now losing a battle to a urinary tract infection. Such irony.

Tan died two hours later, after we exhausted our armamentarium of inotropes, atropine and cardiac defibrillator and maximum ventilator settings.

Throughout the whole episode, only the two of us then house officers were at the forefront. The specialists came, took a peek, shook their heads, gave a grin and left. The medical officers came and had no clue what was going on.


Tan didn’t die however because of incompetent medical officers and uncaring surgeons.

He died from neglect – and that would never happen if I as a house officer then were more vigilant.

Read more!

News Round-up

News Round-Up.

Of late, this web log have taken on a more personal note, publishing stories about me, myself and I, when so much else is happening throughout the world.

I don’t know about the rest of you out there but I haven’t consistently read the mainstream papers for almost two years now. I am not too willing to pay RM 1.80 for The Star or the New Straits Times over here in Sabah, especially not on a daily basis and even more, for a package of well-edited lies. I rely on Raja Petra Kamarudin’s Malaysia-today for my daily updates. It has served me well thus far.

It’s been more than a month now since the so-called political tsunami of Malaysia. Those among us wishing and itching for change must be getting pretty impatient by now. I don’t know. I’m based in Sabah, the bluest of the bluest BN state. Things haven’t changed much for me and certainly not for most of the local Sabahans. The rare times I do read the news, it all sounds so yesterday.

Racist remarks teeming with tones of Malay supremacy are still very much the norm. The latest is from the crown prince of Kelantan, one Tengku Faris. The feedback and backlash from the Malaysian society in general seemed pretty pale when compared to the backlash in response to similar remarks by the UMNO bohemians. The most firm-worded statement had to come from Karpal Singh, who remarked that Tengku Faris’ remarks bordered on sedition. The relative silence from the Malaysian society especially the Malay politicians is a testimony of the prevailing cloud of feudalism among Malaysians. Just because a racist remark came from a human with so-called royal blood doesn’t make it any less racist and rude. We all bleed red and breathe air and rot to nothing after we’re dead. Turds smell like turds be it whether they came from ‘commoners’ like us or ‘royalties’ like this Tengku Faris fellow. Call a spade a spade and call a turd a turd, even when it’s a royal turd.

Crime is still prevalent. I don’t know about the police’s response and attitude to it though. Personally, I feel that the cops of Sabahland are much more courteous and committed to their duty. A friend’s house was broken in juts two days ago. It was a well-planned heist with the principal targets being his high-end laptop and other costly gadgets. The Sabah cops recovered his belongings within a day and arrested all the suspects who turned out to be my friend’s next door neighbours. The Sabah police force also made a remarkable breakthrough in the recent abduction of a 22-year-old Universiti Malaysia Sabah (UMS) student. Both suspects were caught but not before the young lady victim was allegedly sexually assaulted. The arrest of both suspects was only possible with effective communication between the police teams across the state. One interesting point to note in this case of abduction is the fact that the abduction was witnessed by the four friends of the victim. These fiends however, waited two hours before lodging a police report, by the time which the victim was already midway on a terror ride from Likas to Keningau.

It is really mind-boggling why four university students waited for two hours before making a police report on her abduction. Are we producing graduates that are so stoopid and dumb and retarded these days? What in the world were they thinking?

Speaking of UMS, I wonder if Malaysian parents are aware of what institution their children are entering? To many Sabahans, UMS is their pride and forte. The university is supposed to be a reward of sorts for Sabahans’ undying support for the BN regime. After more than a decade in operation, UMS has turned out to be yet another NEP factory. In fact, it is so very pathetic that it can’t even train its own NEP products. The SLAB program for UMS is apparently held in a twinning effort with UM, UKM. Closer to the medical fraternity, some have renamed that the Medical Faculty of UMS as University Myanmar Sabah. It’s really a more appropriate name in fact. Most of its medical lecturers are Burmese. I have nothing against persons of Burmese origin. Some of my own lecturers back in UM were Burmese and some were excellent teachers. Something is terribly wrong however, when most of the lecturers are foreigners from Burma and the Middle Eastern states of Iraq and Egypt. It simply means that UMS was never ready to start a medical school in the first place. There was a time when these Burmese lecturers-surgeons were allowed to operate in the hospital. Except for a few minor surgical procedures, ALL of the other patients died post-operatively – mostly from poor surgical techniques or post-operative neglect. I really pity Sabahans in this respect. They came with high hopes but left with a corpse to bring home. Realising the exceptionally high rate of perioperative mortality among the Burmese surgeons, the Surgical Head of Department decided to put his foot down and cease the daily slaughter of innocent Sabahans. The Burmese surgeons are still operating though, but usually under supervision. Note the emphasis on ‘usually’ as opposed to ‘always’.

Apart from quality, UMS is a slaughterhouse in its own right. Located in Likas, an area densely populated by UMNO’s Project IC citizens, I have lost count on how many UMS students have been victims of violent crime since the day I started working in Sabah’s healthcare.

The Sabah Chief Minister has proudly proclaimed that the BN state government will be building more detention centers to house illegal immigrants. It simply means that more of your money and my money will be used to raise these Filipino and Indonesian children so that they can grow enough lean meat to rob our houses later on.

Tenaganita’s Irene Fernandez and other human rights advocates insist that no immigrant or refugee should be stigmatized and blamed for the increasing crime in Malaysia. I beg to differ. Common sense must always prevail over emotions and personal beliefs. Are Filipinos and Indonesians in Sabah more prone to commit crime than the local population? Facts and figures and news reports may lie and bluff but the harrowing tales and scary accounts of the victims do not. I feel Malaysians should really keep a lid about the human rights of Filipino and Indonesian migrants and re-focus on defending the sovereignty of our borders and seas instead.


I don’t get many readers, if at all from the Philippines but seriously I hope one or two of them will read this article. The population of Philippines has risen to a massive 88 million according the latest Filipino census. This explosive figure is alarming the Filipino government especially more so since the nation is facing a shortage of rice and other essential items. Nevertheless, the predominant Catholic nation remains obstinate on the use of contraceptive techniques. In a nutshell, they are more fearful of angering the Pope than sending a million children to death by hunger.

While the Filipinos have their hands full attenuating hunger and a bulging population, the Pope himself is no less busy over in the United States. He is still attempting to downplay the prevalence of paedophilia among Catholic priests to the extent of defending an Archbishop who defended his church’s paedophilic priests.

Humans are really funny and stupid at times. We put our faith in man and men in religious robes instead of God almighty who created the heavens and the earth and all within it. To me, all humans are prone to temptation and failure.

We’re all turds in our own ways and to varying degrees. We cannot pretend that we’re not turds, not even when we’re dressed in fancy flowing religious robes.


Read more!