Monday, June 12, 2017

Prudent, strategic planning required for medical housemanship programme

It is stereotypical of Asian parents to dream of the day when their child dons the white doctor’s coat or the green surgeon’s scrubs. In fact, there are plenty of opportunities for one aspiring to be a medical doctor in Malaysia.

Over the years, Malaysia has experienced a boom in the number of medical programmes offered by private higher education institutions in order to cater for this demand.  Parents typically invest a hefty sum into a child’s medical education, which would take 4 to 5 years to complete. From just one college (namely, the Penang Medical College) in 2001 to 11 private institutions in 2014, the number of medical graduates from private institutions entering the workforce is 26 times more than what it used to be in 2001. Those who did not enrol in local institutions may opt to study abroad in one of the 310 recognised foreign medical institutions, some of which have lower entry requirements than local institutions. The sharp surge in the numbers of medical graduates seeking housemanship positions has caused a glut in the public system. In 2015, Malaysian Medical Council provisionally registered 5,147 medical practitioners; only 4,121 housemen having completed and vacated the local positions in the same year.

In a recent interview, Deputy Health Minister Dr Hilmi Yahaya stated that out of a total of 10,835 housemen placed in 44 teaching hospitals and Royal Military Hospitals, only 48.6% medical graduates who went through Public Service Commission interview in 2016 obtained a place[1]. Meanwhile, the Health Minister Dr Subramaniam conceded that the waiting time forhousemanship placement was between 6 to 9 months.[2] This prolonged wait caused anxiety and stress to the housemen, as they were left with no means of income and risked losing touch with the knowledge and skills acquired during their years of study.

Since 2008, the duration of the housemanship programme has increased from one year to 2 years. Now, housemen are required to cover 6 disciplines for their postings, namely Internal Medicine, Paediatrics, Surgery, Obstetrics and Gynaecology, Orthopaedics and Emergency Medicine (or 3 alternative choices of discipline). The total number and the turnover rate of house officer positions are determinants for a fresh houseman to secure a place in one of the training hospitals. On the other hand, the number of experienced specialists who are willing and able to supervise the house officers determines the quality of the housemanship programme.

Another difficulty lies in getting sufficient numbers of available specialists in each discipline. Within ‘Emergency Medicine’, MOH has only 139 specialists, and another 3 core discipline areas have less than 250 specialists each[3]. If one were to divide the aforementioned total number of housemen by 6 postings, there would be 1806 housemen on average seeking a placement in a certain discipline at any one point in time. Even if 100 specialists from a particular discipline enlisted as a mentor, he or she would have to supervise a group of 18 housemen on average. With such constrained resources, how could the training quality be good and sufficient under such circumstances? A study done in 2012 by the MOH further confirmed that in 48.4% of all cases, one mentor had to take on 6 mentees and above[4]. There were even cases of over 20 mentees to 1 mentor!

The ongoing ‘brain drain’ of specialists to the private sector and foreign countries is yet another issue contributing to the shortage of experienced specialists and consequently, poorer quality of training. It was found that between 2009 and 2013, about one-third of housemen reported to have extended their housemanship training at least once[5] ; 55% due to incompetence and the remaining 45% due to disciplinary issues. These “extensions” caused a bottleneck to the placement system within the training hospitals. Coupled with the large influx of incoming medical graduates over the recent decade, the training hospitals are becoming even more bloated and simply cannot catch up with the pace.

While the housemanship bottleneck issue cannot be solved overnight, policymakers should be more prudent in planning to anticipate the possible issues and prevent the situation from worsening. We recommend the following measures: Firstly, MOH should train more specialists and retain them in public sector. Besides that, MOH should also plan and design the housemanship programme better, especially to incentivise specialists to become mentors. In broader terms, the government should work with private sector hospitals, providing the latter with incentives to train housemen while sharing the cost burden of training. Finally, the MMC needs to have tighter regulations of local private and overseas medical education institutions to ensure medical graduates they produced are of desirable quality and not quantity.

Given that housemanship training is the bedrock of good skills and professional development for medical officers, government has to ensure that medical graduates receive proper skills training and have an overall satisfying experience during their housemanship period. After all,housemanship training is an important quality safeguard of the provision of medical services to the general public.

[1] “More slots at training hospitals opening up for housemen”, The Star, 15 March 2017
[2] Hashini Kavishtri Kannan, “Med students told: Don't work illegally, wait for housemanpostings”, New Straits Times, 3 August 2016
[3] National Specialist Register, valid as of 24 Feb 2017
[4] Ang K.T. et al., “Mentoring Junior Doctors in Public Sector Hospitals, Malaysia”, Institute for Health Management, 2012

[5] Norrina J. et al., “Housemen Extension: The Concern of All”, Institute for Health Management, 2014

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