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Berita Akademi

Title: Berita Akademi - September 2013
Date: 01-Sep-2013
Description: VOL. 21 No. 4

Table of Contents

 

 

 

 

 


Message from the Master
Dr Chang Keng Wee

Undergraduate Medical Education

Dear Colleagues and Friends,

Much has been said in recent months regarding the quality of our medical graduates with the many medical schools in our shores with very varied standards. With all this rhetoric, we must ask ourselves, as a medical profession, what have we done about it? Other than imposing a five year moratorium on issuing new licenses for new medical schools which expires on 30th April 2016, no other concrete proposals for improving standards have come forth. One need to analyze the root cause of this problem before any solution can be propounded.

There are 33 medical schools in operation with 49 programs. In the year 2012, there were 4,086 new doctors given provisional registration by the Malaysian Medical Council. The obvious question is - are there enough qualified lecturers for these many medical schools. Many private medical schools are dependent on overseas lecturers. Some of them do not possess recognised postgraduate qualifications for registration in the National Specialist Register. The ideal ratio of lecturer to student is 1:6-8 for preclinical students and 1:4 for the clinical years. Clinical lecturers should be in active practice, providing service in our public hospitals to be effective teachers. One wonders whether the Ministry of Education and the Malaysian Medical Council are monitoring these schools to ensure that the ratio is maintained.

An internal study by the Institute for Health System Research, Ministry of Health, from 2009 to 2011 had shown that 32% of house officers who were extended due to poor work performance did not possess the minimum STPM and A level scores as specified by the MMC. Of doubt, are also those universities/university colleges that offer one year matriculation courses with direct entry into their medical programs based on internal non-standardized examinations. It is imperative that strict enforcement be done to ensure compliance by those private medical schools flouting the ruling. Furthermore, results from one year internal matriculation courses should not be accepted by the MMC as criteria for entry.

Approval and continued licensing of private medical schools must be based on strict objective criteria and not on subjective impressions of the MMC inspectors.

We strongly urge the MMC and the Ministry of Education to strictly monitor all private medical schools and ensure strict enforcement of all criteria to maintain registration, to ensure standards that are recognized internationally are upheld.

We continue to talk of Healthcare Performance Excellence; but we forget that we must ensure that the medical schools responsible for producing these young doctors provide proper medical education of international standard to them to meet the expectations of a 21st century doctor.

Postgraduate Medical Subspecialty Training

We have an established postgraduate training program under the Universities and Conjoint Board. However, subspecialty training has not been regularized with each institution having its own program. We propose the establishment of a National Subspecialty Training Board under the auspices of the MMC. A standard curriculum with expected attained competencies prior to being awarded the Certificate of Completion of Training is very much required. The Academy of Medicine of Malaysia is in a good position to assist in this as its membership transcends boundaries; be they from the Ministry of Health, the Universities or the private sector. The Board shall comprise the Training Committee and Examinations Committee.

The Training Committee shall look after curriculum, accreditation of trainers and training centers, as well as monitoring the trainees' e-portfolio. The Examinations Committee shall ensure that our candidates attain a standard that is recognized internationally. For this, we at the Academy of Medicine are working closely with overseas Royal Colleges to quality assure our programs as well as be involved in the assessment.

We are also looking into Advanced Training Fellowships where our trainees can enter a higher specialist training programme in the UK or Ireland in Year 2 or 3 of their subspecialty training; into a focused area of particular interest to the trainee. For this to bear fruition, it requires the co-operation of the Ministry of Health, the Universities and the Academy of Medicine.

As I shall be demitting office as Master after this year's AGM in September, I would like to take this opportunity to thank members, council and secretariat staff for your support and encouragement.

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Inaugural T J Danaraj Oration
by Tan Sri Dr Mohd Ismail Merican
at T J Danaraj Auditorium, Faculty of Medicine, University of Malaya on 10th June 2013

Let me begin by thanking the Academy of Medicine of Malaysia for inviting me to speak at the Inaugural T J Danaraj Oration. It is indeed a great honour for me to stand here and pay homage, through the oration, to one of our most influential, admired and respected medical educator.

To state that Tan Sri T J Danaraj is a medical educator would be incomplete. He was more than that. He was a devoted teacher, an outstanding clinician and a caring human being. His world revolved around his students.

Thamboo John Danaraj or TJD, was born in Perak on 1st Feb 1914. He graduated from King Edward VII College of Medicine in Singapore, in 1938.

He was the Dean of Faculty of Medicine of University of Malaya in Singapore in 1960 but was persuaded to assume the role of Dean of Faculty of Medicine, University of Malaya in Kuala Lumpur in 1962. He was hesitant at first as he felt he had much to do in Singapore but the challenge to start a new medical school from scratch in Kuala Lumpur was too tempting for TJD to refuse. He was excited about infusing the new medical school with his own ideas and creativity, including having its own teaching hospital.

From day one on the new job, he was on his feet, darting across the evolving administrative offices, the pre-clinical and clinical departments, the multidiscipline laboratories, wards, lecture theatres, hospital site, checking drains, toilets, floor ceilings, just to make sure everything is in place for the smooth delivery of the school and hospital, with no miscarriages or prolonged labour. He was a man in a hurry. He wanted to start the training of doctors as soon as possible and helped overcome the severe shortage of doctors in this country. There were already 40 eager and apprehensive students waiting to savour the intricacies of Danaraj's medical course. The curriculum was planned, based on the philosophy that medicine is not only the art of healing but also the art of prevention, healing and rehabilitating the patient and lengthening the span of his productive years, to quote Prof Dr H O Wong in the book "T J Danaraj: Doctor & Teacher Extraordinaire'.

Thanks to TJD's tireless efforts, the then Deputy Prime Minister YAB Tun Abdul Razak officiated the opening of the Faculty of Medicine in Kuala Lumpur on 2nd August 1965 and laid the foundation stone for University Hospital. University Malaya Medical Centre, as it is now called, is beyond recognition, with major and colourful horizontal and vertical extensions, to accommodate the extensive demands of the health service. For those of us who have been trained at the original University Hospital, we can't help but feel nostalgic and sentimental that the building that once witnessed our humble beginnings as a student and doctor, complete with our diagnostic fumbles and tumbles and our daily nerve–wrecking clinical encounters with TJD, has been transformed, to keep up with the times and progress in Medicine, and there is little we can do about it.

But there is something that we all can do, and that is to preserve T J Danaraj's legacy of excellence in medical education and producing doctors of high calibre.

Some of you may wonder why the title of my talk today sounds whimsical and strange: 'Dancing with my patient: A recipe for perfection?' Let me explain.

The Dance theory deals with anatomical movements (such as foot-work, hand-work etc.), as well as partner interactions. It explores the physical, mental, emotional aspects of dance as a medium of human expression and interaction. Dancing may also be regarded as a form of nonverbal communication between fellow human beings and their behaviour patterns towards one another.

So, now you may begin to appreciate how dancing can be related to medical practice where the interaction between the doctor and his or her patient has to be mutually respected and anticipated to avoid missteps and misunderstanding, and achieve the maximum effect of the interaction.

To quote an Indian Proverb "To watch us dance is to hear our hearts speak".

Some aspects of training to be a good dancer is much like training to be a good doctor.

One needs to know the body well and learn the steps and techniques to get the best out of the patient. As with dancing, one needs to be able to embrace the fluidity of the interaction with the other party, perfect the synchrony and understanding of each other so as not to step on each other's toes, literally and figuratively. It takes two to tango, how true for a doctor and his patient.

Like the good dancer, the good doctor needs to be confident, well-trained, prepared to work as a team, emulate the best, know his limitations, perfect his art, be physically and mentally fit and embrace a healthy lifestyle.

But what is the recipe for perfection for these two vocations that will determine the outcome of the whole encounter? Bad dancing will cause blistered feet, red faces, clumsy encounters, rejection and even physical violence. In comparison, bad doctoring can cause blistered egos, literally red faces, adverse outcomes, mistrust and sometimes, yes, even physical mishaps. The only difference is that in Medicine, we are dealing with more than people's ego. We are dealing with people's lives.

My talk, today, is all about medical education and how we can perfect the art and science of medical education and practice. TJD spent most of his working life on medical education. He in fact, published a book simply called 'ME in Malaysia: Development & Problems", 25 years ago. The last chapter in that book, aptly titled "Medicine as a Life Course", included a quote from Sir William Osler's valedictory address given on 14th April 1905 to his students at McGill University: "The hardest conviction to get into the mind of a beginner is that the education upon which he is engaged is not a college course, not a medical course, but a life course, for which the work of few years under teachers is but a preparation".

TJD steadfastly held to the belief that the education of a doctor is a continuous process: extending seamlessly over a lifetime; from undergraduate to postgraduate education, supported and embellished by CPD activities and self-education.

It has been 25 years since the book was published. Have things changed? Have we embraced the ideals and principles expounded by TJD?

Taking the cue from T J Danaraj, medical education is not only about undergraduate medical training. It also encompasses:

  • Graduate clinical training during which the fresh doctor acquires general clinical experience
  • Specialist training during which the more experienced doctors are equipped with specific knowledge and skills in his or her chosen specialty, and
  • Self-learning including CPD to keep doctors, experienced or otherwise, in step with current developments.

Let me begin with Undergraduate training

We now live in a tumultuous world; a world where medical education is considered a lucrative business opportunity. It used to be a calling; a professional responsibility and a desire to produce the best of the best to help the ill and the infirmed. Now, medical education is promoted, not just by professionals but by politicians and businessmen, some with good intentions; others with dubious contentions.

The WHO has set a doctor: population ratio 1: 600 for Malaysia. In 2010, we had a ratio of 1: 800, with 33,000 doctors. Looking at current production, we would achieve a doctor: population ratio of 1: 600 by 2015, with 50,000 doctors serving a population of just over 30 million.

This would be wonderful news if we are assured that the doctors we produce are doctors of high calibre. Doctors, who, like the good dancers, can understand and respond to the needs of their patients without stepping on their toes. Question is: Have we succeeded in doing this? Are we on the right track?

The United Kingdom, with a population of 63 million, has 32 Medical Schools. Australia, with a population of 23 million, has 18 Medical Schools and Canada with a population of 34 million has 17 medical schools. In 2009, the number of medical graduates / 100,000 population in UK was 9.3 (5,600 graduates); Australia had a figure of 10.8 (2,500 graduates) and Canada 7 (2,400 graduates).

Malaysia, with a population of 29 million, has currently a whopping 33 medical schools (11 public and 22 private). In 2009, the number of medical graduates per 100,000 population is 11.2 and in the year 2012, it was 14.6 (4,067 graduates).

So, we are producing more doctors than the developed countries. Perhaps, this is justified, given the fact that we started late and we need more doctors to cater for the needs of our population. But are we too much in a hurry? Are we compromising quality to get the quantity we think we need? In the countries I alluded to earlier, their medical schools evolve over an extended period of time. In Malaysia, medical schools appear in droves. Almost every state and every political party in Malaysia wants a medical school. If you were to examine some of these medical schools, you may wonder how or why they exist in the first place.

Many of our local entrepreneurs also find it tempting to start medical schools with ambitious projections and trajectories only to realise that they cannot keep up with the competition. Some get dictated by more established international partners whom they have unwittingly roped in to supposedly boost their image and standing. I think we have been too forgiving or too naïve to think that we can achieve so much with so few.

The Government has been kind and have offered opportunities for those who wish to invest in medical education. But that is not enough. The Government must enforce as well as assist in ensuring that standards are complied with. In fact, they must insist on it. Medical schools must have sufficient financial and academic resources and adequate facilities before taking up lavish advertisements in local and foreign newspapers to attract students. Browsing through some of these advertisements, one would assume that the advertised schools have a 5-star rating but when students get enrolled, they see stars, just like when they get a blow to their heads. There may be a difference between public and private medical schools. While the former has few worries about resources and funding, the latter have challenges in ensuring the return on investment. We know that many are struggling to get good teachers. Some may have excellent facilities but fall short of having a resident team of experienced teachers with the passion and substance to teach.

I read with concern that the Malaysian Medical Council (MMC) is still expanding this overcrowded list rather than restricting it. More international Universities are being recognised despite the many local ones that we already have. If all programmes, including the 373 medical degrees from 14 countries (local & overseas) recognised by MMC, are enforced, we can expect a total of 6,030 graduates per year.

In 2010, the MMC took cognisant of the phenomenal number of foreign Universities already recognised. Members were not sure how many of these foreign universities still exist or conform to our standards. To revisit these foreign universities is not practical and expensive. It was then decided that it would be better to have a common examination for all medical graduates, obviating the need for MMC to go on expensive trips overseas just to recognise or revalidate foreign medical schools. Besides, our students can then get to choose to go anywhere to pursue their dreams and be prepared to sit for the common examination conducted locally prior to being formally registered in this country. It would also lessen the element of subjectivity of assessment by visiting team members, who may fall into the category of either hawks or doves, which could influence the final decision. The objectivity of a formal licensing examination may minimise this subjectivity.

The benefits of this licensing examination would surely appease the authorities and the public as they will be assured that doctors practicing in this country would have fulfilled the minimum requirements to enter into apprenticeship training to get them into shape. At present, those with poor basic knowledge, limited clinical exposure, and questionable interest for the profession are left gasping for air, with many requiring resuscitation. Our trainers suffer collateral damage and some resort to taking anxiolytics or anti-depressants to maintain their composure and sanity dealing with a motley group of house-officers with diverse backgrounds.

Unfortunately, this decision to have the common examination, although agreed upon during the tenure of the then President of MMC, did not see the light of day and has in fact, been shelved. Why you may ask? I gather from my colleagues in MMC that it was a political decision. Obviously, it has more to do with fear and apprehension rather than standards and quality. Surely, having the examination would have been a good move to weed out weak, incompetent and clueless doctors and blacklist medical schools incapable of producing safe and competent doctors.

But our detractors prefer to use arguments based on sentiments and emotions rather than quality and excellence. So, they settle for mediocrity rather than meritocracy. They would rather save faces instead of saving lives. They seem to trivialise the fact that doctors deal with people's lives.

I would urge the MMC to revisit this decision. Perhaps, they will. But at the end of the day, it would turn out to be a tussle between political and professional considerations. It is my hope that the MMC will brandish the kind of authority associated with medical councils in developed countries like Great Britain and Australia. Let us rise above the fray and be convincing with good arguments. I always believe that one can support or destroy almost any argument with facts and statistics. To quote Christopher Buckley "That's the beauty of argument, if you argue correctly, you're never wrong."

'Great leaders are almost always great simplifiers, who can cut through argument, debate and doubt, to offer a solution everybody can understand' to quote Colin Powell.

Medical students need clinical teaching in hospitals. That is why TJD, in his wisdom, insisted on a teaching hospital to develop concurrently with the first medical school in Malaysia. I must say that at present, the clinical training of our medical students is far from perfect. While the Ministry of Health (MOH) offers training places to students from private universities and public ones that do not have teaching hospitals, there is a mismatch between good training places and students. The allocation of hospitals and training places also varies. While some medical schools get well-equipped hospitals, others get hospitals with limited facilities and run-down or non-functioning operating theatres.

What is the recipe for perfection?

  1. Government must immediately impose a 10-year moratorium on the setting up of new medical schools in this country, and enforcing this without fear or favour.
  2. Medical schools must make substantial investments to have in place an impeccable academic team, provisions for training and retraining of academic staff, and research.
  3. The present crop of medical schools should be right-sized and smaller players be merged to avoid the fallacy of having too many offering too little.
  4. The Government should provide support for private medical schools, with genuine intentions, sizeable investments and a good track record of providing quality education.
  5. MOH should forge partnerships with selected private medical schools to optimise each other's resources and enhance the level of care to the rakyat. This can be done by allowing credible private medical schools with sufficient resources to 'adopt' district hospitals that have yet to offer resident specialist services to the local community. At present, MOH offer such services fortnightly, monthly or even longer. As an incentive, students from the respective universities will have first access to patients in hospitals they have adopted. The costs of ensuring adequate resources for both teaching and services can be shared between the two parties.
  6. The proposal to have a common medical examination for all graduates before they can be registered to practise in Malaysia is worth revisiting.

Graduate Clinical Training (Housemanship training)

Housemanship can be regarded as an extension of the doctors' basic medical education. The two-year posting is to ensure that new medical graduates gain the appropriate knowledge, skills and experience to conform to the standards of the profession and become reliable and independent medical practitioners.

During housemanship training, they need to grasp and retain new knowledge and skills, learn how to make appropriate clinical decisions, work under pressure, perform arduous clinical tasks and face challenging moments in their career. By the time they finish, they are expected to confidently hold the reigns of clinical judgment and be trusted in making decisions that will determine whether a patient lives or die.

As our medical graduates come from various medical institutions their training may be different and the quality of medical graduates may also vary. Therefore, housemanship training is important in nurturing and guiding them.

As future doctors, housemen have a heavy responsibility. They are expected to put aside their personal interests and make their patients, their prime concern. A formal evaluation exercise of the performance of our house officers will make us more objective, discerning and confident with our proclamations and remove all doubts regarding our presumed prejudices.

But there is a major challenge. We do not have enough training centres. We now have 42 training hospitals, from both MOH and the public Universities. Training hospitals are accredited based on case mix, workload, trainers and facilities. How many training places can each training hospital has? No one is sure. In fact, the number used by MOH is actually exaggerated as it takes into account the number of all specialists in these hospitals including pathologists and radiologists who do not provide direct houseman training. The six departments will therefore, end up accommodating some 30 housemen each. Surely, this is not a perfect way of training them. The introduction of the shift system since 2011, makes matters worse as these numbers become even more unwieldy. Many of these housemen wilt under pressure while some become calculative and acutely conscious of when to lay down their tools. They prefer looking at their watches instead of their workload to gauge the intensity of their training.

Workload for housemen is now much less, working hours are shorter, fewer cases are clerked, even fewer procedures are being conducted, all of which have adversely affected their training, not to mention the paucity of training of soft skills and ethics if indeed, such training exists. What an imperfect system.

Under these circumstances, we all wonder how the huge number of housemen gets trained. Surely, they would have difficulty filling up their log books, especially for procedurebased disciplines like surgery and O & G because of intense competition not only from fellow housemen but also medical officers and Masters Students. Strange as it may seem, in many cases, the log books somehow get filled allowing housemen to move effortlessly to their next posting. One wonders how this is possible with the limitation of patients, the intense competition to perform procedures and the scarce supervision provided by exasperated seniors.

Another disturbing trend is that the housemanship training of late includes 1-2 weeks placement in tertiary disciplines. I find this amusing and perplexing as these young doctors, who are still trying to grapple with the broader aspects of basic medical training, have to now absorb and be astounded by more intricate and complex clinical scenarios. They are expected to run before they can learn to walk. It is like asking dancers to do the ballet when they are still trying to perfect the rumba. The focus on houseman training should be on fortifying their understanding of the basic medical sciences and its application to general medicine rather than teasing them with snippets of subspecialty training so early in their formative years. Sadly, this is happening now, simply because of the large number of housemen, the greater number of sub-speciality wards or departments compared with general medical or surgical wards in most of the bigger hospitals.

What about our housemen? Some have poor insight and seem unperturbed that the first two years are the most critical years in their life long journey to become dependable doctors. They do not seem to be worried that they may not be able to function as independent medical officers in remote health care facilities, after their housemanship training. They seem oblivious to the fact that ignorance and incompetence can cause harm to their patients, even preventable deaths? If they are true professionals and wish to become good doctors, surely they will be working as hard as they possibly can during housemanship to prepare them for the different clinical scenarios that may confront them as medical officers? They need to be reminded that they are not ordinary civil servants who have regular off days, shift duties and specified working hours. For doctors, there can never be specific working hours. Sacrifices have to be made. There must be genuine interest to save lives, even if it means working beyond the usual working hours.

Recipe for perfection

  1. Formulate a better way of training housemen; one that ensures adequate training and discipline, reasonable working hours, sufficient rest, proper supervision, an interactive and non-punitive feedback mechanism and remedial measures for those in need.
  2. To ensure adequate training, the number of places for houseman training should be optimised with sufficient number of committed trainers and trainees. The numbers can be controlled if MOH is brave enough to introduce a first-come first-served policy in which placement of housemen will depend on their choice of hospitals.
  3. The number of training places for housemen should be increased and this would be possible if district hospitals which are able to fulfil the requirements for houseman training can be accredited. The MOH has 132 hospitals and the total number of hospital beds in the public sector is 38,394 in 2011. Surely, we can make better use of these beds for better training of our doctors.
  4. Shift duties should be replaced with one that can guarantee continuity of care, accountability and responsibility.
  5. Greater emphasis should be given to general medicine, surgery, paediatrics, obstetrics & gynaecology, orthopaedics and Accident & Emergency in the training of housemen with only a sprinkling of subspecialty exposure, if there is a need.
  6. Measures to look into the welfare of housemen must be in place, including mentorship and counselling programmes for those who falter or are unable to cope with the pressure. Those not interested in direct patient care can opt to do meaningful research, become full time scientists or whatever.
  7. No political or family interference should be entertained during the training period.

Specialist Training

Greater awareness of health and higher expectations on health care has created a demand for specialist healthcare services.

The MOH has increased the training places for postgraduate training from 450 before 2008 to 600 between 2008-2010, and 800 in 2012. Every year, 150 doctors get trained in a chosen subspecialty. That is fine provided we offer them quality training with enough credible trainers and resources.

But have we got our priorities right? While we endeavour to increase the number of specialists and subspecialists in the country, we see a steady decline of generalists such as general physicians, general surgeons and a relatively small number of primary care physicians, all of whom are quite competent to handle the main bulk of outpatient visits and admissions. Sufficient number of general physicians, surgeons and paediatricians will help offer the basic specialist services in smaller hospitals for the benefit of our population.

We now have an estimated number of 7,975 specialists in Malaysia. The MOH has 4,230 specialists (3,518 clinical specialists, 494 public health and 218 Family Medicine specialists). There are 1,427 in the public universities and 2,318 in the private sector. We are not sure how many are subspecialists, how many offer general specialist services and how many offer both, as the National Specialist Register is yet to be made mandatory. We know that the MOH has specialists in 15 areas of basic specialisation and almost 100 areas of sub-specialisation in the various specialties. There is clearly an overemphasis on subspecialisation. So, we have ended up having more and more of those who know less and less. As I wrote in an article recently, a patient with eye problems may end up one day having to see two opthalmologists, one for the right eye and the other for the left.

Surely, this is far from perfect.

The Royal College of Physicians in London, in their paper 'Future Hospitals', clearly stated the lack of generalists as a major concern. Besides affecting the quality of care, it incurs unnecessary high hospital costs and put paid to efforts to promote patient-centred care. In other words, the system is far from perfect.

Recipe for perfection

  1. Specialists and trainers must be reminded that they are the guardians of the standards of our future doctors. They must remain committed and not be swayed by pressure from various quarters. Role modelling is a powerful force in medicine. Professional attitudes and behaviour shown by clinical teachers have tremendous impact on students and doctors in training.
  2. Change the postgraduate training module and length of training to five or six years (by adopting either a '2 + 3' or '2 + 4' formula, depending on the subspecialty)
  3. Postgraduate training should be conducted by MOH, the Universities and the Academy, as is done now, with MOH playing a lead role as it is in a better position to dictate the needs of the nation rather than those of individual specialists.
  4. Trainees must be subjected to high quality and intense supervision and positive role models with strong leadership skills. If they cannot get it here at the present time, we must be bold enough to admit our shortcomings and limitations and look elsewhere.
  5. Networking and collaboration with premier teaching institutions around the world must be encouraged rather than frowned upon.

Conclusion

The brightest students may not end up becoming the best doctors. We all know that. Other factors come into play.

Many of us have lamented on the declining standards of our medical schools and the dwindling quality of our doctors. We know that this is not just a Malaysian challenge but a global one.

Still, could we have done something different in Malaysia?

The stark reality is that we have doctors who are not interested in doctoring and nurses who are no longer keen to nurse. Doctors who accentuate their own complaints and trivialise their patients' complaints. Doctors who think they can do no wrong and end up committing grave errors; doctors who refuse to accept their limitations and refrain from referring patients to relevant colleagues. Simply put, doctors who place self above everything else and who do not have the welfare of their patients at heart. If we have doctors who have considerations other than doctoring, what chance do our patients have?

It is rather futile lamenting about doctors of today without doing something about it. After all, to some extent, all of us sitting in this hall are partly responsible for this situation. To ensure we continue to provide good health services in this country, we need dynamic and futuristic health policies, visionary leaders, dedicated doctors and teachers, and a vibrant health care team. We need excellent medical schools comprising teachers with impeccable credentials, state-of-the-art teaching facilities, conducive learning environments, modern teaching techniques, robust libraries and innovative research facilities. There must be no compromises on standards and quality and academic excellence and independence must always be safeguarded.

Having said all that, we also need to be fully aware of the new challenges we all face today and in the future. Medical education and training are now being delivered in a changing environment. There are now new and innovative ways of learning and teaching in view of the unprecedented technological revolution.

Medical schools must seriously reexamine their curriculum. Imparting medical knowledge and develop clinical skills are no longer enough. Students must be taught how to develop their psychosocial skills, communicative skills, interpersonal and people skills that will enable them to understand and relate to their patients better.

To maintain high standards in medical education, there must not be short cuts or flyovers. The quality of education and training programmes should be thoroughly assessed, internally and externally, to make sure that it conforms to international standards.

The way we teach and train our students and doctors and the way we practice may need to be modified as we now deal with patients who are better informed and anxious to participate in decision-making regarding their health.

As doctors, especially those of us in active practice, we must treat CPD as part of our life–long training if we do not wish to dish out outdated treatment and suffer the indignity of being challenged by patients and their relatives who may know better. Once your ignorance and limitations are exposed, your reputation, credibility and practice will sink into the abyss and you may end up looking for a new vocation or consulting your legal colleagues for salvation and face possible starvation once they are through with you.

Professional Regulation is also changing and regulatory bodies need to redefine their work. The MMC needs to be more pro-active and keep in step with current trends. Punitive threats are no longer effective and may even be detrimental. MMC members should try being more humane and more empathetic. They should listen more to be better equipped in dealing with professional misconduct. There must be effective leadership and a cohesive understanding amongst members. They must stop quibbling among themselves over petty issues and miss the big picture. MMC must be united and work selflessly to protect and safeguard the best interests of the profession.

'If you want to know why your people are not performing well, step up to the mirror and take a peek' to quote Ken Blanchard.

We live in an imperfect world. Let us at least be perfect doctors by perfecting the art of teaching our students and doctors to do the right thing, mindful of the fact that the present crop of doctors and those who come after them may well be the very ones who would treat us one day. That would be the moment of truth.

I once told my young doctors, during one of my ward rounds, that I have recurring nightmares. They asked me why. I told them "Well, I worry that when I get sick, I will be treated by you lot".

Many of you may have similar nightmares. The best way to end these nightmares is to wake up and get serious about perfecting medical education in Malaysia. But as Vince Lombardi once said "Perfection is not attainable, but if we chase perfection we can catch excellence."

So, perfection can still be our target. Let us make our voices heard. Let us act before we stumble and fall. Let us be reminded by the very words of TJD at a speech he gave to the University of Malaya Medical Alumni Association on 27th July 1985:

'The responsibility of the future of Medicine rests in large measure on your shoulders - the graduates of the first medical school in Malaysia, the fruition of many years of my own frustrations, hopes and longing. You have the capacity, the ability, the understanding, the vision and the organisation to change things for the better: in the way we should teach medicine, in the way we should practice medicine, in the way we should organise postgraduate medicine, in the way we should alter public perception of the medical profession, in the way we should influence the government in its delivery of health care. In all these you bear the responsibility and you are the custodians'.

We are all responsible. It does not matter which Alumni we belong to. Let us leave this Hall, with renewed energy, asking ourselves whether we have done enough or work hard enough, either individually or as a group, to stem the tide of imperfection in medical education and practice in our country. We owe this to ourselves, our families, our profession and our beloved nation.

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Joint Meeting with the Royal College of Surgeons of Edinburgh and the Royal College of Physicians of Edinburgh
Royal College of Surgeons, Edinburgh - 5th June 2014

The Academy of Medicine of Malaysia will be holding a joint meeting with the Royal College of Surgeons of Edinburgh and the Royal College of Physicians of Edinburgh, in Edinburgh, Scotland, on 5th June 2014 to explore training opportunities and discuss areas of common interest. The proposed programme is as follows:

Tentative Programme

0900 Registration / Coffee
0925 Welcome Address
Session 1
0930 Overview of Training Pathways in the UK
1010 Overview of Training Pathways in Malaysia
1050 Discussion
1100 Coffee / Tea
Session 2
1130 Standard Setting for Clinical Care in Scotland
SIGN process
1200 Exams – Surgical Perspective
1230 Exams – Physician Perspective
1300 Lunch
Session 3
1345 Faculty of Surgical Trainers
1415 MTI for Surgeons
1435 MTI for Physicians
1455 Tea
Session 4 Standards in training
1515 On-line MSc – Surgery
1535 On-line MSc – Internal Medicine
1555 Discussion and feedback on day
1615 Close

For further information, please contact:

Secretariat
G-1 Medical Academies of Malaysia
210 Jalan Tun Razak, 50400 Kuala Lumpur, Malaysia
TEL: (603) 4023 4700, 4025 4700
FAX: (603) 4023 8100
EMAIL: secretariat@acadmed.my

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Visit To The Royal College of Physicians of Ireland
by Dr Chang Keng Wee

Drs Chang Keng Wee, Peter Wong, Sivasakthi and Hj Abdul Razak visited the RCPI on 27th June 2013 and were involved in discussions regarding Advanced Training Fellowships and collaboration in Subspecialty assessment in Respiratory Medicine. Visit to a training hospital and meeting with one of the Malaysian trainees was arranged. The proposed Advanced Training Fellowship is in any subspecialty in Medicine, and is similar in structure to the Irish Higher Specialist Training Programme. Entry to the programme would be in year two or three of the Malaysian Subspecialty training, after completion of the Malaysian Masters of Medicine programme or after MRCP. Fellows would be fully integrated into the clinical team and participate in all clinical activities.

The governance of this programme would be managed by the RCPI’s Dean and Vice-Dean of Postgraduate Specialist training, as well as the Training Committee of the Malaysian Subspecialty Training Board.

Discussions also centered on joint exit assessment for subspecialty training and for a start, the RCPI shall send a senior examiner to the final examinations in Respiratory Medicine, in 2014.

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2nd Tripartite Congress (47th Singapore-Malaysia Congress of Medicine) of the Academies of Medicine of Singapore, Malaysia and Hong Kong
by Prof Dato' P Kandasami

The Tripartite Congress of the Academy of Medicine of Malaysia (AMM), the Hong Kong Academy of Medicine (HKAM) and the Academy of Medicine, Singapore (AMS) was initiated based on the philosophy that the Academies have many common areas of interest. Therefore, it was felt that the partnership of the Academies will benefit the profession at large. The 1st Tripartite Congress was hosted by HKAM in 2010 and it was agreed that the conjoint congress of the three Academies be held once every three years.

The 2nd Tripartite Congress was hosted by AMS and was held in conjunction with the 47th Singapore-Malaysia Congress of Medicine on the 23rd - 24th August 2013 at the Grand Copthorne Waterfront Hotel, Singapore. It attracted over 400 participants from Singapore, Hong Kong, Malaysia and other countries. The theme of the Congress was "The New Reality in Medicine - Caring for Patients with Multiple Co-Morbidities"

On 23rd August 2013, His Excellency, Dr Tony Tan Keng Yam, President of Singapore and Patron of the Academy of Medicine, Singapore graced the opening ceremony as the Guest of Honor. Honorable Mr Tharman Shanmugaratnam, Deputy Prime Minister and Minister for Finance, Singapore delivered the Gordon Arthur Ransome Oration, entitled "A Fair and Just Society: What Stays, What Changes?" An induction comitia was conducted where the AMS formally admitted 92 medical specialists as Fellows of the Academy. In addition, Presidents of overseas colleges and executive committee members of the AMM were also conferred the Academy’s Fellowship. The ceremony was very well organised and it is refreshing to have the President and Deputy Prime Minister join in the fellowship tea that followed the ceremony.

The Master of AMS, Dr Lim Shih Hui, hosted a dinner at the Grand Copthorne Waterfront Hotel to celebrate the Tripartite Congress on 24th August 2014. It was a memorable, fun-filled informal occasion. The highlight of the occasion was the impromptu, spontaneous singing performed by members of the three Academies, talented doctors and nurses. The evening generated plenty of joy and excitement among the guests.

The Councils of the three Academies had a Joint Council meeting on 24th August 2013 morning. Dr Wong Kok Seng, the Organising Chairman of the 47th Singapore-Malaysia Congress of Medicine briefed the Councils of the progress of conference. Dr Lim Shih Hui, Master, AMS explained Singapore’s collaborations with the Accreditation Council of Graduate Medical Education (ACGME) of the United States and of the USstyle Residency Programmes. It was noted that some specialties continue to retain the UK-style training programmes. There was a generous exchange of views among the Council members of the Academies on post-graduate medical training, specialist registers and continuous professional development. Dr Chang Keng Wee briefed the Joint Council on the preparations for the 48th Malaysia-Singapore Congress of Medicine to be held in Kuala Lumpur on 26th to 28th August 2014. Dr Donald Li, President, HKAM invited the Councils to attend their 20th Anniversary celebrations to be held on the 8th – 10th December 2013.

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