Why do medics want to stay?

I know a lot of people get pissed off when medics decide to stay and work in the country of their medical training or anywhere abroad. People think it's all about the money, and people accuse those who stay of disloyalty and betrayal of the Malaysian public's tax funds. As far as I know, for the majority of medics, working in the UK is not about making money and is a more complex issue involving various issues. Show me someone who wants to make money from working here, and I'll show you someone who doesn't know what they're talking about.

Of course the main logic for not going back is the crazy work hours as a junior doctor in Malaysia, with disregard to the doctors' welfare as fellow humans. The majority of teachers I know (not my freshly graduated KPM friends, but those who have been teaching for a while) would complain and nag if they had to do extra classes, jaga budak2 berkawad or take students to klinik kesihatan (definitely not my mom), because according to them, diorang pun ada anak and laki nak kena jaga. If an architect had to work until midnight to finish a project, he would probably get nagged by the wife. But amazingly, when it comes to doctors, people expect them to be super-robots who can work at any time of day, for as long as necessary, regardless of whether they've had no food to eat for the past 12 hours or no sleep for the past 24. It's not even near funny - my friend who previously had a BMI of less than 16 lost another 4 kg after working for less than 6 months.

Another simpler reason for staying is that during foundation training, doctors are not just thrown into the water to drown if you're unlucky, or kill a few patients if they're unlucky. They are given proper training and education to improve their competency. There are weekly lectures, teaching sessions and various other support resources available to help junior doctors in their practice and to prepare them for choosing and applying for specialist training. I know somebody who's so desperate to get teaching and training during junior doctor years that she stayed and did her housemanship in Egypt. Now, not only is the healthcare system in Egypt generally worse than in Malaysia, but you also have to pay them to do your housemanship there. It doesn't make sense if you think about it, but there you go.

The second thing that puts me off is that there doesn't seem to be any proper system in place for further training for those who want to specialise. Some people get a masters (while working damn hard), some take the MRCP/MRCS/whatever, some go via Kementerian Pengajian Tinggi, it's all very confusing. Then there's the issue of seniority - if you've been there longer, you're given more priority. Unless of course you know somebody (which we will come to in the next paragraph). So it looks like there's no chance I'll be a consultant by the time I'm 35 like the consultants here. Let's hope I don't give up before that stage from weariness of waiting and just become a local GP instead of following my aspirations (whatever they may be).

As in all other institutions in Malaysia, there's lotsa politics involved, so if you don't know someone who's a somebody, you're a nobody to anyone. For patients, if you don't know somebody, you probably won't be given the best care. For instance, when my dad was suspected of having cancer, he wouldn't have gotten the tests done within two weeks if he didn't know anyone. So kalau pakcik petani yang pergi hospital cakap dia tak lalu makan and lost weight (though he would be more likely to see a bomoh), mungkin all the cancer tests would be done later on when his disease has progressed further. All because he couldn't say to the doctor, "Look, my son is the head of department of radiology, so you better not play around and start taking my healthcare seriously."

One of the biggest cons for going back would be that I would often be frustrated at not being able to give my patients the utmost treatment that they deserve. In some places, they won't even do troponins if a patient presents with symptoms and signs of a heart attack. They would just watch and wait to see if an MI is highly likely, and then just treat the patient. Another example, did you know it costs at least RM40,000 for treatment of Hodgkin's lymphoma and that you'll only get it free if you're a government servant? How the heck could anyone afford that? No wonder they let my mom's 17 year old ex-student (who was an orphan) just die from it rather than initiating any treatment. It's not like Hodgkin's is an immediate death sentence, it's got a 90% 5 year survival! Malaysia's not a poor country so we can't say that we can't provide good quality healthcare to our people - I honestly think it's a misuse of resources that's causing all this.

And I know I would love working here because no matter who you are, you are treated as colleagues (by the majority of senior doctors) and not lowly subhuman creatures. Many consultants and all other doctors introduce themselves to you by their first name rather than asking you to call them Dr So-and-so. My dean always pens off his emails to me with 'Simon' rather than 'Dr. Wallis'. They ask you questions to teach you, not to show off or to degrade you. And even if you don't know/understand something really simple, they will explain it in a way that does not make you look stupid. And if they don't know something, they're not afraid to admit it and will even let you explain things to them if you happen to know. Heck, they even make tea for you or ask the nurses to do it; I highly suspect that I'll be the one making tea for everyone on the wards back home, but then I doubt that there'll be endless supplies of tea anyway.

Another thing that really bothers me is the corrupt people and ineffective system in place, starting from way down the ladder all the way up to top dog. For example, at one point, HKT wanted to improve waiting times and consultancy times in the outpatients department. One doctor who didn't really care about improving the quality of care wrote on a patient's card that he started seeing them at 8.15, although it was already 8.30 then. He then went on to write that he finished the consultation at 8.30 before he even talked to the patient. Where is the honesty and integrity of doctors these days? Tak tau la kalau jam dia rosak or dia dyslexic dan tak faham apa borang tu nak. And of course there's the it's-alright-to-make-mistakes attitude. I'm in no way saying it's wrong to make mistakes, but it is unacceptable to not own up to it, especially when it involves patient's lives. I remember a young girl who was given the wrong medication and ended up needing her arm amputated, and yet, no one was accounted for it. A few years ago, a registrar here accidentally took off a bit of Fallopian tube in a teenager who had an appendicectomy - he immediately resigned. I'm saying this not to encourage a culture of blame and litigation, but if horrible mistakes are made, people have to at least be responsible enough to apologise and try to reimburse the patient in some way. Did Islam not teach us the concept of a life for a life, an eye for an eye, a nose for a nose etc (Al-Maidah: 45). I'm not gonna even go into the lack of proper documentation, as I've mentioned loads of times about the clinically anaemic girl who was suspected of having thalaessemia, yet no one could make a proper diagnosis (and thus no treatment was given) despite her having her blood taken at 8 different times because nobody cared to document their findings/results.

I'm not making all this up, nor are these old wives' tales. These are based on personal experience or of those people who I know.

Now, you may say, "Why don't you lot come back and try to fix things up then?" Yes, it would be great if you could make changes here and there while you're working. But remember, in Malaysia, if you make too much noise while you're only a lowly junior doctor, you will probably regret it as you can be 'punished' with anything between being laughed at to extension of placements, bad feedback/referrals, etc. My friend tried to encourage a change in the labcoat wearing culture (which increases infection risk and is foolish considering the humid climate in Malaysia) in her hospital and ended up being ignored by everyone. So any changes would have to wait until you're a senior doctor, which would take around 10 years to get to a stage where people would listen to you. I'd be lucky if I don't actually give up before that and just go straight into private practice.

So people will justify the reason for the poor healthcare system in Malaysia is the lack of doctors because a lot of people won't go home. I have a few simple answers to this 'theory'. A, the majority of students do go home. B, there are more doctors working in the private sector in Malaysia than those who stay abroad forever. C, the quality of a healthcare system does not lie solely on the number of doctors; take Egypt for example - there's approximately 200 consultants per specialty per hospital, and yet, there's a lot of problems over there. I'm not saying the NHS in the UK is great, coz in reality, it is number 17 (or something like that) in Europe (there aren't even that many countries!), but at least it is always open to reform and ready to improve itself for the welfare of both its staff and the public.

Someone said to me that she was so depressed about going back to work in Malaysia because she doesn't want to be an ordinary doctor. She knows that if she stays here and goes into the training field of her choice, she can make a huge difference in many people's lives. So yeah, maybe kalau balik Malaysia, kita boleh treat orang kita sendiri. But I believe you can derive as much (or even more) satisfaction on improving the lives of any human being, regardless of their race or religion. And I'm sure God approves of that as well.

So again, like I said before, it's not about making s*itloads of money and being rich. Because junior doctors get paid here about the same amount as everyone else, i.e. about GBP2000 a month (tak tolak tax lagi tu). Oleh kerana purchasing power between sini and Malaysia is so different, a starting pay of RM3000 is urban poverty. It's not about how much money we can make here, but it's about how far that amount of money goes. Say if you live and work in Preston, sewa rumah GBP200, bills GBP100, food GBP100 and minyak kereta GBP50 a month. Kalau kerja kat Malaysia (Terengganu for instance), sewa rumah RM200 sebulan (kalau jumpa rumah kos murah), bills maybe ok, food RM300 sebulan and minyak kereta RM50 seminggu. Itu belum kira kos pembelian kereta, pakaian dan pelbagai keperluan hidup lain. Dan itu contoh di Terengganu, kalau kat West Coast, tobat la makan maggi hari2 dan tido di spital untuk jimat minyak kereta. But then, you probably would be sleeping in the hospital a few times a week anyway sebab on-call.

Orang kata "hujan emas di negeri orang, hujan batu di negeri sendiri". In my opinion, if I'm gonna be hit by hard and heavy objects falling from the sky, I might as well be hit by gold nuggets. If you've seen and had better, why would you want to go for something worse? It doesn't make sense to settle for less. If a girl broke up with her drug addict, money-laundering fiance to marry a religious and well-educated gentleman, no one would call her a traitor and everyone would probably do their best to support her.

And yeah, I know there's the issue of people's tax money paying for our fees. I know quite a few consultants who are working here who paid off 100% of their scholarships. For the rest of us, MARA says you can stay as long as you want, as long as you eventually do go back home to serve 3 years in the government, so I don't see what the problem is. Kalau orang yang stay tu students JPA yang JPA suh balik and suruh sign perjanjian macam2 supaya balik terus, yet still buat muka tebal nak stay sini tapi tanak bayar balik, tu memang patut bundle in a white van and deport straight away (macam George Galloway kena deport from Egypt).

I think all those MARA and self-sponsored and whoever else whose sponsor doesn't require them to return home and commence government service ASAP are just being smart and reasonable by staying. I made a very difficult decision to not stay here to further my medical training. But that has nothing to do with me being patriotic or having any sense of duty to my country; it's simply because I miss my family and home so so much.

The Final Steps

These are a few notes that I jotted down during those crucial days circa exempting exams.

- I called my grandma earlier (my paternal grandma, not my maternal one who has Alzheimer's now) and she was chatting as usual to me about her anak murid mengaji and all (I miss having leisurely chats like that). When I asked her to pray for me, she said (in Bahasa Kelantan), "Di samping mak ayah, tok nenek, berdoa untuk kita, kita kena berusaha. Man jada wajad." Thank you, Ma. Although I know life isn't that fair, I hope her prayers (and those of everyone else) will slightly tip the balance.

- It's so depressing finding out in these last few moments of other universities' assessments for finals. Contohnya a lot of universities only assess students on what they learn in final year, while others assess their students only on general medicine and general surgery. Some universities use the same OSCE stations for each exam day, so if you're not unlucky enough to be on the first day, you basically know what the stations will be. In Manchester, there's no certainty in anything. You don't know the syllabus properly, you don't know what exactly you need to learn (and to what extent), you don't understand the new exam system, you don't know what will come up in the exams (so you have to study everything from Semester 1), you don't understand the exam questions (which has nothing to do with English proficiency), you don't know what the examiners are looking for, you don't know shit. And obviously, nobody at the university cares to explain, especially since you're in Preston, which is probably why all the revision sessions are in Manchester and we have to travel almost 4 hours daily to attend 3 hours of revision lectures.

Then there's the OSCE marking system. Say there are five major aspects you have to fulfill. Each aspect has four possible marks: 1 - student doesn't know/do much, 2 - student partially fulfills all criteria, 3 - fulfills most, 4 - fulfills all. If you get a full 4 for each of those five aspects, the maximum mark you can get is 5/7. And the passing mark per station is 4/7. To get a 6 or 7, you'd have to do extra things as well. And in the end, the final mark for each stations is up to the examiner to award - if they're impressed with you, you might get a 6; if they think you're just rubbish coz you're following a checklist, they'll probably give you a 4 (if you're lucky). And remember, when they're in doubt about whether to give a 3 or a 4 (or any other mark), in the exempting exams, they are asked to give the lower mark. Yay.

- I don't understand how some people can be slightly insensitive at such a time. I've never been more horrified in my life, and yet some people can say that failure is common and it shows that Allah wants to test us. Yes, that's true, but that's not really something you wanna hear right before you take your finals. And ada pulak yang lain duk cakap senang je exam, kerja nanti lagi susah. Like seriously? You can probably get 9As in PMR if you do it with your eyes closed, but I wouldn't say it to my brother before he took his exams. Because obviously it is easy for me to say that PMR is a piece of cake at my stage now, but it wasn't as simple when I was 15 and sitting for it.

- Tensionnya tengok gambar orang lain graduate. Tengok kawan2 yang memang konfem dah grad pun sedih, inikan pulak tengok gambar kawan2 yang baru habis exams and results belum keluar tapi dah yakin gila and confirm graduate. It's so unfair that some students can be so confident about passing their exams, and yet us kids are struggling to survive here. I don't know how many times I cried thinking about that.

- Life is so unfair sometimes. I thought it's supposed to be "you reap what you sow". Then how come some people can pass exams and do so well so effortlessly whereas others work so hard, with sweat and tears, yet don't succeed.

- I hate it when people said "it's gonna be ok" or "you'll definitely pass". How the f*cking heck do you know that it'll be alright? It's so easy for others to say that when in reality, there's no telling who'll pass and who'll fail. If it was as simple as reading all the books and learning all the facts, then maybe passing is something achievable. But that's not how it is. I know people who got honours and distinctions in their written exams, but failed the OSCE. How does that even make sense?

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As most of you probably know, Manchester medics recently sat for their exempting exams, so called as if you're lucky to pass in the first round, you're exempted from sitting the May exams. But if you fail any of the three exams by even one mark, you have to sit all three again. Last year, half of the Malaysians failed the exempting exams, so imagine how scared we were of anything similar happening again. All of us worked so so hard, harder than we've ever worked before. Our efforts were often accompanied by lots of tears and sweat (ok la, sweat tak sangat la sebab sejuk), and also the occasional manic laughter. At first, I thought it was just me, so it was a great relief to know that my friends were going through the same thing. I bet if we went to a GP, we could have been diagnosed with bipolar disorder - crying so hard for fear of failing the exams one minute (habis kering kulit muka sebab asyik nangis), then laughing at ourselves for not working harder before in the next minute. We often woke up in the middle of the night from nightmares about exams and other medically-related things, e.g. one of the guys often talked in his sleep saying things like "Refer to dermatology", "Refer to urology" etc. It was so bad that even after the exams were over, I would suddenly wake up thinking "Is it exam day?", "Have I done my exams yet?", and it was hard to adapt to not having exams during the first few days post-exams.

And then there was the anxiety of waiting for the results. I actually arrived at the state of acceptance a few days before the OSCE. Which in a way was a good defense mechanism for me, coz then at least I wouldn't feel so upset if I did fail, since the likelihood was very high. That's why when the results came out, and after I checked it was actually my results more than five times and made Kadir check them a few times as well, I felt quite blasé about it. In fact, I was more excited seeing Pierce Brosnan in Athens than getting my results.

There isn't much to celebrate about anyway when people you know haven't passed. The exams and the days running up to it were one of the most painful experiences in my life, and I hate to think that anyone I know has to go through it again. Where do people find the strength?