MY SAY: Whither the Hippocratic oath?

Professor Tan Sri Dato' Dzulkifli Abd Razak
Comment
The Edge Malaysia - 12/20/2010

The news that the government is imposing a five-year moratorium on medical programmes for a variety of reasons cannot be more timely. Malaysia is fast becoming a doctor-exporting country and one could argue that such drastic action should have been taken much earlier.

By now the diagnosis seems to be much more dire. A former minister of health says Malaysia will be producing about 4,500 doctors a year come January 2011. And at this rate of growth, the number of doctors will double from the current 30,000 to 55,000 or 60,000 five or six years from now.

For a long time, the justification for more medical programmes was that Malaysia had yet to meet the desired doctor to patient ratio based on internationally accepted norms. The assumption was that per cohort of some tens of thousands of people, there should be so many doctors to provide "quality" services. Ironically, one of the reasons cited for the moratorium is the quality of the new doctors.

Earlier this year, we heard authoritative sources saying there is still a shortage of 14,000 to 15,000 doctors from the 25,000 needed. This is despite Malaysia having more than 20 medical schools for a population of about 26 million. The UK has almost the same number of institutions with a population more than double Malaysia's. Another comparison is Canada, with fewer than 20 institutions for a population of about 34 million spread over a much larger area.

For Malaysia, the ideal and targeted doctor to population ratio is said to be about 1:650. And it is not presumptuous to say that in most Malaysian urban centres, especially in the Klang Valley and Penang, this ratio has been met — at least close enough. Put differently, should doctors be allowed to flock to places where the ratio has been surpassed?

In fact, a casual observation shows that in increasing numbers of urban centres there are more that two medical clinics in the same row of shop-houses, and needless to say, "competing" against each other in a way that may test the limits of ethical practices.

This "maldistribution" of doctors comes at the expense of areas where there is still a shortage of doctors. Rightly or wrongly, the powers that be have allowed an unjust distribution in urban areas while in the more rural and remote areas the scarcity can still be felt despite increasing numbers of medical programmes. That said, we also need to be mindful of the 80% of Malaysians with an income of less than RM3,000 a month.

It is time, while executing the moratorium on medical programmes, to urgently think of how to correct these longstanding imbalances. A case in point: While the present national doctor to population ratio is about 1:1,145, cities like Kuala Lumpur have a ratio of about 1:500 (which surpasses even the national target of 1:650). On the other hand, in many towns, not least in Sabah and Sarawak, the ratio is still very far off.

The answer to the inevitable question of how much longer those living in the underserved areas have to suffer is not that we have not trained enough doctors, but that few wish to serve in these isolated areas unless they are forced to. Many doctors quit the government medical service to avoid serving in these areas.

This does not include the average of 350 doctors who quit the government service a year for so-called "greener pastures". It is a fact that the annual salary of a doctor in the government sector would be matched just by conducting a limited number of procedures in the private for-profit sector.

Others cite the point that only 30% of specialists in Malaysia still work in government hospitals, where more than 70% of the patients are. To make the situation worse, neighbouring countries have of late been luring locally trained doctors away from serving at home.

Yes, many reasons can be put forward for why certain places are preferred over others — and doctors do have a right to do so. But the fact remains that in such a noble profession, material benefits and comfort should be the last consideration. A lot of students who enter medical programmes do cite such idealism, saying they want to serve humanity, especially the disadvantaged and the destitute.

When exactly they lose their idealism is something that baffles many. Maybe it is during the process of medical education which is increasingly tainted by the powerful medical industry through subtle inducements and commercialism. Perhaps it is during the more vulnerable formative years of housemanship, when the pressure is most intense in trying to make ends meet.

So, it is not just the number of programmes, but also the lack of professionalism that is eating away at the medical ethos, let alone the solemn Hippocratic Oath that doctors take.


* The writer is the Vice-Chancellor of Universiti Sains Malaysia. He can be contacted at vc@usm.my