The MIMS team sat down with Vikkineshwaran Siva Subramaniam, the chief convener and chairperson of the student-led Malaysian Medics International (MMI) to find out more about the main challenges facing our medical students as they seek to graduate and join the community of healthcare professionals. In Part 1 of our two-part interview, he talks about the key issues that need to be addressed to improve the outlook for local medical graduates.

There have been several reports about the backlog of medical graduates awaiting housemanship postings. Recently the Royal Malaysian Armed Forces also suggested that these graduates could serve their housemanship in military hospitals as a way to address this shortage of vacancies. How does this affect current medical graduates?

Those who graduated last year have had to wait a minimum of six months before being given a posting. But this year, that period may even rise to eight months, which could result in their skills becoming rusty.

Moreover, it is challenging for the graduates as many of them have student loans which they are expected to begin repaying upon graduation. With a medical degree, they are not really equipped to take on other jobs nor do they wish to, but unfortunately, many of them are forced to enter other fields of work temporarily in order to sustain themselves during this long waiting period.

Furthermore, we also have a limited number of hospitals in the country which are well-equipped to train the graduates and that is where the military hospitals come in. From 2017 onwards, they have added three government hospitals which have been upgraded to take in housemen and to train them.

Do private hospitals offer housemanships?

Currently they do not, as the problem with doing housemanships at private hospitals is that the patient load they get is not as diverse compared to public hospitals. There are also some cases that come into government hospitals which would not be seen in the private ones due to the difference in socioeconomic status. This does have an impact on houseman training as we would miss out on a wider range of cases as opportunities for learning.

The other issue with this is the difference in salaries which would vary between private and public hospitals.

But is there an opportunity in private hospitals that could be utilised in the future, perhaps to reduce the backlog slightly? Especially because private hospitals normally do not employ their own cadre of general doctors; they tend to focus on hiring specialists. What if each specialist clinic could take on a couple of housemen to assist in consultation?

KPJ Healthcare Group has created a parallel pathway for specialising in surgery. Currently there are two doctors training to become surgeons under KPJ, as part of a trial phase. These doctors have not graduated yet so we must wait to see if it works out well.

Many private hospitals have expressed their interest to do this but another key factor to consider is whether the doctors are equally interested in training. But if these hospitals do have the capacity, suitable patient load and equipment for it, then by all means, we should encourage more such programs. Unfortunately, there is still a lot of room for improvement in Malaysia on this as we have not quite reached the level of other countries when it comes to private hospitals.

Is this more a question of the shift in mindset as compared to Western countries in which it is quite common for residencies to be done at private hospitals?

Yes, in the United States, the hospitals are first created to treat patients and then they start the medical schools, such as John Hopkins. Thus they have already established themselves and have a steady stream of patients coming in, hence they can utilise medical graduates to treat these patients. Our hospitals have not really done that yet but they are currently trying to move in that direction.

Sunway Medical Centre is building a new medical centre and Monash University is affiliated with them so their students will be able to be posted there. For certain postings, the graduates can go out to seek more opportunities, but not for all of them.

Do you think that many graduates are focused only on becoming doctors and surgeons, as opposed to considering alternative career paths such as medical or pharmaceutical advisory roles or even research-based work?

There is a lack of awareness here currently although the Ministry is working on creating alternative pathways for those who have pursued medical studies but are not keen on clinical work or to see patients on a daily basis. But even in the private sector, no university or medical centre currently offers training for this.

However, even if some graduates want to become advisors rather than practicing doctors, they would still need to complete their housemanship first in order to obtain their license before a company could hire them. So once again, this limits job opportunities until and unless we address the issue of unemployed housemen.

Do you think that through the Summit and other events, your organisation has been able to educate the graduates to explore different pathways such as obtaining internships with pharmaceutical companies during their six-month waiting period?

During the summit, we had several workshops, ranging from alternative clinical practice to how to set up your own hospital. A Malaysian organisation called Hospitals Without Borders which was set up by doctors who go to places like Cambodia to create hospitals, talked to the students about how to set up and manage such a practice. Another workshop was on medical law. These workshops allowed students to establish contacts with the doctors, which could blossom into a form of mentorship in the long term. We still have a lack of mentorship in our medical community due to many doctors not being forthcoming about sharing what they know with the younger graduates.

We also had a career exhibition in which we brought doctors from Singapore, Australia and UK to talk about job opportunities overseas for our graduates as opportunities here are still limited at the moment. Singapore in particular is very welcoming towards our graduates as they still have a shortage of doctors.

One advantage to Singapore’s system compared to ours is that their pathways towards specialisation are very transparent which helps the graduates understand what they need to do in order to progress whereas in ours there are still grey areas.

Can you help us to better understand the stress that medical students feel, especially in the current situation whereby most would be unemployed for up to eight months after graduation. Recently we talked about how doctors and medical students are more prone to depression and suicide. Has that been a part of your experience or of others in your circles?

Stress is definitely a part of our challenges, especially from our study load and examinations. By the way, I actually just completed an exam before coming over here today (laughs).

As you move from pre-clinical to the clinical stage, you have to talk to more people, including seniors and experts from various levels. Unfortunately hierarchy in the medical system is still rampant in Malaysia, so this could lead to even more stress, depending on who you talk to. Some doctors are friendly, understanding and fun to work with - but others can be the complete opposite.

When you start working as a houseman, there are different perceptions to deal with. Some doctors assume that if you came from Russia or Indonesia, you are not as good as others. This is still happening as I have seen it myself. In western countries, doctors treat the students more as equals, according to my friends in those countries. Here, mistreatment and bullying are still a reality in our medical scene, so this mentality really needs to be changed.

The lack of available houseman positions would only make this worse due to increased competition. Is there then a lack of connection between local medical graduates and those who studied abroad?

Yes, that’s exactly why we created MMI to address this disconnect. Those who were abroad were not aware of the requirement updates by the Ministry which affected them so when they return, this has a major impact on them.

By contrast, local students may feel a sense of inferiority in comparison to those who studied abroad. They may even have concerns that those graduating from overseas will return to fill the few vacancies that are available.

Yet we also find that those who study in Australia or the UK find it very hard to adapt to the way things are done here, having been trained in hospitals abroad where the patient load and diversity of cases might be lesser than in Malaysia.

Over time, these two groups of graduates may start to form their own cliques based on the impression that they are very different from each other. This happens especially when the senior doctor is a local graduate while the junior doctor had studied abroad, leading to a fear that the younger doctor may outdo them. I have friends who left the local practice and returned to Australia because they felt they were being singled out unfairly.

Does MMI also serve as a support group for doctors to share their concerns?

Currently it is only within the MMI membership as we are unable to branch out further due to a lack of network among older doctors. But we are gradually building networks among the specialists which we hope to grow to include housemen medical officers at a later date. Furthermore, there are many existing medical organisations in the country such as the Malaysian Medical Association, Asian Medical Students' Association International (AMSA Malaysia) and many more with each having a specific focus.

Perhaps that will be the natural evolution for MMI as you begin to graduate to become the next generation which will be better coordinated and united.

Yes, I can see that this is already happening as my generation of students are more proactive and better prepared so there is only room to grow from here on out.

In Part 2 tomorrow, Vikkinesh delves into the ways in which MMI aims to better prepare medical graduates for their impending careers and also shares more about how he keeps his passion burning despite the many challenges of being a medical student. MIMS

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