In our cover story last week, we focused on courses to give new doctors a headstart. In this issue, we feature experts who give their take on medical students and housemen who are unable to cope with the pressures that come with the training.
CHASING dreams are never easy, especially when one has dreams of becoming a doctor.
Surviving medical school which typically lasts between five to six years, and a two-year stint as a houseman requires a great deal of time, effort, money and passion.
Local medical students are put through a meticulous and rigorous schedule of lectures and periodic theoretical tests, examinations and practical clinical procedures in government and university hospitals every semester starting from the second year of their studies.
While most of them are resilient and determined to succeed, there are some who are unable to cope with the stress and pressure.
In 2015, the dropout rate of housemen stood at 30%, a percentage which left many concerned over the fate of the former doctors as well as the lack of talent to be medical specialists in the future.
Fortunately, Health Ministry deputy director-general Datuk Dr Jeyaindran Sinnadurai reveals the current rate of dropouts among housemen has reduced to between seven and eight percent as of this year, due to proactive measures taken by the ministry.
He says students shouldn’t suffer like a fish thrown out of water during the transition from medical student to house resident.
He urges housemen to not give up easily, saying if they feel they cannot complete their stint due to underlying problems, they can always return when they are ready.
“Housemen diagnosed with a medical problem such as a psychiatric issues or adjustment disorder will be suspended for the time being.
“However, they can restart their housesemanship even one, two or three years later, provided they receive approval from the Malaysian Medical Council of Fitness to Practice Panel,” he says in an interview with StarEducate.
Housemen would have to go through two rounds of assessment during for each of their 16 week posting, the first being on the 8th week and the second on the 14th week.
They are allowed to extend a maximum of four months.
Dr Jeyaindran says if there is a problem during the first assessment, housemen will be informed of the areas of concern where they should read up on and another assessment will be done in another period of between two to three weeks to see if the person has improved.
“If we find that their knowledge remains poor, we have no option but to extend the houseman for a maximum of four months in the same hospital.
“After the extension, the houseman will be transferred to another hospital to work with a new set of consultants to ensure fairness in assessments,” he explains.
“Should the houseman fail this second placement, he would be terminated. It is indeed sad, but we have to be firm as it involves the safety of patients,” adds Dr Jeyaindran.
Identifying the cause
While there are various reasons to discontinue studying the programme, Malaysian Mental Health Association deputy president Datuk Dr Andrew Mohanraj cites the stress to live up to high-expectations of the local medical system as one of the main reasons for houseman to decide they have had enough.
He says housemen would be psychologically stressed out with being unable to cope with work load, and also being unable to adjust to the local medical system, which has fairly high expectations.
“Many housemen who drop out are trained overseas in centres of lower academic standards,” he reveals.
He also notes that medical graduates these days feel they are being overworked as opposed to housemen of yesteryears, who accepted any amount of work as part of their training.
“Shift work was unheard of those days, but nowadays working limited hours at a stretch is the norm,” says Dr Mohanraj who is also a consultant psychiatrist.
Malaysian Medical Association (MMA) president Dr Ravindran R Naidu says its hard to pin down the reasons of not completing their placement, but believes most cases are caused by a combination of factors.
“It could be because they lack passion or interest in the profession.
“This is coupled with long hours, demanding superiors and constant reprimands, they may lose their will to complete the housemanship,” he points out.
Dr Jeyaindran attributes the main reason housemen are unable to complete their housemanship to adjustment disorder.
“The new doctors have difficulties when they manage patients, as they return from certain countries where they received insufficient exposure to patients during their training.
“They are not used to retrieving patients’ history, examining, speaking or taking their blood. Terminology also varies in different countries,” he explains.
He adds this throws them into stressful situations because they feel that they pale in comparison among peers who have had received more exposure and proper training.
“These housemen are not stupid, they just have not been given enough exposure,” he stresses, noting they could be too shy or scared to inquire for more information over fears they would be deemed as incompetent.
Coping with the situation
The most effective way to move on in life is to climb back up from where you’ve fallen, dust yourself off and continue moving forwards.
Dr Jeyaindran says if things get too stressful for housemen, they should not take it upon themselves to solve the problem by resigning on the spot.
He shares the administration department of government hospitals are now not allowed to accept a houseman’s one month salary in cash, should they approach the department to tender their immediate resignation.
“The officers are not allowed to keep cash, they have to bank in the money,” he says, noting that once the money is banked in, it means the houseman is effectively terminated.
“To stop this from happening, we allow a cooling-off period of between one to three days for housemen,” he says, suggesting that they should meet with the hospital’s deputy director, or someone who can talk some sense into them during the cool-off period.
He urges all houseman with a problem to alert their immediate superiors immediately.
“With recommendations from the psychologist or psychiatrist, doctors with an adjustment disorder, which we would bring them back to closer to where their family are to have them adjust and get back into the working environment,” he says.
Dr Ravindran agrees with Dr Jeyaindran, saying the ministry provides counselling for those extended in housemanship, and they may be transferred to other hospitals if they can’t complete in the first posting.
However, he notes that many of the problems could be avoided if proper aptitude testing is done before entering medical school.
Before making any final decision rashly to opt out off medicine, Dr Mohanraj suggests those who have psychological stress during housemanship to seek help from a psychiatrist or a clinical psychologist.
“Even those who suffered from clinical depression have managed to complete housemanship or successfully graduated from medical college because they sought help early.
“Do not be shy to seek out such services. It is your life and you should not leave any stone unturned in your pursuit to become a doctor and this includes being brave enough to seek psychiatric help despite the stigma surrounding it,” he stresses.
Dr Mohanraj says housemen must understand that since they have come already come so far by graduating as medical students, they must try to bite the bullet and pursue their ambition without giving up so easily.
“Medicine is a vocation and not just an occupation. Initial hardship will eventually turn into a fulfilling and rewarding career.
“However for those who try but still face insurmountable challenges during their housemanship or those who suddenly realise that being a doctor is not really their chosen career pathway, there are still many other options to choose from,” he says, and adds it is not the end of the world if you cannot, or do not wish to be a doctor.
Next course of action
When one door closes, another one opens.
Failing to complete what one has set out to do doesn’t mean it is the end of the world.
Dr Mohanraj says a wide variety of options, many of which are rewarding monetarily, remain for former housemen to choose from.
“The pharmaceutical industry can benefit greatly by medical graduates joining the industry because they bring wealth of knowledge into the industry,” he says.
Research is another option which can be equally fulfilling in terms of touching the lives of many people in an indirect manner by contributing to the advancement of medical science, adds Dr Mohanraj
He also notes that the insurance sector is another option for medical graduates.
“They can help craft better insurance polices or contribute in coding of illnesses which is an essential component when it comes to deciding on premiums and insurance payouts,” he says.
As for the medical students, Dr Mohanraj suggests for them to move away from the undergraduate medical programme to the ‘graduate entry medical programme’.
“In the graduate entry programme, medical students already have a basic degree usually in a related field like physics, chemistry, biomedical science, nutrition or even nursing though not limited to these mentioned.
“If the students from the graduate entry programme are unable to pass their medical exams, they can always fall back on their basic degree,” he says.
This is not so in the case in the traditional undergraduate system where the medical student goes through an undergraduate medical course after completing secondary education, he adds.
Dr Ravindran says it is unfortunate to opt out of medicine, but notes one can still make a good living in other fields.
“They may choose to work in other fields such as the pharmaceutical industry or research. Some may choose to pursue their own interests in unrelated fields,” he says.
For former housemen, Dr Jeyaindran suggests for them to opt for occupational health and safety where they can be employed by oil and gas companies to work at oil rigs or at factories, which provides a quite decent salary.
“For those who want to remain in the medical field, they can take up a diploma or masters in pre-clinical sciences or take up a bachelor’s degree in law so they become lawyers who handle medical legal issues,” he says.
They can also venture into the pharmaceutical industry due to their knowledge on medicine, he adds.
However, he notes housemen who are terminated during their placement due to their incompetency on the job and lack of knowledge, rarely go back into anything related to the medical profession.
“Terminated housemen usually end up taking any jobs they can find to sustain themselves,” he says.
Dr Jeyaindran reveals these former housemen would hide their status as former doctors when meeting potential employers over fears of being “overqualified” for the job.
As for medical students who failed to graduate from medical school, he suggests that they at least obtain a Bachelor of Science, which is offered in certain universities.
“This certificate enables students to secure jobs when they graduate, and they will be able to get their medical degree (MBBS) at the end of the day should they choose to pursue it,” he says.
He adds that former medical students can also opt for a diploma or masters in chemistry or physiology as this will allow them to become tutors or lecturers for the pre-clinical years in university where there is great demand.
After spending years in medical school and placement but unable to complete it, it would be depressing and disappointing for the housemen and their parents, who had high hopes for their youngsters.
Dr Naidu says parents can’t be much help at this point, except to provide emotional support.
He reminds that parents could find out the reasons behind their child’s decision to stop pursuing the course.
“Parents musn’t force their children into medicine in the first place,” he says.
He also calls on parents to allow some space for their children to learn and develop as individuals. They shouldn’t be overprotective parents who tend to the children’s every request and complaint.
“We often hear of helicopter parents who hover around and interfere whenever their child is facing a little stress or is being overworked.
“This ensures the child will never learn to handle stress or difficulty,” he says.
Dr Jeyaindran says it is important to have the support and understanding of loved ones when stressful situations arise.
“The transition from being a medical student to a functioning doctor can be stressful, as the work and responsibilities are very different.
“If a houseman or medical student has nobody to turn to, he or she would just become more withdrawn,” he says, citing communication as a good way to identify and overcome problems.
Parents or families should provide emotional support and engage with their children, adds Dr Jeyaindran.
He reiterates that parents shouldn’t push their children to pursue medicine ust because they want doctor in the family.
He cites examples where housemen revealed they were pressured by their family to take up medicine, when in fact, they wanted to be inother fields.
There are also parents, he says who are surprised by the long hours put in by young doctors. “Some parents are shocked when they learn about the working hours and how hectic the job can be,” he shares.
Dr Jeyaindran says there are also cases where housemen tell their parents they are at the hospital, when they are “in hiding” at the hospital ibrary, or in some cases in their own car, until working hours are over.
Children at whetever age, will sometimes hide things just to please the parents and also to avoid pressure at home, he adds.
“Some are bold enough to tell their family they will not work in the medical profession after graduating, while some too timid to tell the truth.
Echoing Dr Ravindran and Dr Jeyaindran’s views, Dr Mohanraj says disillusionment among children, specifically medical graduates, is because of the expectations parents have of them.
“Parents must be able to identify the child’s interest and potential rather than forcing them to pursue medicine.
“If a child has made up his mind to stop medical studies due to repeated failure, parents must help by providing other options rather than forcing the child to continue,” he says.
Dr Mohanraj adds that should they face difficulties in going through their housemanship, it may be best for parents to advise their child to consider other career options. “Medicine is a vocation and not just an occupation. Parents must not force their children into medicine to realise their own unfulfilled ambitions through them. Not everyone is cut out to become a doctor, if you want to become rich quickly, medicine is certainly not the pathway,” he says.
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