Many students from developing countries are being trained in Western Medical Schools. T.K. Khoo is a final year medical student at the University of Calgary who will soon be returning to Malaysia. In the following article he reflects on how well he feels he has been prepared for the beginning of his medical career back home.
 

 
"Malaysia? Do you have televisions in Malaysia?" Those were among the first few questions with which we were showered when our Canadian classmates first met us. That was 3 years ago. In a month, I will be graduating with my medical degree from the University of Calgary.

Since 1996 medical students from the International Medical University (then College) in Kuala Lumpur, Malaysia have been coming to Calgary to complete the medical degree. This venture is a collaborative effort between our medical school, the University of Calgary and 19 other medical schools around the world. There are presently approximately 30 Malaysian students in the 3 years of the Calgary program. On completion of our studies we will return to Malaysia to serve the community there.

The last 3 years here as a foreign medical student have been a truly interesting experience, to say the least. Firstly, unlike our Canadian counterparts, we do not have a degree in a science subject. We do, however have an Advanced Diploma in Medical Sciences, conferred by our medical school in Malaysia. The system adopted there is somewhat different; medicine is not a post-graduate program, and is between 5 and 6 years in duration. I had completed 2 ½ years there, and had the option of completing the remaining 2 ½ years there and graduate with an M.B.B.S. or continuing my studies in one of the 20 + partner medical schools around the world; I chose Calgary. Back home, we were taught the basics sciences as well as clinically relevant material, in a systems-based approach, i.e.: The anatomy, pathology, physiology, and pharmacology of the cardiovascular system. The beauty of the system there was, from day one we were taught interviewing skills as well, and had the opportunity to see patients in the hospitals once a week to practice our history-taking skills and physical examination. Also, we had our share of psychiatry, in our behavioral sciences course (or as the students affectionately called it, B.S)

As the system used in our medical school there was very similar to the one in Calgary, the transition to the 2^nd part of our medical education was not terribly difficult. Perhaps the most difficult part for myself was the Canadian accent, the way the North American ‘eh!’ replaced our good ol’ Malaysian ‘-lah!’! Now, as I am near the end of my undergraduate medical education, the question is, how has my education in North America prepared me for the practice of medicine in Malaysia?

Malaysia, although a developing nation, is considered a third world country. An ethnic melting-pot, Malaysia’s people consists of the Malays, the Chinese, and the Indians, with various other minority groups such as the aboriginal folks. Healthcare there is of a two-tiered system; government funded hospitals in every town, as well as better equipped private hospitals in some of the larger cities of the country. This causes quite a discrepancy between the two groups, in terms of comfort (air-conditioned rooms in the private hospitals, a food menu, private televisions), care (lower physician/nurse to patient ratio, more modern equipment), and most definitely, the prices. Patients who can afford it receive ‘better’ medical care, whereas patients who cannot don’t. That is the belief of many. Physicians are paid much better in private hospitals, causing an exodus of doctors out of the government-run hospitals into the private sector. Many physicians work in these government facilities only because new medical graduates have to complete a compulsory 3-year service with the government.

Also, unlike Canada, the patient-physician relationship there revolves around paternalism; the physician is usually (although not in all cases) regarded as the person in charge. It is very uncommon for patients to question the decisions of the doctor, and even more uncommon for one to seek a second opinion. Someone unfamiliar with Malaysians may automatically attribute that to the level of education of the general public. However, it is totally untrue to say that Malaysians in general do not achieve a high level of education. Many Malaysians hold at least a bachelor’s degree, some even more. Yet this phenomenon is seen even in-patients who are engineers, accountants and the like. Conversely, many doctors especially those from the older and more traditional school of thought, do not feel that there is a need in explaining the pros and cons of treatment, and obtaining ‘informed’ consent as what we are taught here. (Remembering that informed consent refers to ability to understand the information that is relevant to making a decision about the proposed treatment and to appreciate the reasonably foreseeable consequences of a decision)

Now, having said that, many patients do in fact, seek a ‘second opinion’, but in this case it is not a second physician they are getting their advise from, but rather, a practitioner of traditional medicine. This is another major difference between Canadians and Malaysians, or any other southeastern Asian country. Because Malaysia is so diverse in its people and culture, we have various types of traditional medicine. The Chinese have their acupuncturists and herbalists, the Malays their ‘bomohs’ or traditional witch doctors, and the Indians their faith healers (though none of these are racially exclusive). Understanding this plays a major role in maximizing patient compliance; if a physician is able to explain a disease condition that is acceptable to the beliefs of the people, they would be more likely to accept whatever treatments the physician recommends. For example, for the Chinese, the hot-cold theory of illness plays a central role in explaining our diseases; sore throats are caused by ‘heaty’ foods such as nuts and fried foods. In addition many believe that the human body is regulated by certain points which can be manipulated by the insertion of a small needle (I personally have been subjected to having 5 acupuncture needles on my face as a treatment for acne!). Now, if a physician is skilled enough to weave an explanation that binds the beliefs of the people together with the current teachings of modern medicine, he would be considered much more credible that his colleague who simply brushes off a patient’s beliefs as nonsense. In this, I do not advocate lying; I consider this merely a way of being sensitive to someone’s deepest beliefs, and integrating our knowledge of medicine into them. Way back in my medical schooldays in Malaysia, we were taught to always ask a patient, "What do YOU think caused your illness?" This in my opinion is an excellent way of teasing out someone’s model of health and illness. The University of Calgary does provide, in its curriculum, education about different cultures, but in the larger scheme of things, inadequate in my opinion.

Of course, the other difference I anticipate when I return home is the relative unavailability of modern equipment, such as diagnostic imaging and laboratory facilities. In the larger provincial hospitals, CT scanners or even MRI scanners are available, but in the smaller primary centers in rural Malaysia, physicians have to use other means as an aid to diagnoses. As well, many hospital labs in Malaysia are not equipped to run the more modern tests, such as PCRs (polymerase chain reaction), d-dimers or the newer cardiac enzyme tests. In general, from my observation during my 14 weeks of electives in Malaysia, doctors there are less dependent on modern diagnostic imaging techniques and laboratory testing (with the exception of ultrasound and the x-ray). One can argue that as a result of this, many doctors there have excellent clinical examination skills (this is a common belief in the local medical community). Here in Calgary, ordering a spiral CT scan of the chest is as simple as clicking in an order into the computer. And throughout my clinical clerkship, physicians routinely order a panel of tests on every patient seen in the ER. CBCs & differential, lytes, glucose, BUN, creats, calcium, magnesium, phosphate… this almost becomes the mantra of the on-call physician.

In conclusion, the practice of medicine in Malaysia is admittedly different from that of North America; vast differences in some aspects, subtle in others. I do anticipate the first year of my work as a new physician to be very challenging, and I suspect that a lot of adapting is in order. However I do believe that my education in Canada has more than adequately prepared me to face whatever challenges in store for me. Finally, contrary to popular belief, we DO have television sets in Malaysia. We make ‘em!