Introduction

I was attached to the general surgical ward in Hospital Sultanah Aminah

throughout my four weeks of elective posting. Hospital Sultanah Aminah is
the main government-funded general hospital for the town of Johor Bahru,
which is the capital of the southernmost state in Peninsular Malaysia. As
Hospital Sultanah Aminah is the main tertiary health centre for the state
of Johor, I was able to gain exposure to a wide variety of surgical
conditions, especially in the field of vascular surgery as my supervisor is a
consultant vascular surgeon. A typical day usually involves starting the
day by joining the ward rounds, talking to patients and examining them,
performing simple procedures such as venepuncture, attending clinics at
surgical outpatient and also observing some surgeries. As this hospital is a
teaching hospital for Monash University Malaysia, I also joined some of
their classes. The challenging part of this electives would be the language
as almost all patients do not speak English. At first I find it difficult to do
proper history taking using Malay and Mandarin, but after a few attempts I
started to get more proficient in it and I feel it was a good practice for my
future career.

Reflection

I think the biggest learning experience for me from this elective is to be

able to appreciate the impact of different healthcare systems on patient
care. After experiencing the well-funded public healthcare system in UK
for a year, coming back to Malaysia allowed me to make better and more
educated comparison with the two-tier system in my home country. As
Malaysia is still a developing country, the government has only enough
funding to provide healthcare to those who need it the most, which are
the low-income group of citizens, though technically every citizen can
access public healthcare if he or she desires. In most instances, the close-
to-being-free public healthcare (only a minimal sum is needed for hospital
stays and consultations) provides a good standard of care to patients, but
the issue of money is still a very real concern in certain disease
management as not all treatments are equally subsidised. Monetary
issues have a strong influence in many cases, with examples like a patient
who had varicose vein ulcer could not afford the three-layer bandage and
got a normal dressing instead, a patient who had to get discharged and
admitted multiple times for dialysis out of the hospital because it was not
funded by the hospital and a patient who delayed her surgery to acquire
funds for the stent needed to treat the pseudoaneurysm in her arm. It is
quite disheartening for me to learn that even now money can still be the
barrier in providing the appropriate care to a patient. Learning in the UK
had instilled in me that we should provide the best care with the available
resources, but it never occurred to me this is a luxury not enjoyed in my
home country and the ethical principles of justice and beneficence come
to mind whenever a doctor has to delay or withhold treatment due to
entirely non-medical related issues. I suppose this can also explain the
different attitudes towards healthcare seeking I observed from the two
countries. People in the UK generally consult their doctors more readily
either when they are ill or when they simply need professional opinions on
their health. This is in contrast with Malaysians where they tend to delay
seeking help up till the point where they cannot bear the symptoms due
to a choice of appalling waiting times in the public healthcare or
exorbitant fees in private healthcare. Another interesting difference from
my point of view is the patient-doctor relationship. I think patients in the
UK generally holds greater responsibility towards their own health and
they respect their doctors as professionals who will guide but not dictate
the interventions they need. In Malaysia, doctors are deemed as
esteemed professionals and patients listen to what they are told, yet the
interesting bit of this paternal relationship is that many patients listen to
but do not do what they are told. The analogy is like that of between a
teacher and a rebellious teen, where the patients know the doctors meant
the best, but the inconvenience of an intervention still outweighs the
complications that will occur in the future due to a general lack of disease
understanding and a slight mistrust towards Western medicine. An
example I saw was a man who simply refused to wear the hernia belt after
an inguinal hernia repair even though he knew it prevents re-occurrences.
I think generally this electives had made me much more aware of the non-
medical side of being a doctor where understanding factors such as
culture, language, logistics, funding and attitude are equally important to
medical knowledge in providing a good quality care. Regardless of the
differences, I think all doctors strive to provide the best care possible no
matter the country they work in.