Update on the Scheme of Service

Efforts to improve the welfare of doctors working in Brunei has long been around. Pensions, On-Call Allowances and Scheme of Services has been the talk of many, but like myself many of us didn't know what was going on in terms of effort done to address these very important issues pertaining our welfare.

From a reliable source eversince 1997 (this might be slightly off) when our then DG proposed for on-call allowances to be implemented, the paperwork has gone through various hands and gone through several revisions until now. Alhamdulillah the final version of the proposal has now been agreed by everyone (Medical & Health services) and in the process of submission for approval to the Jawatankuasa Tanggagaji at JPM. The proposal package now consists of On-call allowances, a new Scheme of Service and 'special allowances' for doctors working in the Ministry of Health.

For everyone's information, prior to the proposal for the revised scheme of service, a proposal for pensions to be returned to the doctors was submitted. Unfortunately the proposal was unsuccessful.

Going back slightly it was since early 2007, Our Minister of Health agreed to form a committee to look into the current scheme of service. The committee is headed by a very senior member of the health ministry and were represented by Hospital doctors, GPs, and Public health to come up with a scheme of service which would be in line with the current international trends, competitive and career progressive. About 2 months ago this committee met with senior representatives from JPM and members of the Jawatankuasa Tanggagaji to discuss the proposal and a few amendments to the proposal was recommended.

Just to highlight some of the challenges that we face are that

1) The number of doctors we produce is still not meeting our demands. As of 2007 our ratio of doctors to population is around 1:900 (that includes ALL the doctors working in the Ministry of Health). Singapore has 1:600 and are still lacking and actively head-hunting qualified doctors to work there. According to OEDC the figure that we should aim for is 1 : 350.

2) The number of doctors leaving the service is increasing. Doctors are highly marketable professionals and continuously poached by agencies with attractive renumerations.

3) Medicine is not an attractive career choice for students. Lengthy undergraduate period, Health-risking career, Stressful & Long-hours of work appeals only to the very few. There are now many other career options that provides a better lifestyle and a better renumeration for the 'cream of the cream'.

In brief the committee want this package to achieve 3 things

1) Attract - Attractive to students to want to do medicine, attractive to qualified experts and doctors to come and work in Brunei.

2) Retain - retention of doctors who are currently working in Brunei to continue working with the Ministry of Health

3) Possess - For the country to possess talented, skillful, knowledgeble Clinicians, GPs, Public health, Scientists, Researchers and propel the quality of health service forward.


Where are we now? This process is certainly not as straightforward as we think. It has to go through to so many levels before approval. Then when approved it will take a while before implementation can take place. How long? I'm not sure if anyone can answer that.. but at least we know that the ball is rolling.. and insyallah hopefully not too long.

Medical Superintendant

Assalamualaikum w. w.

First of all Doctors Mess would like to wish all our muslim readers in welcoming the month of Ramadhan. Hopefully we will all be blessed during this holy month and our 'amal ibadat' be accepted Amin.

Secondly, we'd also like to congratulate Dr Hjh Norlila (ex-CEO of RIPAS) on being promoted as the new Director General in the Ministry of Health. We all wish the best for her, and we'll promise to try and make her life the least miserable as possible...hehe... kidding.. (ops there goes my promotion). We all know it's a very tough and challenging post and we will try to support her as much possible, and I think it's fair to say that the majority of the doctors are very happy with the appointment made so far. All the best to Dr Hjh Norlila and congratulations again.

Now back to business. I'm sure most of us have heard and if not been to the recent meeting that was held between our DG and the RIPAS doctors at the lecture hall in RIPAS Hospital. For those who couldn't make it, the outcome of the meeting was to nominate a medical superintendant.

What would be the task of the medical superintendant? Unfortunately we don't have the official job description yet... however from the talk that our DG gave we gather that the person that will be appointed will be tasked MAINLY to look after the welfare of the doctors working in the medical services. This means he/she will ensure that issues pertaining salary, allowances, housing, and others that is within the realms of welfare for the doctors are taken care of. The medical superintendant is suppose to be the link between the doctors and the DG, and is responsible to ensure that there is minimal delay in addressing these welfare issues. As for promotion, we not sure if the medical superintendant has authority to promote doctors but I'm sure the M.S. can recommend them to the DG.

The DG also conveyed the message that our ministry is seriously looking into this welfare issue and is working very hard to ensure that our welfare is looked after. The ministry would like to make sure our doctors are happy working in Brunei and will continue to stay working here.

The medical superintendant will be chosen from amongst the Local Specialists and will be working directly with DG, thereby bypassing the CEO of RIPAS. And will receive a certain amount of allowances which we are not sure yet of the figure. Apparently this post is not something new. Before there was CEO and Director General, the medical superintendant post had already existed, but after the Ministry of Health was reorganized, the medical superintendant post was replaced with CEO, and since was left vacant until now.

So who has been nominated? That we don't know but we've heard a few names being mentioned several times. Perhaps it's too soon to mention. However that person will have a busy task ahead because as well as performing their responsibility as a medical superintendant, he/she would have to perform their normal clinical duties. Whoever it is we wish them the best. May god mercy on their soul coz these bunch of doctors are quite feisty! Kidding.. ofcourse we are very nice people aren't we ;-) Aammton that includes you, behave yourself!

Next post insyallah we will give an update on the current efforts made by the ministry of health to improve our welfare. This involves On-Call Allowances, proposed salary scale and other allowances. Happy Fasting!

More locals passing their Membership exams

Congratulations to Dr Ady Adillah (General Surgery) and Dr Helinie (ENT) for having passed their Membership exams from the Royal College of Surgeons, and to Dr Rosmonaliza (Internal Medicine) another fresh graduate from the Royal College of Physician (UK).

Well Done guys, this means there will be more SMOs in RIPAS... keep it coming! And ofcourse we hope to hear an invite for lunch soon ;-)

Dr Ady Adillah (MRCS)

Dr Helenie (MRCS)

The Bowling Doctors of Brunei!

Dr Aziman, Dr Azmi, Dr Athaai, Dr Natalie & Dr Norwani

Today Doctors Mess marks it's 4th Anniversary by bowling it's way through Charity!

45 bowlers comprising of 9 teams from various departments in RIPAS Hospital and Public Health took part in the Doctors Mess RIPAS Charity Bowling Tournament 2008 which took place at Utama Bowling at 2.30pm.

This Charity event raised BND $1,000 which will be donated towards the 'Tabung Kebajikan Pesakit RIPAS" di Kementerian Kesihatan and at hand to receive the donation on behalf of the charity fund was the Guest of Honour Dato Seri Laila Jasa Dr Md Arif b Abdullah receiving the mock cheque from Dr Azmi Mohammad on behalf of the Doctors Mess.

The tournament began with an opening throw from DSLJ Dr Md Arif who was also the team captain for 'Gutter Balls 1' representing Internal Medicine 1.

The Public Health team "Healthy Sihat" led by Dr Fakhri did not waste any balls and commanded superiority throughout the tournament dwarfing other teams with score of 684 - 710 - 658 and collected 31 strikes and a total score of 2052 to be crowned champion of the tournament.

Following at 2nd place was the team representing the Lab Services "Mighty BAMLS" led by Hjh Aishah collecting the score of 616 - 578 - 667 (21 strikes) and a total score of 1861. 3rd place went to the team representing the Department of Radiology "T.N.T - tarik nafas tahan" which scored 548 - 590 -581 (15 strikes) with a total of 1719.

Highest Score went to Hj Shamsul (Public Health) and Hjh Aishah (Lab Services) in their respective categories, each receiving 6 month free membership to Fitness Zone.

The most Stylo-Mylo player for the tournament was awarded to Dk Herny Sharnie (Radiology) for her stylish kick at the end of each throw, and to Pg Ya'akob (Admin) for his verbal & physical antiques.

Prizes were also given to the player with the lowest score (hehe..) and we're proud to say Dr Aammton secured that prize without any difficulty. Well done Aamton! Dr Norainun was disqualified from receiving the prize because she had to leave early... tsk tsk tsk...

Anyhow everyone appeared to have enjoyed the afternoon. There were lots of cheering.. shouting... jumping... and cupcakes (thanx Wadi!) Thank you to the sponsors for making it possible to organize such an event. And special thanks to our docs Dr Athaai & Dr Aziman for getting the sponsors. Dr Norwani & Dr Natalie for their lightening mathematical calculations of the scores and setting up the tournament. Dr Ayu & Dr Rizal for the prizes & deco & Dr Ady our treasurer. And to the rest of the Doctors Mess Committee... Thank you all and well done!

These are the final scores.



p.s. more pictures of the tournament will be posted once we get the pics from our un-0fficial photographers that were scattered everywhere.. tune in..

Bowl for charity

Hello everyone! It's time again for our annual sporting event. Last year during the pool tournament we saw Herry Zul triumphed over Dr Ang, Dr Amalinda beat Dr Dk Norzieda and our Minister demonstrated his skills to defeat DGMS in their respective categories.

This year we would like to see who amongst us health professionals are top kegglers! Personally I'm terrible at bowling... only averaging 180 or so hahaha.. I wish! However the idea of this event is just for us health professionals and other allied health professionals to get out from our stressful working environment and trash it out at the bowling alley... Kidding... just have some fun alright and at the same time do some charity work lah.

And of course since we are all very nice people.. and we like to help others (sincerely)... why not give some to the less fortunate aye. So we are also inviting kind individuals, groups, companies, anybody to donate money towards the 'Tabung Kebajikan Pesakit Hospital RIPAS' which was officiated by our honourable Minsiter not so long ago, to help boost their funds.

This will enable the Social Welfare Unit at RIPAS to channel the funds into buying essential household equipment, food, clothings & blankets, and alleviate some of the burder faced by our less than fortunate patients.

This year insyallah, we will see 2 teams from internal medicine, 1 team from surgery, 2 orthopaedics, radiology, lab services, administration, operating room & public health. There is still room for 2 more teams who ever is interested. Sponsors are always welcome!

See you guys at the alley!

For our MRCP Candidates..

EXCELPACES - MRCP PACES Course

A comprehensive 3 days intensive MRCP PACES Course called EXCELPACES is being organised by 12 Senior MRCP teachers from UK, Middle East and India. Date:- 5,6 and 7 October, 2008.

Venue:- KIMS, Hospital, Trivandrum, Kerala, India.

The aim is to provide a low cost MRCP preparatory course for candidates preparing for PACES exam from outside the UK who needs training in examination technique and presentation skills. It is a known fact that the failure rate of non UK candidates in PACES is as high as 60 to 70 % because of inadequate preparation despite having good theory knowledge. This course will get you battle fit for the PACES exam by demonstrating around 60 cases and with Mock exams, all under the scrutiny and supervision of experienced PACES teachers. Only limited seats to maintain good teaching standards and seats are fast getting filled up by candidates from, Middle East, Malaysia and India.

Visit our website www.excelpaces.com or contact our program secretary Jessy Ajith by mailing to enquiries@excelpaces.com

All the best

Thank You


Dr Prasad Nair
Organising Committee Member, EXCELPACES


Disclaimer: We are not sure if Bruneian candidates will be sponsored for those 1st timers taking the preparatory course, best to double check with DGMS office first. However it's nice to know there are other options available if you've already done the traditional course.

Doctors Mess

Condolences to the families involved

Yesterday, as we are preparing to celebrate one of the most Auspicious occasion in our Islamic calendar a disaster struck right in the middle of our beloved capital city. A total of 4 cardiac arrests on-site most likely due to Crushed injuries and Asphyxiation and many others with injuries requiring admission to RIPAS. It was a very very sad day.

The pre-event incident occured around 1015am as thousands (as many as 4,000) of women rushed into the gates of the garden. An eye-witness account from one of the doctors attending the medical cover at that time, Dr Herry Zul said the victims were piled up on top of each other and situation worsen by the crowd pushing and shoving and even stampeding over the fallen ones. At this point it was evident that there was going to be a high number of casualties.

A major disaster call was activated immediately. With the help of the authorities, Dr Herryzul's team manage to retrieve the victims and prevented what would have been a bigger number of fatalities. Within 5 minutes more ambulances arrived and more back-up doctors and nurses arrived on the scene.

Out of the 4 cardiac arrest, one was revived on the scene by the medical team, but only to succumb later in ICU last night. The 4th victim was revived in A&E and is still in ICU, so 3 fatalities in total. Around 27 patients were admitted with sprains and minor injuries.

Our Deepest condolonces to the victims family who lost their loved ones.... Al-Fatihah..

INTERVIEW WITH DATO YAPP

INTERVIEW WITH DATO YAPP

Q: When did you start medical school?
A: 1961, Leeds Medical School

Q: Were you a Government Scholar?
A: Yes, fortunately

Q: You must have passed with flying colours?
A: No, I happened to be a citizen. In fact we were the first batch to take the exam, at that time the citizenship were just introduced. I was among the first to sit for the citizenship exam.

Q: At what age did you start medical school?
A: 19 years old, but I sat for the Higher School Certs in Brunei, and that was also the first batch ever to take Higher School Certs. There were six of us.

Q: Who were the rest of the six Dato?
A: There was one doing engineering, three doing science and another one doing microbiology. Another two on the art side, one doing law, another one don’t know what happened to her.

Q: When did you graduate, Dato?
A: In Leeds, I must have started in 1962. It’s a six years course. I qualified in June ’68.

Q: And you work there for how many years?
A: I work in Leeds in St. James’s hospital for a year. I was in the professorial unit doing a medical job because at first I wanted to do medicine. After that job I changed my mind to do Surgery

Q: That leads me to my next question, why did you choose surgery?
A: At that time, the surgery was in two parts, one three months each.Three months in urology and three months in general surgery. It seems to be a good job for me, and after that I went to Glasgow and the job was anatomy demonstrator, but the actual job title was assistant lecturer in anatomy.

Q: Was it a full time job? And being a doctor too?
A: Yes, it was a full time job and being a doctor too because at that time at Glasgow university in fact one of the biggest medical school with 250 students. 1968 to 1969, I did one year. After that I passed my primary, then I came back to Brunei. At that time actually we should come back after our house job. It was a compulsory three years, you must come back but because I took up this anatomy demonstrator job, I came back a year later. I started working in Brunei in October 1970 and work under Mr Harris for three years as a surgical trainee.

Q: How many doctors were there in Brunei?
A: You mean, in the whole hospital or the locals? We were the first group of local doctors, there were five of us; Dato Joe Lim, Dato Sherlock Chin, myself, Dato Johar, later became the Minister of Health, and Dato Hussin Daud, who was later became the Director of Medical services. After the first group, there was a vacuum of 13 years before Datin Intan and Datin Lim Ming King came back. When we came back, our salary was exactly the same as any graduates either arts or science, that means not only it is more difficult for us to get into the university but we spent a much longer time in University, so at that time our salary was only $1100 when we came back. Because of that, Dato Hussin and myself wrote in to get our salary revised. The two of us wrote in and they reconsider, that’s why the “M” scale came in.

Q: What other changes in term of health care in Brunei do you see?
A: For a start, previously there was only a Director of Medical Services. There was no Perm Sect, there was no Minister. So the Director General, in fact was the head of Medical Services. He controls or runs the service. Now, you have perm sect, in fact you have two Director Generals, one for the Medical Services and the other one for public health. The other thing that was introduced during these years was decentralisation for the clinics in the periphery. So as to make the Hospital less congested. Also an increase in the numbers of doctors. During our time in the old general hospital, the specialist, there were only four. A gynaecologist, which is Dr Datin Lapru, there were two phycians, Pehin Dato Dr Hart, and Dato Sinatambi. Dato Hart was in charge of the general services and Dato Sinatambi runs the chest clinic and Tuberculosis. And surgeons, at that time there was only one general surgeon, Mr Harris later become Pehin and under him, at that time was Dato Joe Lim and myself. When Dato Joe Lim was away, I was alone for little while, until Dr Gouse came in 1974. And there was an eye surgeon, Pehin Frank, he was also the Director of Medical Services. And later on, Dr Nayan’s (Eye spiecialist) father, Pehin Joshi came. So at that time in the Medical Services, there were four Pehins. That’s another change, from four Pehins to two Pehins today (laughing).

Q: How about in terms of working conditions?
A: Working conditions are better, because it’s so small, it’s like a family. So you almost know all the doctors working in the hospital. Infact you often make referral on the corridor or when you see each other. It a lot less formal and more intimate (smiling).

Q: In terms of investigative machine like x-rays, CT scan?
A: We didn’t have any CT, in fact to begin with, we didn’t have any radiologist. There were two radiographers, Hj Ismail and Pg Mohidin. And often say like IVP (Intravenous Pyelogram) we have to do our own injection and we tell them what pictures we want and then we read our x-rays. If we want to have barium meal, the technician would do the x-ray and we do the interpretation, so our investigations were fairly basic. The CT scan didn’t come in until we moved into this hospital (RIPAS Hospital) in 1984. And there were two radiologists who came, Dr Tony Jones and his deputy Dr Robinson. They came in the 70’ but they didn’t stay for a long time, I think only one or two contracts. I think it was during their senior register time they came to Brunei and then they went back and became consultants. Dr Jones was in Cardiff and Dr Robinson went to North Wales I think.

Q: How about the changes in surgery, Dato?
A: Surgery at that time, Mr Harris was doing all the major surgery. He was a very good all round surgeon and he was thoracic trained as well. He was able to do General Surgery and Orthopaedics. I went back to UK again in 1974 for another five years. I came back to Brunei in 1979. So when I came back I took over most of the General Surgical work, Urology and Paediatrics. Mr Harris still do Thoracic and Orhopaedics. We had two wards, one for General Surgery and one for Orthoaedics. He retired in 1987 and then Mr Wie came. Mr Wie graduated from Leeds and he was orthopaedic and neurosurgical trained. So he took over the neurosurgery and orthopaedics, and because he was also trained in plastic surgery, he took over the burn’s as well. That’s why Burns Unit came under Orthopaedics.


Interviewer: We, that all we have time for now Dato, thank you for spending time doing this interview.
Dato: My pleasure, thank you.


Thank you Ady, Amalinda & Khairul for doing the interview

DERMATOLOGY QUIZ

This is a skin lesion found on the medial aspect of the right thigh. A 16 year old male who has had this for the last 13 years. It was initially excised when he was 3 years old. He presented to A&E with pain and limping of his right Leg because the area surrounding the lesion got swollen. The lesion to begin was not as bad as it is now according the the patient, only recently exacerbated after playing bouncer!

Any guesses?

The SICU story continues.... from Ero Sennin

Last time, I was telling about our 50plus year old lady with a prosthetic metallic mitral valve who came in breathlessness & later on pulmonary haemorrhage. Check the link: http://doctorsbrunei.blogspot.com/2008/05/interesting-chest-x-ray.html

Her pulmonary haemorrhage settled, whilst on heparin & her ventilation requirements did seem to improve. We did a battery of blood tests on her, autoimmune screen turned out negative, and yes, sputum AFBs and PCR AFB turned out negative too. We even did tumour markers, yes a shot in the dark and debated about the relevance of a high CEA. We did however notice her going into obstructive jaundice.

Eventually, she became stable enough for a CT chest, abdomen & pelvis. We were expecting to find lung metastasis. The only thing that was reported from our radiologist was that she had a dilated common bile duct and some narrowing near the ampulla. (I'm recalling this from memory sorry)

After the CT, she proceeded to have a tracheostomy as she had been intubated all this time and we felt it would improve her chances of being weaned off ventilation.

Our friendly gastroenterologist reviewed the CT film and suggested an ERCP, which unfortunately, she was not fit for. She actually deterioated post tracheostomy (acute lung injury) & required a higher ventilation requirement. I thought she wouldn't make here at that time, but she weathered round.

Surprise

It was time to tell the family what we found & what the options were. When we discussed with her husband regarding the CT Abdomen findings, he asked if the 'stricture' in the billary tract was a result of her previous radiotherapy or chemotherapy ! This completely knocked us off our feet, coz' this was not mentioned before and there was nothing in the medical notes to say that she had cervical carcinoma a few years ago !!

We traced the Obs&Gynae notes, which were completely separate to her normal medical notes, to find the cervical carcinoma with NO mets diagnosed in 2006, this was however treated 'conservatively', to summarise a complicated story, at family request. She did however go to KL for chemotherapy and radiotherapy.
Later on, she had a cervical lymph node biopsy which confirmed metastasis, but it is unclear on whether her or her family were informed about this as they refused follow up from then onwards.

With that in mind, we formed a definitive treatment plan with the family, to continue her on artificial ventilation, but not for aggressive cardiopulmonary resuscitation in the event of cardiac arrest.

She slowly continued to deterioate, and died within 1 week after the discussion.

May she rest in peace.

Coolbrunei Weblog

What's hot in RIPAS at the moment?

Even officials at the ministry are talking about it...

It's a website.... not any ordinary one... A very interesting weblog which discusses many issues that involves the doctors. Although the sources can be controversial, it has so far manage to 'un-earth' issues that has been quite difficult to discuss openly, like pay, promotion, brain-drain etc.

Comments:

At last ... a place where you can just let it out...
A recommended site to visit..

http://coolbrunei.wordpress.com/

Medical Students in RIPAS Hospital Brunei

A Local student (undergraduate from University of Queensland Australia)

Posing with the Orthopaedic Team

RIPAS Hospital continues to accept students from local institution as well as abroad for either just a short period of 'get-to-know' experience, to a 4-6weeks of clinical attachments in various specialties. It is open not just to students who are interested in medicine, but also in other allied health professions such as psychology, dietetics, pharmacy, physiotheray, labs and many more.

For those who have successfully gone through their attachments at RIPAS in whatever speciality... Congratulations. We hope the time you guys have spent with us have not been too boring... hehe... and hopefully the experience that you have gained with us can be of use in the future.

If you are interested in doing a stint in RIPAS, it is a good idea asking your friends who have done the particular specialty, for there is always varying experiences. In general, for surgery & Orthopaedics, I think this hospital is very good at providing hands on experience for the students as you can see from the above picture. The students also get ample teaching from the MOs, SMOs, & Specialists. If they don't... you must nag them!! Of course it also depends on the students enthusiasm. We can usually suss out which ones are the keen ones and which ones just want to get through the painful experience as quickly as possible.

My personal experience, students are usually quite keen to get their hands dirty and get stuck in. However they don't like being asked questions during ward rounds... hey that applies to everyone I think.. but of course the doctors like to pick on the students... don't worry... it's not because they want to catch you out, or make you pay for staying up late at night watching the Euro 2008 instead of reading your Kumar & Clark. It's because it makes them feel 'good' when they can explain things to the bewildered students.... Have you noticed the expression on the doctors face beaming when they explain the significance of an Arterial Blood Gas results? My tip.. an enthusiastic nod... accompanied by 'awh....' when the specialists starts explaining the causes of Acute Renal Failure.. goes a long way.

You also get more points when you ask an intelligent question like.. what is the current trend in Management of Head Injuries... but becareful not to ask too difficult questions... the doctors might think you are trying to be a 'smartass' and ignore you throughout the ward round at risk of not being able to give a decent explanation.

I think the A&E department here are also good at providing clinical attachments. I have seen students clerking the stable acute cases, assisted in life-threatening cases, and learn to make decisions. There are plenty of scope to learn suturing here. Dr Ang, the HOD is very helpful and keen to teach.

In Internal Medicine, you have the likes of Dr Arif (aka Boss) a walking encylopedia of knowledge, Dr Syafiq (HOD), Dr Haslinda (Endocrinologist) to name a few who are more than willing to ensure that the ward round and clinics will be firing you with questions..

In ICU, i have not personally seen students attached here, but I don't see any problem with it, just as long as you specify that your interested in spending some time there. There's plenty of really unwell patients here hooked up to fancy machines that their lives depend on. You can learn a lot here especially when Dr Yazid is around who's always keen to teach. If you bump into a young dashing, handsome Doctor Aamton... I have bad news... he is married hehe.. but I'm sure keen to teach too... right Aamton? Skills to learn here... Arterial Stabs, Central Line insertion, and if your lucky.. intubation.

Alright guys.. I'm running out of ideas plus it's 1am now. Need to sleep coz ward round starts at 7.15am... yes boys & girls if you are planning to do surgery... be prepared to get up early!!

Golf set for sale

Selling my Precept Golf SA71 set with bag.

Bought last year at Empire Hotel Driving Range and used about 4 times.

Price $400 or nearest offer.

ps. Amy, bali tah since you are now an SMO .... hee hee

Anyone interested can contact Ero sennin directly in ICU, or jst leave a message here. Cheers

Vacancies for doctors to work in Brunei

We have received a lot of requests on how to apply for work in Brunei. I'm not sure what is the official requirements for doctors in Brunei, but having worked here for almost 2 years, I can say that we are still short of doctors both in the Health Services (GPs) and in the Medical Services (Hospitals).

We have about 460 doctors working with the government of which 2/3 are expatriates. We serve a population of about 300,000 people at 4 different districts, Brunei Muara, Tutong, Kuala Belait & Temburong. So the ratio of doctors to population is about 1 to 800 not taking into account the attrition rate.

If you are interested to work in Brunei, below are information regarding on how to apply

This information has been extracted from the official MoH Website

Vacancies are follows:

• Department of Medical Services
• Department of Health Services

Requirements

• Recognized basic medical degree
• Relevant post-graduate qualification
• At least 5 years of post-registration working experience
• Working in a job relevant to the post being applied for

Salary and level of appointment will be determined by qualifications and experience.

Benefits:

• Tax-Free salary
• Passage to Brunei Darussalam for you, your wife and up to four children under the age of 18 years.
• Heavily-subsidized housing, charged only at BND130 per month.
• Education allowance of up to BND800 per month for up to four children.
• Free treatment at government facilities for you and your wife, and your children under the age of 18 years who are resident in Brunei.
• 48 days of paid annual leave.
• Shipment of personnel effects.
• 25% gratuity on successful completion of contract.

How to apply:

• Download and print application form (SPA 1).
• Send completed form with required documents to relevant Department (Medical or Health).
• Required documents:

a. Up-to-date CV giving details about the work you are doing now and have been doing in the last 5 years, and your clinical skills and responsibilities, as well as information about the hospital or clinic you are working at size, workload etc.

b. Proof of registration after completion of medical training.

c. Copies of your certificates

d. A copy of a letter/certificate of Good Standing from your present Medical licensing board (under which you are currently practicing) which should be less than
6 months old.

e. The names, full postal addresses and other contact details (and preferably email addresses) of at least three referees.

Please also provide an email address for ease of contact.

Applicants considered suitable will be invited by the Public Service Commission to attend an interview. Successful applicants will normally be given 3-year contracts. In exceptional circumstances two year contracts will be considered.

Applicants must be prepared to work in any of the four Districts of Brunei Darussalam.

---

Department of Medical Services

Vacancies for Doctors In Department of Medical Services

Specialty	Specialist	Senior Medical Officer	Medical Officer
A&E Medicine			Yes
Anesthesia	Yes		Yes
Cardiology	Yes	Yes	Yes
Respiratory Medicine		Yes	Yes
Critical Care Medicine			Yes
Dermatology			Yes
Infectious Diseases/Tropical Medicine	Yes	Yes	Yes
Internal Medicine (Endocrinology)		Yes	Yes
General Medicine		Yes	Yes
Neurosurgery			Yes
Obstetrics & Gynecology	Yes	Yes	Yes
Oto-Rhino-Laryngology			Yes
Renal Medicine			Yes

Applications should be sent to the Director-General of Medical Services at:

Director-General of Medical Services

Department of Medical Services
Ministry of Health
Commonwealth Drive
Bandar Seri Begawan BB3910
Brunei Darussalam

Or by email to moh_dgms@hotmail.com

---

Department of Health Services

Specialty	Specialist	Senior Medical Officer	Medical Officer
Maternal and Child Health Services			Yes
Primary Care Services + School Health Services			Yes

Applications should be sent to the Director-General of Health Services at:

Director-General of Health Services

Department of Health Services
Ministry of Health
Commonwealth Drive
Bandar Seri Begawan BB3910
Brunei Darussalam

Or by email to phc_moh@hotmail.com

An Interesting Chest X-Ray

A busy ICU

ok, first photo is of some of busy people in Surgical ICU. Note our hardworking nurses, Dr. Izzati & Dr. Nurul (surgical).

Anyway, the Chest Xray I've got here is of a 50 plus year old lady who has had a prosthetic metallic mitral valve replacement. She's basically come in with severe breathless. A&E saw this Chest Xray and thought she was in severe pulmonary oedema, gave her frusemide and intubated her & admitted to SICU.

On initial history taking from her relatives, she has been unwell for the past 5 months, easily irritated, not eating well, having chronic dry cough WITH on average once weekly haemoptysis. She has no previous history or contact of pulmonary TB. She normally takes warfarin for her metallic mitral valve replacement.

What's her INR or clotting profile ?

It was so high, it was beyond the scale readable to the machine !! & yes, she was having pulmonary haemorrhage visible in the endotracheal tube.

She was very unwell & went into Acute Respiratory Distress Syndrome (ARDS) and we managed her to improve her lungs or rather her ventilation after a couple of days. Magic, isn't it ?

At this point, it has to be Tuberculosis until proven otherwise. We sent 3 sputum samples and so far negative, and the PCR AFB is negative. We note that she has a hard enlargened left supraclavicular node.

Her ventilation requirements have improved and right now she is awake, and we are continuing to keep her on heparin infusion for her MVR.

What's our working diagnosis....

Could this be Wegner's granulomatosis, SLE, some other vasculitis, malignancy ?

We're still waiting for the autoimmune screen / profile to come back and she's not stable enough for a CT everything (thorax, abdomen, pelvis)

If the autoimmune screen and the CT comes back negative, what else could it be ?
Was it a warfarin overdose of the massive kind ?

Will let you know when we have the answers.

Ero Sennin

The Temburong One Week Duty

I’m back! Phew… just got back from Temburong duty last week and still recovering haha… not from the travelling but from catching up with my post-poned outpatient appointments in RIPAS. I thought I might write something about Temburong Hospital for the benefit of future doctors who will be posted there, unfortunately I could not dig out much information from the web, so had to do a bit of research. The information provided below is based on the 2007 Temburong hospital statistics and my observation during my one-week stay there. Enjoy…

Introduction:

The Pengiran Isteri Hajah Mariam Temburong (PIHM) Hospital is one of the smallest district general hospitals in Brunei Darussalam and supposedly houses no more than 50 beds with two main wards (Male + Children & Female), 1 isolation ward (converted into doctors on-call room and a multi-function area) and a newly furbished day-care renal dialysis ward. The hospital provides general medical services to a population of around 9,000 people in its district.

On average Temburong hospital sees around 123.5 patients per day in it’s Out patient Department (General & Specialists). The ratio of doctors to population in Temburong is approximately 1: 3000 with only 3 permanent doctors to serve the whole district.

Amongst the services that it is able to provide includes Outpatient & Inpatient services, Outpatient specialists clinics, Pharmacy & dispensary, X-ray, Accident & Emergency, Dental Care, Physiotherapy, Laboratory services and until recently a Day care Dialysis centre for 11 of it’s patients requiring Haemodialysis. 3 permanent medical officers have been dedicated to this hospital; one of them is a female doctor with experience in Obstetrics & Gynaecology. There are no local doctors posted permanently here as yet.

Doctors’ duties in Temburong

During a regular working day, the doctor who has been on-call for 24 hours the night before will be responsible to do a ward round in the morning before going Off Duty for the rest of the day. This leaves the other 2 doctors to run the general outpatient clinic, which regularly sees around 85 patients a day, and admits around 2-3 patients per day during their on-call period. Majority of the cases they see in clinic are mainly cases you would see in a typical General Practice, and for those requiring admission to hospital 70% are medically related, 13.3% Paediatrics, 11.8% Obstetrics & Gynaecology and only 4.7% Surgically related.

Since March 2008 the Department of Medical Services through RIPAS Hospital initiated a new move to support the medical services in Temburong. It offers a separate paediatric service every working day and sends one local medical officer from RIPAS hospital to spend 1 week working in PIHM Temburong Hospital. These extra doctors were incorporated into the on-call rota and will also be doing clinic sessions during their time in the hospital.

With the new initiative Temburong Hospital Medical Service can now operate with a 1 in 5 rota and relieves some of the burden in managing paediatric cases in the outpatient. However if a paediatrician is doing the on-call, there will be no next day paediatric cover, and if a RIPAS junior medical officer is on-call, there should be a senior person to be 2nd on call as well.



After completing a week’s duty in Temburong hospital, several observations has been made and are as follows:

1) The majority of the cases seen in the outpatient are very much cases you will see in a general practice.
E.g. Cough & Cold, Headache, General Obstetrics & Gynaecology, Management of Diabetes & Hypertension.

2) Despite Paediatric Cover, there will be a day in the week when the Paediatric On Call will be off the next day, leaving you and the other doctor to deal with Paediatric Cases. (NB Paediatric admissions accounts for 13.3% of total admissions, the majority are medically related adult admissions).

3) Hesitation in management of Paediatric & Medical Emergencies for the surgeons and expecting a paediatrician/medic to handle an Adult trauma case is sometimes a concern.

4) Certain important drugs are not available and some were found to be out of date
E.g. Intravenous Phenytoin for management of prolonged seizure (not available during one of the RIPAS doctors week of duty)

5) There were actually only 27 beds available & functioning (instead of 50 beds)


6) The person On-Call is supposed to do the next day Ward Round alone. The problem arises because the M.O. is sometimes quite junior and inexperience in certain specialty cases like Gynaecology and Paediatrics, but most importantly there is an issue of Continuity of Care.

7) No CME Activity listed or planned for the month

However there are some positive feedbacks about this hospital service

1) There is 24 hour Lab Service & X-ray Service
2) All round pharmacy service
3) The On-Call Room is decent & Clean
4) Good food provided by the hospital (apparently this is not a common phenomenon, if you are nice to the nurses and attendants you might get it I guess)
5) Dr Elangovan, the Senior medical officer is very helpful
6) Small Hospital, therefore very friendly environment
7) Hospital Drivers are helpful in transporting us to wherever needed (very useful when you need to get some food for dinner when you are on-call)
8) Helicopter transportation is prompt and almost 24hrs weather permitting


Taking into consideration that it is a small and fairly remote hospital, it is quite impressive that this hospital is still able to provide a fairly good all round medical service.

Suprisingly although the doctors’ population ratio is huge (5x of Singapore) the in-patient activity only accounts for 2.85% of its total activity, the majority of which is medically related. Below are several issues that have been highlighted and followed by suggested recommendations.

Suggested Recommendations:

1) To incorporate Local General Practitioners into the Temburong Hospital Initiative. This would definitely be beneficial for the population of Temburong. Not only it fulfils the objective of exposing our local doctors to Temburong, but also the added benefit that the majority of illness treated are very familiar to their expertise.

2) Incorporate a period of 1-2 month compulsory placement to Temburong Hospital for all Basic Specialty Trainee (GPs, Surgeon’s and Medics) during their A&E placement, perhaps the last 2 months of their rotation in A&E. However a permanent senior A&E staff (specialist preferably) should be placed in Temburong to ensure training continues for the trainees.

3) To give a Special Allowances for any Health Staff working in remote areas, especially in Temburong district in this case. This is to act as an incentive and appreciate the hardship our staffs have to go through to work at remote places where many facilities are limited, and to recognize that some of them have to leave their family behind to work at these places. Not only will this promote good morale but may even attract health professionals to work in the rural community. The allowances should be awarded to temporary, visiting and permanent staffs at the particular hospital/health centre. The ministry of health can help ratify the rates, so that it is appropriate and always-in line with the standard of living.

4) Provide a simple guideline handbook to management of common Paediatric, Medical & Surgical outpatient & Emergencies.

5) The morning ward rounds should be led by the Temburong doctors every day, to ensure good continuity of care and provide a potential teaching session for the junior MOs. It also promotes the sense of teamwork amongst the Temburong doctors. A timetable should be set to do ward rounds and all MOs should make an effort to come to the ward rounds.

6) Regular update of important emergency drugs.

7) The more experienced visiting MOs can do teaching sessions during their week stay for the Temburong health professionals. This not only gives the opportunity for the permanent staff to score CME points, but also encourages a teaching & learning environment for every health professional.



Conclusion:

In general approximately 97% of the activities in Temburong Hospital are outpatient based and only 2.85% are inpatient work, of which the majority of the cases are medically related followed by O&G and paediatrics.

This raises two important issues, firstly is the proportion big enough to justify having a hospital in Temburong. If it is, then should we allocate more money to ensure that it has adequate expertise, facilities, drugs and equipments. Perhaps we can start by placing a A&E specialist there. I could suggest Dr I.... from RIPAS for a start. Alternatively if it’s not, then we should concentrate on making it a better equipped health centre, with the current facilities that it already has.

However I think the general picture is quite clear from the figures mentioned earlier (derived from Temburong Hospital Statistics 2007) Temburong hospital would benefit from having more generalist clinician around to support the population’s demand of healthcare provisions.

The one-week experience of working in Temburong Hospital has highlighted several issues on how we can better improve the quality of medical services to a small population district general hospital like Temburong. It has also given us the 1st hand experience of working in a hospital environment where facilities, manpower, and expertise are sometimes of limited supply.

The objective to expose our local doctors to our people is most probably a very good step forward not just enriching the doctor’s experience as an individual but also in identifying & highlighting issues for improving our medical services in the future as a whole. After all it is our own people that we are looking after and it is our Health Service that we want to better. My last comment would be, the choice of doctors sent could be better.. ahem.


Btw .. Don't forget to:

1) Be at the RIPAS Jetty by 7.00am for a boat to go to Temburong
2) See the Temburong CEO (Pg Sabtu) on your last day there and ask for the overnight form to claim for your allowances working there

More future Budding Specialists

Congratulations to our latest graduates Membership of the Royal College of Surgeons, Dr Amalinda Suyoi and Dr Amy Thien who recently sailed through (hehe... nda kan?)the final part of the gruelling 3 part MRCS exams at Edinburgh, UK. Both Miss Amalinda (graduated from Nottingham) and Miss Amy (graduated from Southampton) are currently working in the Department of General Surgery, RIPAS Hospital and will be pursuing Higher Specialty Training abroad in their respective field of interest.

Miss Amalinda Suyoi
MRCS (Edinburgh)

Miss Amy Thien
MRCS (Edinburgh)

Also who recently passed their membership exams are Dr Anas Naomi Hj Harun, Dr Yong Chee Kuang (I may get the spelling wrong) & Dr Dk Hjh Norzieda who have successfully completed their PACES of the Membership of the Royal College of Physician Exams last year. Dr Naomi & Norzieda are pursuing a career as Neurology Specialist and Dr Chee Kuang will be training to become an Endocrine Specialists in Singapore soon.

Dr Chee Kuang
MRCP (United Kingdom)

Dr Dk Hjh Norzieda
MRCP (United Kingdom)

So congratulations again to these guys for achieving their exams.. I was just thinking as I'm writing this article, the question why do we need to get our membership exams? Is it absolutely necessary? What is our motivation to achieve this exam? After all it is very very tough... and expensive! Doing the final part of MRCS exam can cost you easily $5,000 bnd! and usually it takes 2 to 3 try to pass.. Is there an alternative around it?

Hmmm....it's quite controversial issue since membership exams only apply to UK recognised Health Care System. What about Malaysia, USA, Australia... does having membership exam offer an advantage there?

In Brunei we have a scheme of service for the doctors and we follow a certain set of criterion advised by the Post Graduate Training Advisory Body. And most of these criterion has been set quite a while ago during our predecessor time. So within the guidelines already set we will see that MRCS, MRCP, MRCGP, MRCOG etc. exams play an important aspect in deciding that a doctor will be entitled to

1) Senior Medical Officer Post & Pay!

2) Ticket to Higher Specialty Training sponsored by the Government

It was one established method of deciding that a doctor has undergone sufficient amount of basic specialty training and are now ready for Higher Specialty Training with more responsibility.

But as training in medicine evolves, newer method of training & assessment has been developed and perhaps the days where Membership Exams will be over and replaced with SEAMLESS training like in Singapore where trainees are chosen right from the start of their post graduate period and undergo a 5 to 6 year period of training straight into a specialty.

In Malaysia the system is slightly different, where you can become a specialist after completing 4 years Masters programme in a particular specialty. What about USA, Germany, Australia, India, Pakistan.. ? I'm not sure how the training is like there but certainly the requirements for training will also be different.

As we get many doctors local and also our expatriate friends coming to work in Brunei, it's necessary that we are able to recognize these qualifications that they come back with and allocate them a post that they deserve and of course the correct pay. Something like a Specialist Accreditation Body like the one they have in Singapore is good start, comprising of local and invited oversea specialist with no conflict of interest, that can recognize and filter the right person for the right job.

Next topic we will discuss the pay of doctors in Brunei, the exact figures according to the current scheme of service according to your qualifications. If you are interested to find out the payscale of the doctors in Brunei from Medical Officer level up to specialist, please tune in next week, after I return from my 1 week duty in Temburong. We will also try to update on the latest with our ON-CALL Allowances...