The Device That Changed The Practice Of Medicine: The Stethoscope

Imagine for a moment the year 1800. A doctor is meeting with a patient – most likely in the patient’s home. The patient is complaining about shortness of breath. A cough, a fever. The doctor might check the patient’s pulse or feel their belly, but unlike today, what’s happening inside of the patient’s body is basically unknowable. There’s no MRI. No X-rays. The living body is like a black box that can’t be opened.

The only way for a doctor to figure out what was wrong with a patient was to ask them, and as a result patients’ accounts of their symptoms were seen as diseases in themselves. While today a fever is seen as a symptom of some underlying disease like the flu, back then the fever was essentially regarded as the disease itself.

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But in the early 1800s, an invention came along that changed everything. Suddenly the doctor could clearly hear what was happening inside the body. The heart, the lungs, the breath. This revolutionary device was the stethoscope.

The inventor of the stethoscope was a French doctor named René Laennec. In medical school, he had learned to practice percussion – a technique in which doctors tap their fingers against a patient’s chest and listen to the sound to try and hear what’s going on inside.

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One day, he tried percussing a patient but had trouble hearing. So he rolled up his notebook into a little cylinder and put one end on the patient’s chest and one end in his ear. He was so impressed by the quality of the sound that he decided to construct a device for listening to the internal sounds of the body.

The result was the original stethoscope. Laennec had invented a way to hear the inner workings of the human body. Now he needed to connect the sounds he was hearing with what was happening anatomically inside the patient’s body.

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To do this, Laennec listened to people right before they died, and then connected these sounds to discoveries made during the autopsy. Soon, Laennec made some key discoveries using his stethoscope. For example, he found that when a person has fluid beneath their lungs, they make a bleating sound, kind of like a goat. A sound he called egophony. He also discovered sounds that tracked with the different stages of tuberculosis.

Laennec published his results, and soon doctors were making other important discoveries that changed the way people thought about disease. Little by little our entire understanding of disease shifted from one centered around symptoms to one centered around objective observation of the body. Medical language completely changed, as doctors invented new anatomical words for diseases, like Bronchitis, which means the inflammation of the bronchial tubes.

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In parallel, the device evolved as well. In the 1840s, doctors began experimenting with flexible tubing and soon an Irish physician invented the binaural stethoscope design with two earpieces that we still use.

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This evolving device got doctors thinking about disease in new ways, changing their dynamic with patients and giving doctors a lot more power. Before the stethoscope, to be sick, the patient had to feel sick. After the stethoscope, it didn’t matter what patients thought was wrong with them, it mattered more what the doctor found.

René Laennec actually felt that patient’s accounts of their own disease were still important, but the quest for objective information about disease was underway, and the stethoscope was just the beginning. Now we have X-rays, CT scanners and MRI and PET scans. All of these devices are basically trading upon the same paradigm that the stethoscope created: that doctors should be able to detect abnormalities inside the body to reach a diagnosis, regardless of how the patient is feeling.

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These new technologies have led to so many important discoveries about the human body and disease. Today, we can spot tumors before they become life threatening and diagnose problems like high blood pressure before they causes heart disease. But this new way of thinking has also pushed doctors and patients farther apart. The doctor is no longer in your bedroom interviewing you about every detail of your experience.

René Laennec died in 1826 at the age of 45, mostly likely of tuberculosis, a disease he and his stethoscope helped us understand. It’s been 200 years since he first rolled up his note book and pressed it to that patient’s chest. Medicine looks completely different than it did back then, but somehow the stethoscope has endured.

It’s no longer a wooden cylinder, but to this day, when you walk into a doctor’s office for a routine exam, you can expect to feel the familiar stethoscope on your back.

But that could be changing. Powerful imaging technologies like ultrasound have made the stethoscope exam less critical to the diagnostic process. Medical students aren’t as good as using stethoscopes as they used to be, and across the board doctors today rely less on the stethoscope to make diagnoses. The rise of portable ultrasound has some doctors arguing that we don’t need the stethoscope anymore. They say that if you have that technology right at the bedside, why not use it right away? Ultrasound is an incredible tool, but it still isn’t widely available in many developing countries, and even in the United States it’s expensive. Right now the stethoscope functions as a screening tool so that patients don’t need to go get an expensive ultrasound unless they need one.

Dr. Andrew Bomback is a nephrologist and an assistant professor at Columbia. He still uses his stethoscope, but he says that in general doctors aren’t as good at listening to the body as they once were, and they rely on the stethoscope exam less and less to make a diagnosis. “It’s become almost a ritual more than an actual tool in terms of making diagnosis,” Bomback explains.

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Regardless of how it’s used, the stethoscope remains omnipresent in our culture. Do a Google image search for doctor, and you will see what a physician is supposed to look like. The plurality of the doctors pictured on the first page of results are white men in white coats. Some of them are peering inside patient’s ears, others are writing something down on a clipboard. But all of them have stethoscopes.

And they are wearing the stethoscope in the exact same way–which is like a shawl around the back of the neck. Andrew Bomback says this way of wearing the stethoscope is a relatively recent fashion trend, probably borrowed from TV shows like ER and Scrubs. Doctors used to wear their stethoscopes dangling down the front of the shirt like a tie, which was practical. If you needed to use it quickly you could just pop it into your ears. Bomback observes that “it’s almost like this new version of wearing it like a scarf or a shawl is almost a concession that it’s more a fashion accessory than actually a tool that we’re using.”

But even if it’s become a fashion accessory, Dr. Bomback isn’t ready to give up his stethoscope. He says it’s an important conduit to connecting with his patients. Physical contact between a doctor and a patient has become increasingly rare. Doctors visits are short and physicians often spend much of time staring at a computer screen. Bomback says the stethoscope provides an important opportunity for intimacy.

“The stethoscope is still a part of the exam” he says, “aligned with the laying on of hands” associated with healers. “When we go to do the physical exam, we move away from our desk, we move away from the computer, and we stand right next to the patient and it’s a much more intimate conversation.”

Bomback says he thinks the stethoscope lives on in part to keep doctors and patients from drifting too far apart. To make sure doctors keep close to their patients, and keep listening.


This article originally appeared on 99pi.org. 99 Percent Invisible is a podcast on the design of things we never stop to think twice about. If you enjoyed this article, head over to their website and listen to their playlists.



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 A few weeks back Malaysians were shocked to hear of a man  impersonating a medical officer at a hospital  in Alor Setar. What was impressive was that the man kept the act up for about a year before authorities caught him! 

 There have been many cases of people impersonating doctors or surgeons for all kinds of reasons. These are some of the most interesting throughout recent history. 

 1. Kristina Ross 

   

  Fake profession : Plastic Surgeon 

 Kristina Ross frequented bars and pubs, claiming to be a plastic surgeon. She’d approach unsuspecting women, sweet-talk them and get them to know about her “private practice.” Under the guise of a plastic surgeon, she would conduct “breast examinations” on these women, and have them contact her number. 

 Her years of fake activities was brought to a halt when two recipients of her “free breast examinations” contacted the number Ross gave. The number belonged to a real plastic surgery clinic, but had no surgeon that went by the name of Kristina Ross. Their suspicions of the phony surgeon grew, so they called the police. 

 The authorities launched an investigated, and arrested Ross sometime later. But that’s not the last part of the story; upon arrest, it was discovered that she was actually a transgender man who changed his sex. 

 Bottomline: don’t subjugate yourselves to medical exams in non-clinical settings. 

 2. Francisco Rendon 

   

  Fake profession : Dentist 

 Rendon was able to practice his own twisted brand of dentistry for about 16 months before the police finally caught on. 

 His dental clinic was situated between two automobile workshops. His patients grew wary of his dental credentials as they had to sit in a leather office seat instead of a reclining chair. 

 Hygiene was not maintained well; Rendon made his patients spit into a trash can rather than a proper sink. He used unlicensed tools, including a tool which purpose was to polish cars on his patients. 

 When the authorities came to his “office” to arrest him for practicing without a license, he still had many patients in the waiting room. 

 3. Keith Allen Barton 

   

  Fake profession : Doctor 

 This lying physician claimed that he could cure serious diseases like HIV and cancer. He claimed he could “stop the diseases before they spread” and “nip it off from the bud.” He spread lies about the pharmaceutical industry, propagating the myth that corporations were hiding the real cure to those diseases. 

 In reality, what he did was charge his patients exorbitant fees for his homemade cures. Most of his remedies were made of cheap ingredients and did nothing to improve patients’ conditions. Sometimes he even made it worse. 

 He shares the same name as a registered doctor in California, and used this fact to swerve past the authorities. He was finally arrested under charges of identity theft and grand theft. 

 4. William Hamman 

   

  Fake profession : Cardiologist and Medical Speaker 

 Everybody liked him; he flew commercial planes for a living, and was also a cardiologist with 15 years of experience at the side. He frequently published papers in academic journals. He went around delivering lectures at universities and Cardiology seminars. 

 One day he submitted an early draft to a university committee that oversaw publication for their medical journal. One staff member spotted a glaring flaw in the otherwise impeccable paper; he had no M.D. (medical doctor) qualification. 

 What makes Hamman so interesting is that his academic achievements as a fake cardiologist were particularly impressive. His focus was on team-based efforts and how to get cardiology teams to work better together to improve outcomes. It had real academic weight to it. 

 5. William Bailey 

   

  Fake profession : Doctor 

 Bailey was an eccentric man. Being born in the late 1800s, when radioactivity was still a poorly understood science, he was obsessed in marketing the health benefits of consuming radioactive substances for the masses. 

 In 1918, he released Radithor; a tonic that he claimed could cure diseases and restore health by stimulating the endocrine glands. Of course, there was no scientific basis to this. Radithor was made by adding radium crystals into water. It gave off an emission of 1 microcurie per mole of Ra. 

 Despite not being proven to be effective, the public lapped up Bailey’s bogus claims of the healing properties of Radithor. Eben Byers, a young Pennsylvanian competitive golf player, was urged to take the irradiated substance after a consultation with his doctor. He was suffering from pains in his side; so he bought and drank Radithor on a daily basis. 

 Byers died in 1932. He had holes in his skull due to radiation poisoning; his jaw even fell off as it degenerated. He had to be buried in a lead coffin to contain the radioactivity from his body. 

 Bailey died after the Second World War, after having suffered from multiple cancers and poisoning. 

 
 Source: 

 
	  http://www.dailymail.co.uk/news/article-1330725/Kristina-Ross-pretended-plastic-surgeon-conduct-bar-room-breast-exams.html  
	  http://www.nbcchicago.com/news/local/francisco-rendon-fake-dentistry-charges-91216374.html  
	  http://www.nbcsandiego.com/news/local/Phony-Doctor-Keith-Barton-Claimed-He-Could-Cure-HIV-Cancer-DA-186240712.html  
	  http://abcnews.go.com/Health/MindMoodNews/fake-cardiologist-william-hamman-duped-real-doctors/story?id=12395288  
	  https://en.wikipedia.org/wiki/Radithor

Top 5 Fake Medical Practitioners

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  1. Specialization tasks  
 2. Pathway  
 3. Common job scopes  
 4. Common terms  
 5. Career opportunities  

 Cardiology 

 Cardiology is a branch of medicine dealing with disorders of the heart as well as parts of the circulatory system the field includes medical diagnosis and treatment of  congenital heart defects ,  coronary artery disease ,  heart failure ,  valvular heart disease  and  electrophysiology . Physicians who specialize in cardiac surgery are called cardiothoracic surgeons or cardiac surgeons. The supporting role of the surgeons and physicians are  cardiology nurses . 

 Although the cardiovascular system is inextricably linked to blood, cardiology is relatively unconcerned with hematology and its diseases. Some obvious exceptions that affect the function of the heart would be blood tests, decreased oxygen carrying capacity, and  coagulopathies . 

   

  source: Resus.me  

 Specialization Tasks 

 All cardiologists study the disorders of the heart and all cardiology nurses are trained to take care of either adult or children conditions. This is due to differing aspects of training for adult and paediatric physiology. Surgical aspects are not included in cardiology and are in the domain of cardiothoracic surgery. 

 For example, coronary artery bypass surgery and cardiopulmonary bypass are both surgical procedures performed by surgeons, and not cardiologists. As a nurse, your task will be that of assisting the cardiologists in this matter. A properly-trained cardiology nurse would have the necessary critical thinking in order to draw conclusions to make meaningful impact of treatment. 

 Common tasks in the wards that you might have to do include the insertion of stents, pacemakers, and valves. 

 Pathway 

   

  source: verywell  

 Cardiology is a specialty of internal medicine. To be a cardiology nurse, a three-year work experience followed by a post-basic or relevant course is required. It is possible to sub-specialize in Malaysia. Recognized sub-specialties in cardiology for Malaysia are cardiac  electrophysiology ,  echocardiography,  interventional cardiology, and  nuclear cardiology . 

 Currently there is insufficient data for Malaysia, for salary, but it is guaranteed to be higher or on par with other similar nursing specialists. 

 Common job scopes 

 Cardiology is a vast field. Not only does it involve the heart and its systems, it also involves supporting systems such as haematology and its diseases. It is important to know and train for this when pursuing this specialization. 

 Cardiac electrophysiology 

   

  An example of echocardiography  

 This is the science of elucidating, diagnosing, and treating the electrical activities of the heart. The term is usually used to desccribe studies of such phenomena by  invasive catheter recording  of spontaneous activity as well as of cardiac responses to programmed electrical stimulations. These studies are performed to assess complex arrythmias, relieve symptoms, evauate abnormal ECGs, assess risk of developing arrhythmias in the future, and to design treatment. 

 Cardiac examination 

 The cardiology nurse is able to carry out cardiac examinations of patients. It is performed as part of a physical examination, or when a patient presents with chest pain suggestive of a cardiovascular pathology. It would typically be modified depending on the indication and integrated with other examinations especially the respiratory examination. Like all medical examinations, the cardiac examination follows the standard structure of inspection, palpation, and auscultation. 

 Paediatric cardiology 

   

  source  

 Paediatric cardiology is a specialty of paediatrics. To be a paediatric cardiology nurse, one must complete at least three years of registered working experience and pass all the required courses. Adult cardiology certifications are not valid due to differences in physiology in children. 

 Common complications that you will see as a nurse practicing paediatric cardiology are  paediatric hypertension ,  paediatric hyperlipidemia , heart palpitations and arryhthmias. 

 Diagnostic tests 

 Diagnostic tests in cardiology are the methods of identifying heart conditions associated with healthy vs. unhealthy pathology heart function. It is commonly started by obtaining a medical history, followed by auscultation. Blood tests soon precede after, and imaging can be done on a need-to-do basis. 

 Common terms 

 1. Tetralogy of Fallot 

 It is the most common congenital ehart disease arising in 1-3 cases per 1000 births. The cause of this defect is a ventricular septal defect and an overriding aorta. These two defects combined causes deoxygenated blood to bypass the lungs and going right back into the circulatory system. The modified  Blalock-Taussig  is used as a treatment for this condition. 

 2. Pulmonary atresia 

 This happens in 7-8 births per 100,000 and is characterized by the aorta brancing out of the right ventricle. It causes deoxygenated blood to bypass the lungs and enter the circulatory system. Fixing it can by done by a team of cardiologists and nurses by redirecting the aorta and fixing the right ventricle-pulmonary artery connection in surgeries. 

 3. Double Outlet Right Ventricle 

 Double outlet right ventricle is when both great arteries, the pulmonary artery and the aorta, are connected to the right ventricle. There is usually a ventricle in different particular places depending on the variations of DORV, typically 50% are subaortic. A VSD closure is the most common form of treatment for this condition. 

 Career opportunities 

 Search for  high-paying cardiology nursing jobs  on  MIMS Career . Browse, save, and apply for nursing jobs, all in one-click. Take the opportunity for higher pay and better work locations. Our pages are all mobile-responsive, allowing you to take that leap for a better job whenever, wherever you are. All our job postings are heavily screened to  prevent scams and mistrustful behavior . 
   

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 Why do we, as nursing professionals, have to put in effort to continuously learn? 

 The rate of progress in technology is growing at an exponential rate. The more things we discover, the faster we do it. What we learnt in nursing school 10 years ago might already be obsolete next year. As nurses, we are at risk of endangering our patients as our skills are steadily becoming more outdated. 

 Lifelong learning is a term that is freely being thrown around these past two decades. Lifelong learning means that education does not end at the academic level upon graduation; it means new skills, knowledge, and practices are always there to be learnt to improve oneself. 

 New Methods of Nursing 

 Take CPR, for example. 

 A vital procedure, many lives are saved with it. You would think that for something used so much in hospitals, it would be a science that’s very well established. 

 Unfortunately, no. Researchers and new observations change the way CPR is done. A decade ago, CPR was considered futile after a certain amount of time. Now, you are encouraged to  not give up  those chest compressions until medical help arrives. 

 Even the steps for CPR ten years ago are in different order. It used to be A-B-C; clear Airway, apply rescue breaths, then begin compressions.  Now compressions come first and foremost . The reason is because rescue breaths lower chest cavity air pressure, slowing circulation (which is exactly what we do not want in cardiac arrest). 

 The new methods are more effective than the older ones. And it took only ten years for the old methods to become obsolete. 

 Not knowing the newer, more effective method could cost someone his/her life. 

 Renewing Your Nursing License 

 In Malaysia, you have to renew your license every year. 

 When you renew your license, they will check your CPD points:  Continuous Professional Development  points. These are points that you gain when you go for any nursing related courses. 

 For example, attend a Midwifery course and gain 5 CPD points. Attend a Wound Management course and get 3. 

 These points accumulate throughout the year, and when you want to renew your license, you need about 20-30 points. Otherwise, you will not be able to renew, thus leaving you without any form of registration. Meaning you can’t practice nursing! 

 Improving care towards patients 

 Nurses with a higher level of education are able to think more critically of their patients. They are able to aid in diagnosis, notice patterns in communication, and other physical cues that would help in determining the best course of treatment. 

 A nurse with a post-basic in cardiology is much more useful to a cardiologist compared to a general staff nurse. They can work together, exchange information, and execute procedures that the latter would not normally have the ability to do. 

 21st Century patients 

 Nowadays, patients are have more access to information than ever before. They are more learned, and have different set of expectations. They query a lot; so nurses have to be armed with the right set of information to cater to these patients. It goes a long way in establishing their trust towards you. 

 A good nurse-patient relationship is very important to achieve successful recovery. 

 Great nurses are always on the lookout for new, exciting, and better opportunities to grow their career. Find out your next employment with MIMS Career, a fast, secure, and convenient portal to connect you to top-class healthcare employers in MY, SG, ID, and PH.

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 For those nurses serving with  Kementrian Kesihatan Malaysia  (KKM), the start of your work life will present you with one of the toughest choices you’ll make: 

 
 EPF (Employees’ Provident Fund, also known as KWSP), or choose the pension fund? 
 

 Both are viable options in securing your financial health after you retire. Although retirement might seem like ages away, a good amount of planning and successful investments can mean the difference between being able to live comfortably in your golden years, or struggle with daily or medical expenses. 

 So which to choose? We’ll break down the points below. 

 Pension fund 

  What is it?  
It’s a monthly stipend of a set amount, provided by the Public Services Department upon your retirement. In addition to that, you also receive a  gratuity  payment, and medical/health benefits. 

  Calculation  
Here we will be assuming that you start work at 20 years old, with a starting salary of RM2,000, and continue working until you retire at 55 with a salary of RM5,600 (3% annual pay increase). 

 Your monthly pension will be your last drawn salary, divided by two. For example, if your base salary is RM5,000 when you retire, your monthly stipend will be RM2,800/mo. 

 In addition to that, you will receive gratuity payment, which is calculated as such: 

 
 gratuity = 7.5% x 35yrs x 12 months x RM5,600 (final drawn salary) 
= RM 176,400. 
 

 RM176,400 will be given as a lump sum, while RM2,800 will be given per month. Again, this is all assuming you retire at 55, with a final salary of RM5,600. 

  Benefits  

 
	 No subtraction from base pay. 
 

 Unlike EPF, as we will see later, there is no subtraction from your base salary. 

 
	 Guaranteed monthly retirement funding 
 

 Again, unlike EPF, where your money can be withdrawn for other uses, pension takers are guaranteed to have a monthly source of income. 

  Disadvantages  

 
	 You have to start and end your service in the public/government sector. It might hamper your ability to seek work overseas, better base salaries, or even some chances to study. 
 

 EPF or Employees Provident Fund (KWSP - Kumpulan Simpanan Wang Pekerja) 

  What is it?  
EPF is the accumulation of savings generated from deductions of your base salary. Currently, you can choose either 11%, or 8%, as  recently announced . 

 This accumulation of money is further grown by annual dividends. On average the dividend is around 6%, depending on the GDP (gross domestic product) of the country. 

 What makes EPF great as long term savings is due to the magic of  compound interest. . Your employer also contributes to your fund (12% of your pay). These two things make an EPF account grow substantially when properly managed. 

  2 accounts  

 Your EPF savings are divided into two accounts. 70% goes into account 1, and the rest to account 2. Account 1 is your retirement funds. Account 2 is withdrawable, under a few conditions: 

 
	 more than 50 years old 
	 Housing downpayment for your 1st house 
	 housing loan payment 
	 education 
	 medical costs 
	 Hajj pilgrimage 
 

 Upon reaching the age of 55, you will be able to withdraw from account 1. You will have to choose to withdraw one lump sum, or as a monthly stipend like a pension. 

  Calculation  

 Let’s take the same example as just now. Start work at 20, salary RM2,000, retire at 55, salary RM5,000. 

 
 Deduction from pay = 11% = RM220 
Employer contribution = 12% = RM240 
 We will assume no withdrawals are made over entire working period  
EPF annual dividend = 6% 
 

 The interest adds up year over year, and with the help of EPF’s  online calculator , 

 Total EPF savings at 55 years old = RM461,900 

 It is a marginally higher amount than RM176,400 gratuity you will receive from a pension. 

  Benefits  

 
	 Flexibility. At the age of 55, you can withdraw that money and invest in another scheme, venture, or fund that offers greater returns. 
	 Faster growth. As shown, even with a contribution of 11% of your pay, over the course of 35 years it balloons into a large amount of money. 
	 Freedom of employment. You no longer have to work within the constraints of the government or public service. You are free to pursue study or work opportunities as you wish. 
 

  Disadvantages  

 
	 Sometimes things don’t go as planned. You might hit a financial roadblock that forces you to withdraw from your EPF fund. An example of this is a medical emergency. 
	 It subtracts 11% of your base salary. 11% might not seem like much, but for people who live paycheck to paycheck, it can be a bitter pill to swallow. 
	 Annual dividend from EPF can decrease, depending on economic climate. 
 

 Making a comparison 

 Monthly funds 

 Assuming that you live until the mean life expectancy age in Malaysia, which is 76 years old. 

 
 Years to live off retirement fund (pension) = 76-55 = 21 years 
 

 To make a fair comparison, let’s subtract the gratuity amount of a pension scheme from the lump sum of EPF savings. 

 
 EPF at 55 years old - gratuity of pension at 55 years old = RM461,900 - RM176,400 = RM285,500 

 Stipend per month that EPF provides = RM285,500 / 21 years / 12 months = RM1,132.94/month 
 

 Even if we did not subtract the gratuity value, it would be: 

 
 RM461,900 / 21 years / 12 months = RM1,832.94/ month 
 

  It is far less than RM2,600/month from a pension scheme . 

 What if we invest all of EPF savings? 

 Say at the age of 55, you embark on another investment with better returns. We will assume 8%. You pile up all your savings into it. 

 Investment return x EPF savings = 8% x RM 461,900 = RM36,952/year or RM3,079.33/month. 

  It is more than what you’ll obtain from a pension.  However you’ll need to ensure that the second investment has better returns than EPF dividends. That in itself can sometimes be a challenge. 

 Conclusion 

 They both have their advantages and drawbacks. It seems like it is up to you to play it well, to ensure you can lead a comfortable life upon retirement. 

 However the main question of choosing either EPF or pension as retirement savings often boils down to your choice of employer. 

 Will you stay with the government sector for another 30+ years? You don’t want to end up with no retirement fund… No EPF or no pension. That’d be the worst. 

 If yes, go for the pension scheme. It is safe, guaranteed, and offers great peace of mind in your golden years. 

 However, with EPF, you are free to take up opportunities that come your way. Countries like Saudi Arabia, Singapore, and Australia are actively seeking out Malaysian nurses with extremely attractive pay. Opportunities for post-graduate education are more limited in the government sector; if in private, you get to choose when you want to do it. You can also fund it with your EPF savings, something you can’t do on a pension. 

 Choose the freedom of choice. Search for high-paying nursing jobs, and overseas jobs on MIMS Career. Browse, save, and apply for nursing jobs, all in one-click. Take the opportunity for higher pay and better work locations. Our pages are all mobile-responsive, allowing you to take that leap for a better job whenever, wherever you are. All our job postings are heavily screened to prevent scams and mistrustful behavior. 
   

 
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For those nurses serving with Kementrian Kesihatan Malaysia (KKM), the start of your work life will present you with one of the toughest choices you’ll make: EPF (Employees’ Provident Fund, also known as KWSP), or choose...

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