There has been a flurry of reports recently on the excess of doctors within the government service of Malaysia.
Much has been written on how the issue was allowed to fester despite the numerous warnings from the medical associations calling for tighter control over the medical graduates both produced locally and returning from overseas training.
I would like to state that I disagree that we have a glut of doctors. We have a large number of doctors with little chance for permanent employment within the government service that is true, but the crux of the problem is that there is a SHORTAGE of positions for these doctors to serve despite their willingness to do so. And this to me is where the problem lies.
At the current moment, we have around 12,000 house officers (HO) in training with about 2,000 new medical officers (MO) awaiting placement. The positions for doctors within the government sector is completely filled (>100 per cent) with extra positions having been taken from nursing and support staff.
From our simple survey, we have found around 20 per cent of these newly graduated medical officers have been appointed to permanent positions within the government service. As such, around 1,500 doctors will be left to accept the UD41 contracts offered (which again was NOT what was promised at the start of the contract policy) and face the uncertainty of unemployment at the end of two years.
Should we fast forward a little, in two years from now, we will have around 8,000 doctors, having been released to the private sector to look for jobs, which may or may not have anything to do with the last nine years of their lives (five years medical school, four years HO and MO training).
This loss of knowledge, training and service would be a great loss to the implementation of universal health care.
Coming back to the issue at hand, we do not have a glut of doctors. Ask any medical officer serving in the interiors of Malaysia, the less popular hospitals, where their applications for leave has been rejected due to insufficient coverage due to being shorthanded.
Look around us and see how some medical officers are still doing six to seven calls per month to ensure that the services are covered and maintained no matter the stress on the providers. Or how in some hospitals and KKs there is a need to do stretch passive calls, again for the infamous saying “kepentingan perkhidmatan”.
Even in the more luxurious major hospitals where we have a surplus of house officers, the number of medical officers are actually still insufficient to ensure timely service is provided to all patients while ensuring that the healthcare workers receive adequate rest and days off.
Look at the various Klinik Kesihatans and emergency departments. Waiting times are long, with one of the most often excuses being the shortage of doctors, but of course the insufficiency of available consultation rooms being another limiting factor.
Is this indicative of a glut of doctors? I would think not.
Look at our operating lists. The waiting times for some surgical disciplines are months, some even as far away as six months to a year for non-urgent surgery. Clinic waiting times are still long, with more and more patients coming into the government system as the cost of private health care increases. Does this suggest the glut of doctors we have been told?
Look around again and recall your fellow colleagues wearing a mask and fighting a fever, yet still working next to you as they were unable to or afraid to take a sick day, as not to be a burden to you and the team. A colleague who is worried sick for their loved one at home, be it a child or parent, but unable to get some time off as the roster and service dictates it impossible, yet providing care and relief to the patients in hospital.
Think back again to a colleague or friend that is paralysed with depression or anxiety, but soldiering on with a smile at work trying not to be a burden to the those around them by taking a few precious days offs to rest and recharge.
Look around, there are many around us fighting silent battles and inner demons, but with little avenue to take the break they desire and deserve.
The fact of the matter is that we in the government medical services have been undone by our own efficiency. Look at how we work at the moment, we push ourselves above and beyond what any normal person out there would do. We are creative and innovative, working within our limitations to maintain the highest level of care. Let us look at some examples.
Would you trust a person that has been working for more than eight hours straight to drive the bus you are on long distance?
Or to fly a plane you are about to board? Would you put your trust in a lawyer that has been awake for 24 hours to defend you in court? Or a mechanic to fix your car if sleep deprived for 36 hours?
I am sure no one would agree to the conditions above. But we expect our medical officers and specialists to do exactly that. Most of us oncall would still be working the next day. Some departments have attempted to allow the next day half-day off to allow their MOs some respite, but the majority of times we are still working a full day following a 24-hour oncall.
Post call, surgeons are still operating and providing services to the people. Physicians are battling fatigue from a busy night, but pushing onwards to finish the never ending clinic cards as the patients wait anxiously just to see a doctor for a 15-minute consult.
With the introduction of the shift system, we had attempted to address the issue of 36-hour workdays for the house officer, but when they become medical officers the system thinks that miraculously they become superhuman and can function well after 24 hours of work with little rest.
It was hoped that when the House Officers graduated, we could gradually move to the shift system as well for the MOs, but with the shortage of positions, it appears that this would not be the case.
Our current staffing conundrum would not be easy to solve. On one hand we have the belief that the civil service is bloated with the directive of NO new positions and to reduce the positions where possible. But we have a growing population with an increase demand on the health care services.
We have been told that the request from MOH for new positions to the JPA and Ministry of Finance (MOF) was denied. So, again our efficiency becomes our downfall.
Instead of reducing the services provided, or limiting our expansion of services, we squeeze and push ourselves to do more. We continue to expand and stretch our available staff to the very limits possible. Asking for longer working hours, extended clinics and operating times, thinking ourselves invincible and impervious to physical and mental health hazards.
And now we are at our breaking point.
Look around and see the burnout faced by the specialists who has too long carried the burdens of care. The medical officers pulled in too many directions from too many requests on their time and efforts. Look at our nurses working double shifts to cover the needs of service.
Health care workers have the among the highest rates of suicide, substance abuse, depression, divorce and other social issues. Yet we still go on. We still turn up daily, and give our best to the patients under our care.
So how do we move on from here? The short term solution is clear.
Lift the block on new doctor and health care worker positions. Increase the number of positions to ensure that the working hours of all health care workers are fair and does not exert a toll on the individual. The implementation of the shift system would need at least an increase of positions by 40 per cent to 50 per cent. Look at the processes that we have now and see where we can better allocate resources to increase the productivity of our workforce.
The long term? Relook at the number of doctors being produced. The conditions for medical graduates must be tightened, both locally and overseas.
The implementation of a common qualifying exam to enter medical studies for all, be it local or overseas would go a long way in ensuring quality of students entering medicine. And of course a common exit exam for MMC registration akin to the USMLE would ensure quality of graduates.
We have to also look at the projections for future growth of health care services as well as population needs. The numbers we have estimated before appears to be wrong and grossly underestimated as seen by the reality we have now.
Let us be honest with our needs for healthcare as well as look at how we can incentivise the placements in areas of need (district hospitals and rural areas) to ensure better access to universal healthcare.
So how do we fund all this?
The least popular but simplest way would be to increase the non-emergency consultation fees from RM1 to RM5 per visit.
All emergency charges should remain the same but the outpatient reviews should definitely be increased to RM5 per consultation for outpatient services.
In 2017, we had 42 million outpatient visits to public health facilities and 20 million visits to hospital outpatient services. With the increase in consultation fees, even if only half of the visits were charged, we would see RM150 million per year increase to fund the new positions needed.
The introduction of a mandatory health tax / contribution, increasing the existing sugar, alcohol and tobacco taxation, and even generating income via solar energy mounted on our various hospitals and clinics are all possibilities.
Am sure the more business-minded out there would have more suggestions, but these are the few we have suggested and discussed before.
The journey ahead is long and arduous. The medical fraternity needs the leadership at its helm to stand strong and to make the right decisions no matter if it means rocking the boat. We need to ensure that we do not lose a generation of doctors to the wilderness due to our inaction to solve what is essentially an administrative crises.
I personally hope that the various meetings and presentations we are preparing and conducting will bear fruit and those that can make the change hear our pleas. We have 12,000 house officers now in training, 2,000 just completed and another 5,000 awaiting posting, not to count the numerous other medical students currently.
All are waiting for a brighter future and that their pleas for a stable employment and a chance to fulfill their ambitions be heard so that they may all fulfill the passion to serve the people for the betterment of health care for Malaysia.
Dr Kevin Ng is an anaesthesiologist who advocates for a fairer work place for all health care workers.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.