Too many doctors? Or too few job openings?
This has been a debate for over five years now. Unfortunately, most health care workers, including doctors, feel overworked and underpaid.
It was known that Malaysia has yet to meet the World Health Organization (WHO) standards for the number of doctors per population. WHO recommended that there should be 1 doctor per 400 people and as of 2018, Malaysia has a population of 31.8 million and should require 79,500 doctors.
A human resource report from WHO showed that Malaysia had 36,000 medical practitioners and 9,000 house officers in 2011, which did not satisfy the population at the time. Malaysia required 71,000 doctors for a population of 28 million.
Retrospectively, you can understand why those numbers were needed to be met, given the situation of the pandemic. To overcome that, our nation decided to open more medical schools, and accept more overseas medical schools as recognised training. Shortly after, we were facing a bottleneck of medical graduates transitioning to house officers (HOs).
It was approximated that 30,000 fresh graduate doctors would join the workforce from 2017-2022. In 2008, the number of house officers doubled from previous years. Reports state that the measures taken were to increase the duration of housemanship from 1 to 2 years.
The Ministry of Health (MOH) noticed this and shifted their approach from permanent staffing of doctors to contractual staffing of the doctors, understandably so, as it encourages healthy competition amongst the doctors. A similar pattern is seen to recur in 2020 as contracts for UD41 grade become 3 years long (note that responsibility increases upon two years of successful completion of housemanship).
Evidently, this was a major shift in the system which required thorough planning, anticipation of other issues, ongoing support, and remodelling of the system as the system and its staff underwent the changes. Nonetheless, the system set was uncared for.
Three years have passed, and the collective issues have not been addressed; the first three batches of contract house officers have completed their two years of housemanship and worked some months of medical officer jobs.
For the first batch, 50% of the contract house officers were retained to permanent positions. The second batch was small, but around 40% were retained as permanent status, and approximately 120/ 1,379 were retained as permanent for the third batch. Even so, the selection criteria to retain medical officers were opaque, leaving too much room for interpretation.
Experiences as a contract MO
The ongoing issue of medical careers, contracts, and opportunities available in Malaysia has been persistent and is still pertinent. Medical graduates are still facing a bottleneck issue with a 8-12 month waiting period, the contract system has not evolved with time, selection criteria for retaining permanent staffing is not transparent and despite the voices of many young doctors and politicians, discussions behind closed doors are barely audible from the outside.
Scoping in on the impact this situation has on each individual doctor will demonstrate that they have difficulties in obtaining loans, pursuing specialty training programs, and obtaining similar salary as house officers with increasing workload and responsibility as medical officers.
Most are expected to work a hefty 80 hours a week (depending on department and staffing) and most junior medical officers were encouraged to join the frontline during the pandemic (proud as we are to serve the frontline, we took risks with our lives and some even with our families).
Training pathways
Conventionally, there are two ways to specialise in Malaysia:
1) Masters in a public university
2) Parallel pathway with external exams (MRCP > Paces, MRCOG, MRCPsych etc).
There are pros and cons of each and many doctors in the past have undergone them simultaneously.
Recent times have shown that there is also a bottleneck situation in entering the Master programs, so most are encouraged to take parallel pathways. But are they our only alternatives?
Parallel pathway exams come with a hefty price tag, and with our current contract, we are not financially compensated for our training, which means we do not have educational allowance for attending courses and attending exams.
Furthermore, we are not provided adequate support as we sought specialty training at our own capacity. We were not allowed to take study, or even unrecorded leave, to prepare and sit for the examinations. We are required to use our annual leave to pursue our own educational efforts.
While our currency weakens, with no compensation for these exams and house officer salary, we are expected to push our limits even further to pursue parallel pathway exams on our own. There is no doubt Malaysians have very bright minds, but unfavourable training conditions have led many, including myself, to seek pastures afar.
The prospect of a career in medicine and surgery as a junior doctor in Malaysia seems bleak with truly little structure to the career pathway for contracted staff and newly appointed permanent medical officers.
Recommendations
The Ministry of Health can improve the situation in many ways. The Covid era has shown the world where it needs to work on such as disinfecting high contact surfaces, improving sanitation and hygiene, health policy writing and implementation, and research and clinical development into areas such as telemedicine and digital health.
It is understandable that certain jobs are more glorified than others, but by incentivising and encouraging pathways in need, easing access to other clinical or non-clinical jobs that help provide solutions, and integrating these jobs into housemanship training and allowing greater flexibility into the current contracted UD41 issue may be possible solutions. Furthermore, a revision in Human Resource policy on the benefits of contracted staff is required.
Our conventional perception of “the doctor” should not restrict us, but be used to integrate our clinical experience with the dynamism of our globe today to provide modern-day solutions.
References
- Wong R. S., &. A. (2017). Medical education in Malaysia: quality versus quantity. Perspectives on Medical Education, 10-11.
- World Health Organization. (2013). Human Resources for Health Country Profiles. World Health Organization.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
Update at 4:20pm: The title of the article has been amended to drop Dr Sean Thum who was incorrectly listed as co-author.
