“I can’t do this anymore.”
“Patients keep deteriorating while admissions simultaneously pour in.”
“There is just not enough time and staff.”
“We left work at 1am yesterday when our shift ends at 8pm. Again.”
My colleague crumples, her eyes well up with tears. And she is not alone in feeling this way.
None of us can constantly function at full capacity, but when we’re pressured to, what you get is burnout. A deadening of emotion, a feeling of detachment.
A majority of contract medical officers (MO) are placed in Covid-19 teams, and since early April 2021, our resources have been stretched thin. The number of Covid-19 cases have been rising rapidly since March 29.
The current third wave which started on September 8, 2020, dipped to its lowest on March 29, 2021, but due to failure to comply to SOPs, among other various reasons, the number of cases steadily climbed back up and exceeded the previous peak at 4,571 new cases a day.
To date, the record was 9,020 new cases and 76,218 active cases on May 29, 2021.
At the Malaysia Agro Exposition Park Serdang (MAEPS) in Selangor, currently the biggest Covid-19 quarantine centre in Malaysia, new halls have opened, but with the same volume of manpower since March.
We recently received slightly more staff, but our workload has simultaneously increased exponentially with the rising number of Category Three to Five patients and the care and attention they require.
The maximum available number of beds is approximately 6,000, and there is only an average of 55 MOs per shift. That makes for a ratio of one MO to 109 patients per day if we reach 100 per cent capacity (which has happened many times).
On multiple occasions, we have exceeded our maximum bed count, and patients had to sleep on canvas beds, or even on the floor overnight.
This has been happening in many hospitals in the Klang Valley, and yet, it is evident by the number of cars seen on the road daily despite lockdown that the public does not understand the gravity of this dire situation.
I implore the public to stay home unless absolutely necessary. Otherwise, we will never flatten the curve.
It is understandable that due to the rapid rise in Covid-19 cases in Malaysia, every health care facility is struggling to stay afloat. However, with this doctor-to-patient ratio, compromises in patient care and exposure to medical errors are inevitable.
Since opening in November last year, we have experienced a number of “code blue” (hospital code indicating a medical emergency) situations in the last two months, as compared to the period prior to May, when we had none. No one can say for sure if it was due to lack of staff resulting in less-than-ideal patient monitoring.
However, one study by Z. Or (2000) demonstrates a 10 per cent increase in doctors per 1,000 population could result in a 4 per cent reduction in premature mortality in women and 3 per cent in men. (1)
Patient care also suffers in other ways when a doctor is exhausted and emotionally detached. There will be a lack of connection, and a sense of being cared for and being heard.
When patients tell us their concerns, we feel…nothing. When they collapse, there are no tears or heartbreak. When we have to gently explain the situation to their loved ones, we desperately hope they cannot detect the emptiness behind our words.
Dr J, anonymous contract doctor at MAEPS
In addition to the above, we work up to 12 arduous hours in hot, stuffy PPEs, whereby we cannot even have a sip of water or go to the toilet throughout the entire duration.
Picture doing this on a daily basis for at least half the days in a month, and you will get a sense of a contract MO’s life.
In contrast, the World Health Organization (WHO) has recommended that N95 masks be worn for preferably only four hours, which is approximately the median health care worker tolerance time. (2) (3)
However, this is not feasible with our current patient load. Increasing the number of times PPEs have to be removed or doffed also significantly increases chances for us to become contaminated ourselves.
At the time of writing, seven MOs at MAEPS have ongoing active Covid-19 infections, which undoubtedly might be be caused by the long hours of exposure to Covid-19 patients every day.
On top of working long hours during the day and throughout the night for the past year, putting not only our own lives, but also those of our loved ones at risk, all while having no job security and uncertainty for our future, with no clear pathway to specialise, our on-call claims which amount to roughly RM1,000 a month which were previously promised to us have been unpaid since January 2021.
To some, this amount might be little, but for others, they could be the sole breadwinner of their family, especially during these trying times, when businesses are grappling to make ends meet.
The heavily discussed but not resolved issue of contract medical officers burdens us daily. Many of us are nearing the end of our contracts, either this year or next.
All of this translate into very low morale, on top of the inevitable burnout. The risk of developing a major depressive disorder is greater when the level of burnout becomes more severe.
On a daily basis, many of our colleagues have fallen sick or cannot bring themselves to get out of bed and face yet another distressing day at work, leaving those present with an even more daunting workload.
Yet, the answer, we are told, is resilience. Fix the doctors, get them to manage the workload.
The fact that the workload is not manageable is not addressed.
The management has provided counseling and psychology services, but unfortunately, this has done little to nothing to solve the above issues.
While everyone is focused on the Covid-19 pandemic, other departments such as orthopaedics, general surgery, etc. have been languishing with understaffed clinics and increased number of on-calls per month.
A majority of these departments are also made up of contract MOs who had to sacrifice quality time spent on their own wellbeing and family.
Many say this is part and parcel of a doctor’s life, that we signed up for this. It is Third World mentality to think we should not strive for constant improvement and progression, to enable production of more specialists and consultants resulting in better work-life balance and greater patient outcomes.
There needs to be a strong support framework for doctors so that we can cope with burnout and enhance our will to persevere in our career.
While we are tirelessly taking care of patients, who is taking care of us?
References
1. Or Z. Determinants of health outcomes in industrialised countries: a pooled cross country time series analysis. OECD Econ Surveys 2000; 30: 53-75
2. World Health Organization (2020). Rational use of personal protective equipment (PPE) for coronavirus disease (COVID-19): interim guidance. WHO/2019-nCoV/IPC PPE_use/2020.2
3. T M Cook. Personal protective equipment during the COVID -19 pandemic – a narrative review. doi: 10.1111/anae.15071
This letter was jointly written by an anonymous contract doctor with the pseudonym Dr J and the doctor’s colleagues working at MAEPS. CodeBlue is publishing this letter anonymously due to the government’s gag order on civil servants.
