Kudos for voicing this out; it took too long for the issue to be finally raised. The brain drain issue is the mere tip of an iceberg in consideration of the bigger picture of what fails.
Radical Institutional Reformation Required
It boils down to the issue of system letdown. Not too long ago, doctors and health care workers stormed social media with the hashtags #overworked, #underpaid, and #saveourcontract.
The issue of overwork and underpaid is multifactorial. It is essentially a systems failure. Similarly, the brain drain issue is as well. Just a few points to consider:
External Brain Drain: Donating to Other Nations Our Brightest and Best
With the environment of overwork, miserable paychecks, and ever-increasing cost of living, it is no wonder that people are leaving.
It is dreadful and alarming how the brightest are leaving because there is little this place is offering them. We are losing our own, but we are not getting talents from elsewhere. I am not sure what are we achieving.
Draw a bell curve with the number of doctors on the Y-axis and the quality of doctors on the X-axis: With the brightest and best leaving, the painful truth is that the average, or median, of doctors’ quality as a whole will drop. The bell curve will negatively skew. It is terrifying to consider that what we are left with are mostly those who could not leave.
Yes, “brain drain is everywhere (in every industry),” says our Health DG. The question should not be who is leaving, but what are we doing about it?
The loss of medical professionals is devastating to health care and the effect will be apparent very soon, at the current rate at which we are losing our very best.Concerned resident doctor from a public hospital
Many who were on federal scholarships have left after being paid by taxpayers to complete their medical education. Whether they pay back or are punished for their departure deserves a different deliberation.
Few who worked hard see any meritocracy rewarded in this home country. Few saw any transparency in employing and awarding the brightest and best. There is a need for us to reflect on why other countries attract them more.
Questions need to be answered: Do we get any incentive in seeing more patients, doing more surgeries, doing more calls, and passing more exams? Are we doing justice to those who work harder than average? Are talents recognised and nurtured? Are merits rewarded?
The on-call pay, with doctors working often more than 24 hours, still average less than RM10 per hour. Whether 10 emergency surgeries are performed or two surgeries are performed, we get the same pay of less than RM10 per hour.
But it is not just the money that really pushes people away; it is the loss of job satisfaction that we all hoped for. Our hard labour goes unappreciated, and our future remains uncertain for a little too long.Concerned resident doctor from a public hospital
Some consider it a good opportunity for them to be exposed to training in foreign lands. But the truth is, most will unlikely come back. The medical career does not permit one to change the place of practice as easily as other profession does.
They cannot come back easily with the same position to serve in Malaysia and practice once they leave the country. The council and many red tape and variations in certification and recognition do not allow that.
We may have lost them forever to serve communities elsewhere. Good for them, good for other communities, but a loss to us, a tragic loss to the general public.
Not too sure if anyone feels the loss yet. I felt it all too strongly because among my batch of 103 doctors, I am one of the only few who remained here. Most of my batchmates who used to profess their sure conviction of serving this beautiful country have now left the country or left the profession altogether.
I grieve for the nation’s loss of wonderful talents who could have shaped the nation’s health care better.
Not that I am let down by my fellow comrades’ decisions; the system let them down.Concerned resident doctor from a public hospital
We may not feel it now, as we still enjoy the service of the senior doctors, our regular GP (general practitioner), or go-to specialists. In 10 to 20 years’ time, we will begin to see the devastating effect of these brain drains. For now, health care workers are the ones who suffer from overwork due to worsening shortages.
Is there a real shortage? Take the number of graduates who applied for housemanship. Five years ago, we waited for almost a year to enter housemanship because of the number of applicants. More contracts were offered, shorter waiting times, and permanent positions were offered, but we have fewer applicants now.
Where are the medical graduates? Serving elsewhere, I suppose.
Internal Brain Drain: Brain Drain From the Public Sector to the Private Sector
It is a vicious cycle — lack of reward causing brain drain, thus overwork for those who remain, thus an even worse working environment, and finally, people leaving as a consequence. We are seeing doctors leaving at every level, from house officers to medical officers, and to specialists.
The public-private disparity is too great. The private health care system, with mostly single consultants making the team and thus, the one-man show, limits what cases can done in the private sector. Most complex cases are managed by public hospitals that constantly cry for resources.
Most specialists, upon completing their specialisation, leave the government service for the private sector. There is little reason why one would stay in the public sector, except for sheer altruism perhaps.
The pay to break off the bond keeps increasing, in hope of deterring specialists from leaving the public service before the required service years. That does not help in making anyone more willing to stay and serve in the public sector.
With the mushrooming of graduates and premature departure of most medical officers after serving their contract (only two years) or the compulsory service, they now open rows of private health care facilities. On one hand, this results in a severe shortage of doctors in the public service.
On the other, the training, number of training years received, as well as the maturity gained by doctors before they leave the public training hospital are minimal and concerning. We will see a decline in the primary care provided by our new junior medical officers who left the public service.
The lack of doctors became apparent in secondary and tertiary public health care facilities and the possibly overcrowded primary health care services.
Why should the public doctor who served much harder be rewarded less than their counterparts in private?
Call For a Paradigm Shift
It still echoes fresh in my mind that during orientation of almost every posting, one the first things briefed was how “leaves are not your right; it is a privilege”. The Employment Act somehow doesn’t apply to us — there is no ceiling to the number of hours doctors are required to work per week.
A military-grade sacrifice is demanded in the name of service.
To the horror of many relatives and friends outside the fraternity, junior doctors do not get off on public holidays or weekends. If they work on public holidays, the holidays are not usually replaced. Instead, if one wishes to celebrate Raya or Chinese New Year, they have to deduct from their annual leave, with a maximum of 25 days a year.
Perhaps that was how the seniors were trained — to work till you drop. And now, seniors expect the same for junior officers.
If pilots are not allowed to fly planes if they lack sleep, why are doctors allowed to manage patients or perform surgery on you when they had barely any shuteye over the past 24 hours? We have read about doctors who lost their own lives after on-calls.Concerned resident doctor from a public hospital
There are many measures where medicine has progressed in equipment and technology to improve patient safety. But human error remains a significant cause of morbidity, even mortality.
In the name of service, we ignore personal needs. “Take it or leave it,” my friend was told when she appealed to Putrajaya for the change of placement.
“Bilakah penempatan akan dimaklumkan?” “Kalau Doktor tak nak tunggu, tak payah tunggu”. Many waited without knowing how long or where they are placed. People have no control over their future, no matter what toils they have laboured in the past.
No, we need to fight and plead for local talents to serve.
The central governance of public service has little knowledge of the local needs or the qualification of the staff, or do they even care? Perhaps decentralisation and learning from other countries on their matching system would be a potential solution. People get to apply directly to the hospital of choice based on their merits.
Seniors argued that during their time, they had fewer doctors and more patients to care for per patient, yet they could perform better. But the truth is that back then, doctors were called to do a doctor’s job. Now, many house officers are called to do non-doctor work, such as ever-increasing ineffective redundant paperwork.
Sometimes, they are called to go to the medical record office to trace records from piles of case files, wasting their precious time caring for patients.
Nurses too are occupied with other mundane tedium themselves. A centralised computerised system should have been in place long ago to solve all the redundancy and inefficiency of the system. Take other industries like aviation, business, and finance — we can observe how technology has improved those services, but the health care system lags far behind.
Let nurses do their nurse’s job and doctors do their doctor’s job, then we will be able to better serve patients, in keeping with the needs of the time.
Is it still surprising that we do not progress if the seniors, who are now in power to effect change, still hold the mentality of the last century?Concerned resident doctor from a public hospital
When asked why people leave, many lament the lack of certainty in their future, unrecognised merits and labor, and frustrations with the lack of resources that limits our care for patients. Some just feel that their future lies with an employer who cares little.
Congratulations to the newly minted health minister, Dr Zaliha Mustafa. We are glad that someone from the fraternity has risen in rank.
It reminds me of the words of Dietrich Bonhoeffer: “We are not to simply bandage the wounds of victims beneath the wheels of injustice, we are to drive a spoke into the wheel itself.”
Please do not let anyone sugarcoat things or blind you from seeing the inadequacies and problems with the current outdated system.Concerned resident doctor from a public hospital
There is a need for a more sustainable health care system with better health economics. This heavy and immense responsibility needs more than just the labour of the Ministry of Health, but also from other ministries and agencies.
We need to compete better than other countries in preserving these valuable talents and assets. We also need to humble ourselves and learn from other countries’ health care to see what works better. There is a need now for political will to change the fate of our health care.
I was offered a lucrative job elsewhere before, with better pay and a better working environment — a place where, compared to the looming uncertainty concerning my contract here three years ago, was undeniably a greener pasture.
With supportive seniors and some dwindling hope, I chose to stay and persevere. I am now beginning to see a glimmer of light at the end of this tunnel.
Do I question my decision daily? Yes. But I do harbour hope. To quote St Augustine of Hippo: “Hope has two beautiful daughters; their names are Anger and Courage. Anger at the way things are, and Courage to see that they do not remain as they are.”
I do hope for courage for myself and my fellow comrades to continue on the conviction of the Hippocratic Oath. We are seeing change, slowly and surely. But there is more that can be done before it is too late.
CodeBlue is publishing this letter anonymously because civil servants are prohibited from writing to the media.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.