KUALA LUMPUR, Sept 6 – Rising doctor burnout is reportedly driving high turnover, particularly in Malaysia’s government health service that is already struggling with dire shortages of doctors across facilities.
Yet, physicians with mental disorders often hesitate to seek treatment and be honest about their condition, fearing it could harm their careers – a concern that is often warranted.
Diagnosed with depression since 2018 while pursuing his Master’s and doctorate in public health, Dr Stephen (pseudonym) was open about his condition with his academic supervisors during his studies and field supervisors during pre-gazettement as a public health medicine specialist.
Pre-gazettement refers to the period before a medical professional is officially recognised and designated as a specialist by the Ministry of Health (MOH). It usually spans six months.
By being honest about his mental illness, Dr Stephen hoped he would be able to obtain the support he needed to facilitate the completion of his evaluation process.
While academic supervisors at his public university offered extra guidance and support that enabled him to complete his Master’s and doctorate studies, Dr Stephen’s pre-gazettement experience with the MOH has allegedly been the opposite.
Despite fulfilling all of the requirements for pre-gazettement – which included submitting logbook, outbreak reports, and special project documentation – Dr Stephen was eventually told that he “lacked leadership skills”, had “difficulty handling complex tasks”, and took prolonged medical leaves that “affected his work performance”.
He failed twice to complete gazettement as a public health medicine specialist – May 2022 and January 2023.
Dr Stephen said that the futile pre-gazettement evaluation – which boiled down to personality and behavioural assessments that superseded knowledge and skills assessment – seemed illogical, considering his ongoing mental health treatment and his supervisors’ awareness of his condition.
He described his pre-gazettement evaluation as being driven by “sanism” (prejudice or discrimination against people with mental illness) and lack of compassion.
“These assessments of personality, character, and attitude should not be used to stigmatise a gazettee with mental health issues from being gazetted as a specialist, as such an action is a direct discrimination,” Dr Stephen told CodeBlue when met in June.
“I was informed that I would have to undergo pre-gazettement for the third time if I am still determined and eager to practise as an MOH public health medicine specialist.
“Honestly, undergoing the evaluation process repeatedly has had a considerable impact on my mental health, as it exacerbates my anxiety and triggers severe episodes of relapses,” Dr Stephen said.
“Furthermore, the act of advising and convincing me to prioritise my mental health treatment first and later to repeat the pre-gazettement evaluation once well prepared to vanquish the challenges with great fortitude is certainly an indirect discrimination.”
He said he was informed verbally by the MOH last Monday that his appeal for reconsideration of his pre-gazettement evaluation to be a public health medicine specialist was rejected.
Dr Stephen had included, in his appeal, a four-page medical report of his condition from the Psychiatry and Mental Health Department at Kuala Lumpur Hospital (HKL).
“I will have to repeat another six months if I still wish to be gazetted as a specialist. There are no alternate pathways or options.”
Pre-Gazettement Failures Led To Relapses
Major depressive disorder (MDD), or clinical depression, is a chronic condition that usually occurs in episodes which can last several weeks or more. Treatment of major depressive disorder typically involves medication and psychotherapy.
Major depression includes symptoms of depressed mood or loss of interest, most of the time lasting for weeks, that interfere with daily activities. It is one of the most common mental disorders in the United States, according to the US National Institute of Mental Health.
Dr Stephen links his MDD diagnosis and relapses to personal, work, and financial problems. He has faced multiple relapses, which led to adjustments in his medication dosage frequently in the past three years.
During these relapses, he experienced automatic negative thoughts, dwelling on his past and current situations, worrying about his uncertain future, losing motivation, having reduced interest in his usual activities, sleep troubles, and needing medical leave.
These symptoms were most notable after two failures to complete gazettement in May last year and January this year.
Pre-Gazettement Evaluation Open To Personal Biases
Throughout his two pre-gazettement attempts, Dr Stephen actively participated in various field activities, including outbreak controls and community engagements. His dedication to work, enthusiasm, communication skills, and teamwork were all highly praised by his former field supervisors, he claimed.
“The reviews given upon me for not supporting my gazettement as a specialist were very subjective in nature, which can vary from one evaluator to another.
“Those items that were highlighted were aspects which cannot be evaluated on paper or any documentation and purely observatory, which may be influenced by personal prejudgment or prejudice of the evaluator. Additionally, it would take years of experience to develop leadership, managerial and decision-making skills,” Dr Stephen said.
Dr Stephen believes that modifications of pre-gazettement criteria should be strongly considered for gazettees with mental health issues in order to accommodate and facilitate them and not to be used against them to disrupt their professional pathway.
Dr Stephen has a deep passion for public health, specifically on health policymaking and implementation, monitoring and evaluation of health programmes, resources management, diseases outbreak control, as well as health strategy and plannings.
His particular fields of interest are non-communicable diseases (NCDs) and health nutrition.
“I was obese as a child, and nothing was done back then. There’s definitely a lack of awareness and education when it comes to obesity, which is the precursor for almost all NCDs and the biggest challenge regarding NCD burdens. Health policymaking and strategies should begin to emphasise the availability, accessibility, and affordability of healthy food in view of the rising rates of obesity and obesity-related diseases in Malaysia,” Dr Stephen said.
“We are surrounded by cheap, unhealthy junk food and highly sugared beverages. Anything healthy comes at a higher cost. How can we expect the lower-income group to be healthy? We are not subsidising fruits and vegetables. Instead, we are subsidising cooking oil and capping refined sugar prices to ensure affordability.”
Unable To Serve The Public As A Public Health Specialist
Despite having obtained the required doctoral degree from a prestigious local public university along with the necessary credentials, Dr Stephen is incapable of contributing his service to the public as a specialist due to sanism and the MOH’s inability to provide compassionate assistance and facilitate his pre-gazettement evaluation process.
On the contrary, he has been deemed unfit and unqualified to be gazetted as a public health medicine specialist due to his current mental health illness.
Dr Stephen was granted a scholarship by the MOH after a meticulous selection process that included written exams and interviews.
However, despite receiving a fully funded academic scholarship from the government, Dr Stephen is currently unable to hold the title of a specialist due to the subjective evaluation based on his personality, character, and attitude which was significantly influenced by his underlying mental health condition.
This circumstance further exacerbated his mental health illness, as it hindered his ability to apply his acquired knowledge and skills.
The lost potential to serve the public as a specialist enormously impacted his self-esteem, Dr Stephen said, perceiving himself as a failure.
“I wonder if I had been diagnosed with major depressive disorder and had decided to disclose it prior to the scholarship selection, would I have been selected at all?”
Studies On Mental Health And Burnout Among Malaysian Health Workers
The prevalence of mental health disorders has been on the rise in Malaysia, even before the Covid-19 pandemic. Highly demanding work situations in the health care field make it one of the most challenging professions.
A 2018 study examined stress, anxiety, and depression among 140 emergency department medical officers in seven general hospitals in Malaysia. The study found a high prevalence of anxiety at 28.6 per cent, followed by depression at 10.7 per cent, and stress at 7.9 per cent. There were no significant differences in depression, anxiety, and stress levels among the seven hospitals.
In a 2020 study involving 314 doctors in North Borneo, the prevalence of severe or extremely severe anxiety symptoms was 27.4 per cent, followed by depression at 22.9 per cent, and stress at 18.5 per cent.
Another study conducted during the Covid-19 pandemic in February and March 2022 assessed burnout, quality of life, and resilience among health care workers in Putrajaya and Selangor hospitals during the fifth wave fueled by the Omicron variant.
The study revealed that roughly half of the health care workers in the study experienced moderate to high levels of burnout in occupational exhaustion and depersonalisation, while showing a low level of personal accomplishment.
Health issues varied among different groups with individuals aged 25-35 reported lower physical health, while those working more than 10 hours daily reported poor psychological health. Income level and working hours also affected the environmental aspect of health.
The study also identified a strong correlation between physical and psychological health, suggesting that individuals experiencing physical health issues are likely to face psychological health issues as well. These findings highlight the need for targeted interventions.
