This follow-up is issued not merely to clarify our earlier position, but to place on record a series of grave developments now unfolding behind closed doors at Hospital Sultanah Aminah Johor Bahru (HSAJB). What is at stake is no longer administrative inconvenience or operational strain—it is patient safety, and the risk has become systemic.
Our original article – “Overworked, Understaffed, Overwhelmed: A Data-Driven Reality For Medical Officers At HSAJB — Medical Officers” – was never intended to be a commentary on Emergency Department congestion.
It was written from the vantage point of the Internal Medicine Department to highlight a chronic and worsening manpower crisis that is obstructing ward care, delaying admissions, and eroding the sustainability of on-call services.
References to the Emergency Department were contextual, illustrating downstream consequences rather than assigning blame. The locus of failure has always been internal medicine—and it remains so today.
In response, the Johor state health department (JKNJ) announced the deployment of medical officers from other institutions to support HSAJB. This reassurance has since proven illusory. Within a short period, all temporary medical officers stationed at HSAJB were recalled without replacement. Despite earnest efforts by hospital leadership, internal medicine staffing has not improved; it has deteriorated further.
At present, 46 medical officers are nominally assigned to the Internal Medicine Department, responsible for 13 wards comprising 469 inpatient beds. This headline figure, however, significantly overstates the manpower actually available for general internal medicine care.
Of these 46 officers, 14 are required to provide fixed subspecialty coverage, while an average of five are unavailable at any given time due to emergency leave or medical certification. This leaves an effective general medicine pool of approximately 27 medical officers to sustain ward care, acute admissions, and on-call services. On paper, this corresponds to a doctor-to-bed ratio of approximately 1:17 for general medicine.
In practice, the situation is far more severe. Once on-call rostering, post-call, and service exclusions are taken into account, night on-call services are staffed by just seven medical officers. These seven doctors are collectively responsible for approximately 560 inpatients and active cases across the hospital, encompassing ward patients, acute admissions, and ongoing referrals. This translates to an on-call ratio of roughly one doctor to eighty patients (1:80).
These doctors are expected to manage deteriorating ward patients, new admissions, and referrals from nearly every clinical department—often under conditions where urgency and appropriateness are secondary considerations. On-call duties routinely extend for approximately 33 continuous hours, from 8:00 a.m. until 5:00 p.m. the following day. In reality, the volume of work frequently deprives doctors of any meaningful rest.
Prolonged wakefulness beyond 24 hours is a well-established risk factor for impaired cognitive performance and medical error. Yet under current staffing levels, critical decisions—escalations of care, invasive procedures, and emergency interventions—are made under profound physical and cognitive exhaustion. This is not an issue of resilience or professionalism; it is a predictable outcome of structural overload.
As manpower dwindles, coverage expands, delays become inevitable, and response times lengthen. Clinical judgment increasingly gives way to crisis management. The danger is not an abrupt collapse, but a silent degradation of care under the illusion of normal operations.
Deteriorating patients are reviewed later than appropriate, complex decisions are made through a fog of fatigue, and near-misses quietly accumulate. Such near-misses are recognised indicators of system strain, not individual failure.
Patient safety is further compromised by the erosion of essential on-call infrastructure. The removal of the largest designated internal medicine on-call room exemplifies the neglect faced by frontline staff. A formal internal complaint submitted months ago—highlighting exhaustion, overnight safety concerns, and the risks of prolonged duty hours—was met with silence.
At present, the number of designated on-call rest spaces is grossly inadequate relative to the number of doctors on duty. Many on-call doctors have no safe place to rest; some sleep in their cars after extended shifts. The few remaining rooms are allocated on a first-come, first-served basis, without regard for gender or privacy—conditions that are indefensible in any hospital, let alone a tertiary referral centre.
Fatigue is not a minor inconvenience; it is a proven contributor to medical error and compromised patient care. Doctors are subjected to prolonged duty hours, expanding responsibilities, and shrinking support, while even the most basic provisions for rest are withdrawn. Left uncorrected, this trajectory will accelerate attrition among junior doctors, producing a reverse pyramid with no sustainable future workforce.
This reality stands in direct contradiction to the principle of Kemampanan under the Madani framework, which calls for sustainable, resilient, and equitable public services. A health care system that relies on 1:80 on-call ratios normalises prolonged exhaustion and depletes its workforce faster than it can replace it is not sustainable—it is being quietly hollowed out.
The Internal Medicine Department at HSAJB continues to function not because conditions are safe, but because its workforce continues to endure. That endurance is finite. Patient harm may not yet dominate headlines, but the conditions that precipitate it are firmly entrenched.
This follow-up documents these realities before they are normalised—before fatigue, error, or attrition forces recognition through inevitable adverse outcomes. When unsafe ratios become routine, harm is no longer an aberration; it is only a matter of time.
Editor’s note: CodeBlue has requested comment from the Ministry of Health.
The author is a medical officer at HSAJB. CodeBlue is granting the author anonymity as civil servants are prohibited from writing to the press.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
