All health systems can only function with healthcare professionals (HCPs).
The attainment of the health component of the Sustainable Development Goals (SDGs) and universal health coverage is dependent on the availability, accessibility, acceptability and quality of HCPs.
The healthcare workforce has a vital role in the ability of a health system to respond to natural or man-made disasters, as well as related environmental, technological and biological hazards and risks.
The consequences of the Covid-19 pandemic were devastating, with Malaysia having the highest death rate per capita of the population in Asean.
Not only that, the illnesses and disabilities from long Covid-19 have yet to be quantified.
Malaysians owe a mountain of debt to the sacrifices of the junior doctors who provided them care, whether in hospitals or clinics for Covid-19.
Junior doctors faced very challenging personal and professional conditions, like long working hours in personal protective equipment (PPE), trying to protect themselves and their families from potential illness; having to adapt to new ways of working; and lack of training opportunities and examination postponements.
The sacrifices of the junior doctors were critical in containing the pandemic; some junior doctors even gave their lives for their fellow citizens.
Yet it appears that many people, particularly decision-makers and politicians, have forgotten the critical contributions of these doctors during Malaysia’s worse public health disaster.
This memory lapse was reflected in reports of the Health Ministry’s management of the transfers of its junior doctors, who were offered permanent positions, over the past two months.
Various unflattering adjectives have been used to describe the exercise including “KKM treats its doctors like slaves”, written in an op-ed published on a health news website by a government doctor using a pseudonym (as they are not allowed to make media statements).
A hot mess
It is difficult to dispute that the transfer exercise was a mess, which included, among others:
- Lack of communication between Putrajaya and state health departments – This resulted in major hospitals, with heavy workloads, being short of doctors, with the consequential disruption and/or suspension of healthcare service delivery, which had to be announced to the public.
A doctor group estimated that the waiting times in emergency departments for admissions at major hospitals would increase by 50-100% with all its attendant consequences for patients.
There were also allegations that patient safety was compromised due to the shortage of medical officers.
- Doctors were not eligible for transfer claims – This resulted in some having to pawn jewellery, withdraw monies from their savings accounts, etc, in order to foot the bills resulting from uprooting and moving to a new town.
- The financial loss incurred by doctors transferred to Sabah and Sarawak from Peninsular Malaysia were particularly high.
- Doctors posted to Sabah and Sarawak instructed to return to Peninsular Malaysia at short notice – One example posted on X (formerly called Twitter) was a medical officer who was posted to a Sarawak hospital from Negri Sembilan, only to be told the next day after reporting for duty on a Monday that the result of their appeal, posted the Friday before at 4.45pm, had changed their posting to a hospital in Johor.
They were told to report to Johor as soon as possible.
- Doctors posted to facilities that had no more vacancies for medical officers
- Doctors posted to a hospital still under construction
- Disruption of speciality training – Doctors preparing for, or in the, Masters specialisation training were transferred to other healthcare facilities, even though their training necessitated them to be in specified facilities.
Some appeals were rejected, while others were subsequently instructed to report back to their original facility.
- Issuance of transfer instructions on the weekend prior to reporting for duty
- Not permitting mutual exchange of postings.
The contract doctor issue has been around since 2016 and transfers are a norm in the Health Ministry.
Yet, 2023 was the first occasion that such messiness came into the public domain.
Who was responsible for this mess?
Was it poor communication, poor coordination, incompetence, irresponsibility, or a combination of these factors?
Were there other factors?
Suggested improvements
The healthcare workforce, particularly the junior doctors, have a critical role to play if the country is to achieve its health and developmental objectives in the next few decades.
A paradigm shift has to be adopted with strategies to plan, educate, deploy, manage and reward the healthcare workforce, particularly junior doctors.
It is critical that urgent steps are taken to improve the working lives of these doctors.
This would include, among others, some of those listed below.
It is an immediate priority to address burnout, which has been described by the World Health Organization (WHO) as “a syndrome conceptualised as resulting from chronic workplace stress that has not been successfully managed and characterised by three domains: feelings of energy depletion or exhaustion; increased mental distance from one’s job, or feelings of negativism or cynicism relating to one’s job; and reduced personal efficacy.”
Burnout is associated with adverse personal behaviours, like drug misuse/abuse, relationship breakdown, and consequential effects on patient care, as doctors who suffer from burnout are more likely to be involved in adverse patient incidents.
The fair financial compensation of junior doctors and specialists has been a long-standing issue.
The on-call allowances of junior doctors per hour have been reported to be less than that of fast-food staff.
The unkindest cut of all were reports of delays in payments of on-call allowances.
One wonders whether other civil servants are treated in this manner.
With the rising cost of living, accommodation, etc, the issue of financial compensation contributes to the poor morale of junior doctors.
Speciality training is through the Masters programmes of local universities or the Royal Colleges examinations (also termed the “parallel” pathway).
Selection for the Masters programmes can be described as opaque, to say the least.
Some contract doctors, who have difficulties in entering local Masters programmes, have taken the parallel pathway examinations on their own.
However, there is no clear pathway for these contract doctors to be absorbed into permanent service as specialists.
Many politicians who exhort the Health Ministry to deploy more specialists into hospitals in their constituencies have strangely been silent about this administrative logjam.
Nurturing resilience
The Health Ministry response via a media statement on Aug 4 (2023) were general statements that did not address the impact of doctor shortages on patient safety and quality of care.
The Health Ministry claimed that “through these new placements, officers will obtain more exposure about the healthcare system and can develop their own capacities.
“This experience will make officers more mature, empathetic and tougher (berdaya tahan) in surviving their career as a public servant.”
Resilience is desirable of all junior doctors as they have substantial responsibility for patients’ lives and wellbeing, work long hours, encounter difficult situations, and have to try to balance personal and professional challenges.
However, resilience is not an innate attribute in everyone.
It often needs to be nurtured by various means like good physical and mental health, recognising and managing conflict situations in the workplace, and maintaining strong personal relationships – all of which would be enhanced by mentorship and other support mechanisms, as well as resilience and leadership training programmes, which are sadly lacking in the Health Ministry.
The gratification from doing a good job is an important factor in keeping junior doctors resilient.
Doctors who experience joy in work are happier, more secure, have greater job satisfaction and greater career fulfilment, and consequently, provide higher quality and safer patient care, which is what the public wants.
The goal has to be joy at work, which was stated succinctly by the institute for Healthcare Improvement: “The most joyful, productive, engaged staff feel both physically and psychologically safe, appreciate the meaning and purpose of their work, have some choice and control over their time, experience camaraderie with others at work, and perceive their work life to be fair and equitable.”
The current junior doctor mess has to be cleared up urgently for the sake of healthcare in Malaysia.
Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. For more information, email starhealth@thestar.com.my. The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only, and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
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