Growing concern: The number of medical students in Malaysia has gone down, which can lead to a shortage of doctors in the future. — 123rf
“AKU bunuh kau nanti!”
Whether it was made jokingly or with real criminal intent, the “I will kill you” threat hurled at Hisham* during his first referral as a house officer had shocked him to the core.
But what finally pushed him to quit medicine was the hospital management’s response when he reported the incident: “I don’t care what happens – bullying or not – as long as the officer can work well.”
At that point, Hisham says he had to be honest with himself about his future.
“What good is a career if it destroys the person living it?” says Hisham, who is now 35 years old and thriving in auditing instead.
Hisham’s story reflects the ongoing crisis of a high attrition rate among doctors in the public healthcare system.
It was reported last May that the number of housemen at the Health Ministry has dwindled by 50% since 2019.
Health Minister Datuk Seri Dr Dzulkefly Ahmad at the time also acknowledged the shortage of housemen.
“In fact, those who are working are feeling the burden due to the workload and manpower shortage,” he said at the time.
The Health Ministry has since undertaken an ongoing review of the housemanship programme, which includes a proposal to shorten the training duration from two years to one year.
The Health Director-General Datuk Dr Muhammad Radzi Abu Hassan has said this change aims to address efficiency.
While experts and stakeholders see the shortened programme as a net positive, they stress that improving workplace support and modernising archaic hospital systems remain critical to retaining young medical talent.
Reverting the housemanship programme from two years back to one year is expected to accelerate career progression for junior doctors, especially those who intend to undergo training for specialisation in the future, says Malaysian Medical Association (MMA) president Datuk Dr Kalwinder Singh Khaira.
“We are thinking that if it’s a one-year housemanship, you may be able to move to the next scale faster.”
But that is upon the condition that adequate training for young doctors is maintained, he stresses.
Vicious cycle
Addressing the concerns of career progression for housemen is good says Dr Kalwinder, but ultimately, they have to figure out how to increase the number of young doctors and also how to retain them.
“If you don’t retain them, who is going to run your service and who is going to train (new doctors)?
Dzulkefly had previously noted that the number of medical graduates has gone down over the years.
“There was a time where there were 6,000 to 7,000 medical graduates a year. Now we have a little over 3,000 which has led to fewer housemen at hospitals,” he was reported as saying.
Dr Kalwinder believes that part of the reason there are fewer medical students is due to the growing fear of the issues that comes with becoming a doctor in Malaysia.
“You only hear the negative aspects - bullying, career progression, doctors leaving, stress, work-life balance. To a certain extent, it is true.
“But the effect it has had is negative. So because of that, the numbers have dropped. Because the numbers have dropped, there are fewer doctors to carry the burden and when that happens, the doctors get stressed and some of them just leave,” he explains.
The exodus of doctors is a vicious cycle that leads to fewer and fewer young medical professionals, he says.
As more doctors leave the profession for a multitude of reasons, those who remain have to take up more duties, which further adds to their stress, causing even more doctors to quit.
“We have to improve the work-life balance and the quality of life (to retain doctors), and for that, we need numbers,” says Dr Kalwinder.
Overburdened and burned-out senior doctors are also often unhelpful towards junior doctors who may need guidance to adapt to the public healthcare system, further contributing to the vicious cycle.
Lily* expected the long working hours and heavy workload when she started her housemanship programme, but it was the uncaring and sometimes downright mean behaviour from her seniors that made her quit the training after just one week.
Vulgarities and name-calling were a constant during her brief time as a houseman, and while she says she did not bear the brunt of it, she witnessed others in her cohort who received the worst of it.
As a result, at least two other housemen quit around the same time she did.
While Lily did not reveal further details, she says the other two are currently under psychiatric evaluation.
“What I didn’t expect was the lack of help, and I would say the environment was pretty toxic.
“There was no one that was really willing to help people because they were just too busy to help,” she says.
The numbers game
Dr Kalwinder acknowledges that workplace bullying does happen among doctors, but adds that he does not think it is as rampant as it is made out to be.
Regardless, he says, it is most important that junior doctors feel they have a trusted channel to lodge complaints.
“We proposed to the ministry to create an ombudsman system.
“An ombudsman system is whereby somebody can complain confidentially and that ombudsman has the authority to investigate.
“The trust in the system and the process is very important,” he says.
Hisham agrees, saying if there were a way to report abuse without fear, he might have opted to stay in medicine instead of pivoting to auditing.
“There should be an independent body – outside of the medical fraternity – that listens to housemen and acts on misconduct. Real consequences. Real accountability,” he says.
When it comes to mental health, Manvir Victor, a World Health Organisation (WHO) global patient advocate, who was a member of the Healthcare Work Culture Improvement Task Force (HWCITF), says there are simply not enough psychiatrists or counsellors in government hospitals to provide adequate care to the doctors.
“Let’s say we have 100 people in psychiatry – they are serving the patients, not the doctors. So if you are a young doctor, who do you go to?”
The HWCITF was established as an independent committee in 2022 under the then health minister Khairy Jamaluddin to investigate the death of a house officer as well as the work culture and human resource management in government hospitals.
The task force released their report in August the same year but Manvir says there have been few updates on their recommendations since then.
Among the recommendations they made to improve workplace cultures in the public health sector are improving remuneration rates for doctors and standardising onboarding policies across all government hospitals.
It is obvious that improved remuneration rates will help retain more doctors, but the benefits of a standardised orientation for new housemen may not be so clear at first.
Manvir says currently, the onboarding process is slightly different at every hospital, where some may provide housemen with a full day of orientation while others can be done within an hour.
This ends up creating a maldistribution of workforce issue as more medical graduates may choose to apply for a hospital with a comprehensive onboarding process, leaving the other hospitals understaffed, he explains.
The maldistribution of the workforce is something Dr Kalwinder is very concerned about too, as he says the MMA has suggested creating a digital dashboard system that is accessible to healthcare officials to show the current distribution of the medical workforce in government hospitals across the country.
This would help hospitals plan their workforce better, he says.
“I must know how many (doctors) I have and how many they (other hospitals) have so that if I know you have more than me, then I can say, can you send some to me?” says Dr Kalwinder, who is based at the Sarawak General Hospital.
This also goes back to the numbers game mentioned by Dr Kalwinder earlier.
“I don’t mean (we need to increase) absolute numbers. I mean the correct distribution of numbers everywhere so that in the country, every doctor should have the same kind of lifestyle and work-life balance,” he says.
This vicious cycle must be stopped, he adds.
“Ultimately, what is it for? It’s all about patient safety, so it is very important to have adequate manpower.”
* Not real name
