Tackling the problem of burnout

Take five: HCPs (in this file photo) have been working flat out with few breaks since the start of the pandemic in Malaysia.

THE doctors, nurses, pharmacists, paramedics and other healthcare professionals (HCPs) of Malaysia are burning out.

A study by Universiti Sains Malaysia (USM) involving 933 HCPs last May revealed that 54% of them were already reporting symptoms of burnout only three months into the pandemic.

Twelve months later, it is likely that even more HCPs are experiencing deeper burnout.

This is especially true as Malaysia has continued to report new highs of daily cases and deaths throughout this month.

This week, we take a look at two under-appreciated reasons for burnout, two under-explored long-term implications of burnout to the health system, and two under-prioritised solutions to the issue.

Ethics and career

The causes of burnout among the HCPs are well-understood.

They have been facing unimaginable workloads, emotional pressure, physical fatigue, the risk of contracting the SARS-CoV-2 virus, and many other stresses, for at least 16 months.

Yet, there are two under-recognised reasons for burnout among Malaysian HCPs, especially in the third wave of this pandemic.

Firstly, the HCPs are facing increasingly difficult ethical dilemmas in clinical practice, both in intensity and frequency.

The recent weeks have seen an influx of stage 4 and 5 Covid-19 patients who are rapidly nearing the capacities of intensive care units (ICUs).

Providing care with limited resources leaves doctors and nurses with ethical dilemmas that are not familiar with them.

For example, should patients with poorer prognoses be prioritised or those with a better chance of survival?

Who should be admitted to the 1,388 ICU beds in Malaysia?

Who should be given ventilators and what should be the threshold of withdrawing care?

These ethical dilemmas weigh heavily on the soul, as more patients get admitted during this third wave.

Secondly, there is professional uncertainty looming over the HCPs.

Many doctors and pharmacists are on short-term contracts, and their job security and career progression are not assured.

Most contract medical officers have been mobilised to the frontlines and perform Covid-19 services just like permanent medical officers.

Despite their sacrifices, the UD43 contract medical officers are clearly struggling; their pay and perks are less compared to when they started out as house officers.

No other profession will pay their employees less as they become more senior.

Contract medical officers also have ambiguous career paths as they are not eligible for specialisation under the Health Ministry’s Hadiah Latihan Persekutuan Masters route in local universities.

They are eligible for parallel pathways via international postgraduate exams like the MRCP (for physicians) or MRCS (for surgeons), but those are equally challenging.

These exams have several papers and usually require a few years to complete, but contract workers are not given study leave to take their exam.

With their shorter contracts, these doctors will be unable to complete the exams before they end their contract, leaving them with no place to practise and no money to pay for the exams.

More importantly, their employment with the Health Ministry might end next year, even after they have served at the pandemic frontlines, forcing them to venture into private practice or non-clinical careers.

Personnel and patient care

If we do not address HCP burnout today, Malaysia faces two long-term implications to our health system.

Firstly, at a macro level, our healthcare system will see a reduction in personnel.

HCPs dealing with burnout are 5-19% more likely to retire early, leading to a shortage of skilled workers.

A year into the pandemic, there are already multiple anecdotes of junior HCPs leaving the government service.

If burnout is not managed today, there will be an even sharper shortage of skilled and trained HCPs in the public sector.

There will be brain drain from the public to the private healthcare system, from Malaysia to other countries, and from healthcare to other sectors.

Without clear action against burnout, future generations of Malaysians will refuse a career in healthcare, preferring more lucrative jobs with better working conditions in finance, IT or banking, for example.

Doctors and nurses who leave the system also mean that Malaysia has lost our investment of time, money and energy to train them.

There will also be time gaps while awaiting new HCPs to fill up vacancies, affecting the level of healthcare provided.

The second under-explored implication of HCP burnout is deteriorating patient care.

Burnout causes psychological changes like depression, aggression and impaired decision-making ability, resulting in suboptimal treatment for patients.

Apathy or lack of enthusiasm due to burnout will adversely affect patients’ satisfaction and outcomes.

In a time-sensitive situation where the system is already overwhelmed, burnout can lead to medical errors with substantial cost to patients and the healthcare system.

Workforce and environment

We would like to propose two systemic solutions to improve this situation.

Our first solution is in reconstructing the healthcare system to expand the workforce.

The short-term measures that can be taken include task-shifting and recruiting more HCPs to cope with the expanding demand of the healthcare system.

The Health Ministry has periodically made decisions to temporarily increase its workforce during this pandemic.

This ranges from recruiting retired nurses and medical doctors to mobilising private general practitioners for the vaccination process.

At the same time, the drastic increase in cases have compelled the ministry to recruit non-HCP volunteers at different Covid-19 centres to cope with the crisis.

However, these measures are reactive instead of proactive, and do not improve the resilience of our healthcare system in the long run.

In other words, we are providing a “band-aid” solution.

The long-term solutions should be planned today so that they can be delivered tomorrow or after the pandemic.

This includes more permanent posts for contract officers, as well as longer contract durations.

This has the additional benefit of allowing doctors to complete their specialist training.

Our second solution is focusing on the work environment, involving the practices in different departments and hospitals.

The managers or team leaders (like department heads or specialists in charge of wards or units) should be trained to recognise and manage mental health issues in the workplace and encourage help-seeking behaviours.

As many Covid-19 centres are makeshift in nature, they gather HCPs from diverse backgrounds and work practices.

Modification of working arrangements can help reduce emotional fatigue and burnout.

This includes allowing the HCPs to take annual leave when needed, adequate quarantine time for HCPs who are identified as close contacts, and avoidance of punitive action for HCPs exposed to the SARS-CoV-2 virus.

HCPs who have been urgently transferred could also be provided with assistance to obtain accommodation near their healthcare centres before they report for duty.

More humane administrative services like adequate notice and logistics assistance before transfers to another hospital are also fundamental.

The recent story of 430 HCPs being given just five days to relocate from Peninsular Malaysia to Sarawak is unfortunate and could have been handled very differently.

It is critical for us to recognise the threat of burnout among Malaysian HCPs.

Band-aid and superficial solutions are inadequate in the face of a systemic issue; systemic action is needed to address burnout among our HCPs.

This is crucial not only for ethical and legal reasons as the Health Ministry is a large employer, but also because the health of Malaysians and our health system depend on it.

Dr Nur Nabila Nasharuddin is a recent medical graduate awaiting clinical placement and Dr Khor Swee Kheng is a physician specialising in health policies and global health. The views expressed here are entirely their own. For more information, email [e-mail].