Dr. Mary Cardosa who is the President of MMA wrote the letter below in the Star today. It is a well written letter which summarises whatever that I have been saying all this while.
For budding doctors, please realise that being a doctor is stressful and demanding. Even in UK, about 30% of the doctors are having stress disorder and needed psychological help. So, don’t assume that stressful situation only happens in Malaysia. It is everywhere.
The more developed a country becomes, the more demanding the patients become and the litigation rate will increase. With the poor quality of doctors being produced lately, the litigation rate is only going to get worst!
Job demands long hours
THE recent tragic death of a young doctor (The Star, April 12) has led to renewed discussions on the working conditions and training of housemen in Malaysia. In initial news reports, working long hours was implicated as a source of stress for the young doctor.
In fact, the complaints about “long working hours” of housemen had been forthcoming for some time and the Health Ministry implemented a flexi-hours system for housemen in the third quarter of last year.
The Malaysian Medical Association (MMA) has been monitoring the system since its implementation, and has continually sought feedback from housemen as well as from medical officers (MOs) and specialists involved in houseman training.
We have called on the ministry to carry out a comprehensive review of the new system, not just in terms of the workload of the housemen but, more importantly, in terms of how it affects their training.
Based on feedback, we are concerned about the reduction in houseman training time, resulting in inadequate exposure to patients, limited opportunities for observing and performing basic procedures and operations, and lack of continuity of care for patients.
We would like to emphasise that the housemanship training period is a critical time in a doctor’s career, the time when he/she applies all that he/she has learnt during medical school in real-life situations – fully supervised by more senior doctors.
It is thus extremely important that the young doctor uses this time to learn, and to gain as much experience as possible, as it will be the foundation of his/her future career in medicine.
The medical profession is such that one cannot work “by the clock”. Sickness does not recognise “office hours” or “shift times”.
When caring for a sick patient, e.g. someone who has just been admitted or someone who has taken a turn for the worse, a doctor has to examine, send for the necessary tests, and do the needful to resuscitate and stabilise the patient before “clocking out”.
The nature of the profession calls for such a commitment and dedication, and this culture is instilled in us during our formative years – medical school and housemanship.
Young doctors are also taught to put their patients’ interests and welfare first, before their own.
Sadly, this culture of commitment and caring seems to be getting lost in the name of improving “quality of life”.
This brings up what is, in our opinion, a more important negative impact of the flexi-hours system – the possibility that this will result in doctors lacking a sense of responsibility for a patient.
While discussing the plight of young house officers, the equally (or more) strenuous working hours of MOs and specialists in government hospitals may have been forgotten.
Training and supervision of housemen is the responsibility of MOs and specialists in the respective departments, who are already overworked with patient care.
These more senior doctors are finding it difficult to cope with training the large numbers of house officers being posted to our public hospitals, especially the many who lack basic medical knowledge and skills.
Which of course brings into question the quality of our medical graduates now. In this regard, the MMA welcomes the recently tabled amendments to the Medical Act 1971 which includes a proposal for the establishment of a Medical Qualifying Committee to look into the accreditation of qualifications of both local and international training institutions.
However, we are disappointed that the original proposal – for a common qualifying examination for medical graduates – was set aside.
We call upon the Malaysian Medical Council to carefully examine the quality of medical schools (local and international) and to take the necessary action where shortfalls in quality occur.
With regard to training of housemen, the MMA feels strongly that decisions on these matters should be left to medical professionals, with no external interference from parents, politicians or others.
As doctors, we know what training is needed to produce a good doctor, and hard work and long hours are certainly some of the necessary “evils” that we cannot escape from!
The MMA calls on the ministry to ensure that the number of house doctors posted to each unit is based on the number of trainers (i.e. specialists and MOs) available.
Only then will specialists and medical officers be able to guide each houseman in the right direction.
The MMA would also like to recognise the specialist and medical officers who have continued to train housemen despite being overworked themselves.
Dr MARY SUMA CARDOSA, President, MMA.
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The sad part about this issue is that the president of MMA has to write an open letter to the newspaper to explain what the young doctors should expect from their profession, when they should aware about these expectation before they applied to get into medical schools.
If you read some of the comments in this blog, you will realise what the public and budding doctors don’t know!
Finally someone decided to write openly to the news papers about the issue of housemen and their parents complaining about long hours of work. Thank you Dr. Mary. What she has said is the essence of everything about being a doctor and unfortunately the very things the young doctors seem to not understand or realize. The picture of being a doctor, being painted as a glamourous and money spinning one is the major cause of some school leaving innocents committing to a life long mistake.
In the past when the Public medical collages were the only ones that conducted these courses, only the ‘creme of intelligentia’ in the country were chosen to pursue them. Although one may argue that intelligence alone is not enough, the interest, dedication and passion was evident due to the fact that they could cope up with the needed responsibility, hard work and perseverance. Have we heard of any similar complaints from doctors of that era? Never. Parents left the children to manage themselves and allowed them to mature into good and responsible doctors through the tough training instead of trying to mollycoddle them and interfere with the system by demanding that their babies get special treatment.
These young doctors do not seem to realize at all what they are doing to themselves, in a overwhelmingly competitive field where one mistake they make as a clinician can spoil their names for good. Neither do their parents.
It is a sad and a serious situation. Most of the damage is already done. The horse has already left.
This is my opinion. If a M.B.B.S. or an M.D cannot cope with the few years of houseman training he/she will not be able to cope with the trials and tribulations of the rest of it which is going to be a life time thing, and a life time can be a very long one.
It is obvious that something serious and proactive needs to be done. It is hard to oppose the marketing tsunamis of the mushrooming medical collages in the country and outside. But it is the duty and responsibility of those who are senior in the medical fraternity to find some way to stop these dangerous ongoings regarding the medical education of our country, for everyone’s benefit.
Posted by ‘Disappointed”
“As doctors, we know what training is needed to produce a good doctor, and hard work and long hours are certainly some of the necessary “evils” that we cannot escape from!”
Hard work is correct, but I do not agree long hours should be a necessary “evil” to produce a good doctor. After all HOs are human being made of fresh and blood and not machines. Their standard working hours should be reasonable like the rest of the civil servant, but must prepared to stay on to finish their work when circumstances arises.
Since MOs and specialists are also overworked, it is therefore crucial that more HOs should be trained to become MOs, and more MOs should be trained to become specialists, to take care of our growing populations. It is therefore the responsibility of the MOH to work with MMC/MMA to come out with short-term and long- term solutions so that nobody will be overworked !!
Being a doctor, you cannot run away from being overworked! What she meant was that there is no such thing as clocking out in time! I don’t think she was referring to working 36 hours etc which no one agrees.
There are 2 elements to the issue of long hours for doctors-in-training (or “junior doctors” as they are referred to in the UK system): one is service, the other is training.
As far as service issues are concerned, there is constant pressure to reduce working hours of junior doctors to make their working lives more bearable and to provide a degree of quality of life outside work. So long as the service needs to the patients do not suffer, I have no problem with this.
But there is the other rather important element of a junior doctors’ career which is the training aspect. Medicine and surgery is an apprenticeship and like any skill that is gained with experience and time on the job, shorter working hours dictate that the training period will have to be longer.
It takes ~10,000 hours to gain expertise in any skill. There are no shortcuts to be had, particularly in surgery. I tell my surgery trainees that if they want shorter working hours and better quality of life, then that is fine. But do not expect that at the end of 6 years of specialist training, they will have the same level of expertise as their predecessors who worked much longer hours.
As working hours are reduced, there will be a need for training programmes to be extended. The trainees cannot have their cake and eat it. The trouble with generation-Y is that they want to get to the top with less work, more free time, better quality of life and in shorter time.
Particuarly in surgery you can’t take shortcuts to the acquisition of technical skills. Might be fine for physicians though… 😉
In actual sense, will this letter make any difference to how things are going to turn out or bring any changes? Will the MMC or MOH care about it at all? Sometimes, I just don’t understand how these corrupted and ignorant minds get to climb so high up the ladder in the first place.
hello doctor, I was wondering if you could write a post about how much a doctor earns, in contrast with the amount of work a doctor puts in both in the private and public hospitals. this will help budding doctors understand that being a doctor isn’t really lucrative anymore, considering the amount of work one has to put in, and the various sacrifices. I completely agree that putting in long hours during housemanship is a must for the doctor to learn skills properly, as these are skills that you can’t study theoretically or practice on your own at home. I am still in medical school, but I can already see how practice is much more important than bookish knowledge when it comes to medicine (though bookish knwledge serves as a good foundation). The thing is, people don’t understand that the only supervised practice you are going to get on real patients is during housemanship.
I have written about it if you read some of my earlier post. Pls read under “For Future doctors” page. See “government doctors salary?” And Malaysian healthcare system for the dummies series”
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Ah, didn’t notice it before. Thank you dr.
Though this article provides very crucial insight on not to jump the gun when thinking about the demanding nature of the medical profession, very often people fail to see that it is the intrinsic job design characteristic that cause the downfall of the system. There are numerous domestic studies available to point out that most doctors are demotivated by the relationship they have with their superiors and the organization culture in entirety. If you don’t believe this, you can look it up yourself, it was researched by many of our own peers.
Secondly, an urgent revamp to improve the solidarity of doctors is required. And when we talk about solidarity, we are not bothered if you are a consultant, specialist, medical officer or house officer. Neither am I concerned if you are from the clinical or the preventative health division. We should interact based on the desire to protect the sanctity of a profession that is, in our country, deeply divided and fractured.
And when a problem arises, discussion should involve every fabric of the institution and ego should be cast aside and not magnified based on your status. I request the other to provide his input on this and also think about whether anything was done to improve the framework most doctors function in at present. I know I am on the verge of publishing a scientific article that addresses this. How about you?
Whatever you are saying is true and NO ONE denies that. YOu can do 100 studies on these issues BUT who gives the damn? When I was in SCHOMOS at state and national level, I brought up these issues to the state pengarah and even during the meeting with the Minister but you get the same answers all the time: we will send circulars about bullying, we will ask the pengarahs to improve the “on-call” rooms etc etc but at the end, nothing is done!! So, don’t think I only talk but don’t do anything. It has been done BUT the doctors themselves are so disunited and do not talk with 1 voice.
A lot of the remaining specialist/HODs in the gov service, sorry to say, are apple polishers and world travellers. They are in a comfortable chair and earning a monthly salary whether they do any work or not!!
You have just reinforced my point exactly. So the main problem isn’t about the long hours. It isn’t even about salary. It isn’t even about recognition. It is a purely structural, psychological and organizational dilemma, something that clearly no one has the courage to confess.
You have approached the right people, but they are not the right people anyway because they are so entrenched in the system that they will do what they need to maintain the status quo. They are part of the system – nothing will help if you approach them. We need to resort to other avenues. I have done not only studies, I have also, like yourself, proved to all of them the system is fatally flawed.
Firstly, there should be a total demolition of the pre-existing health policy. The anachronistic nature of superiors have to be deal with. I am sure you have experienced that in major countries abroad, superior take pride in what they do and the preach this to their juniors.
I have had the fantastic opportunity to talk to such an individual. And never in my life in Malaysia, during my undergraduate, postgraduate or my double postgraduate tenure did I see individual similar to his stature.
Why is this happening here? Easy, simply because people don’t deal with the main issue – reprimanding superiors for errant behaviour, promoting a culture that encourages passion so that doctors take pride in what they do and making sure that quality of care for all patients is of paramount importance is something we lack so much.To cut the long story short, suggest to a minister/head of department/superior that our fraternity has ZERO ORGANISATIONAL CITIZENSHIP. That’s the word.
I am not surprised that this has occurred mainly because Malaysia has among the worst track record of Human Development Index (HDI). Check out how egalitarianism has promoted excellent work culture in Scandinavian countries. And yes, they rank the highest in HDI.
In other words, you can’t look at medicine just as a clinical field – it has to also be addressed in a social science sort of method, something that most doctors fail to realize.
I rest my case. But I will continue with my work to assess this amongst doctors and perhaps publish it in a recognized journal so that it will gain wide attention. Maybe after that, I’ll propose the health policy to our local ‘jaguh kampung’ ministry on what to do to eradicate this problem. After all, they would only want to believe in something so obvious (staring right at them) when it is credible.
And yes, I forgot to add. Get the medical fraternity to be an independent body like the rest of the world. We can be non partisan and advise the government on what is best for us. We don’t need an MMA, we just need to have a collective voice under the umbrella of just one organization the we all belong to – DOCTORS. Don’t allow politicians to dictate our needs. Instead, we should be the people to lobby to them the right policies.
Yup but in Malaysia, everything is politisied! Forget about MMA, what about MMC? totally toothless!
Agreed with you, MMA is just a social club with no legislation or influence on Malaysian health policy or practice.
The working environment and organizational attitude is part of the factor and not the ONLY factor. It is one of the contributory factors in stress of doctors. The rest, as you mentioned are STILL important factors. I had seen many housemen who could not cope even when most superiors were nice to them. The fact remains that many were not interested in doing medicine or were not aware about the life of a doctor.
Our healthcare system is in a mess. I have said that many times. It is screwed and need a strong political will to change. Incompetent ones cannot be removed as the procedure is the same as any other civil servant. As long as this type of archaic system is in place, nothing will change!
Quick, get this bunch of houseman under the new shift system to graduate as MOs…then the MOs can start having the shift system as well. Don’t we all love shift work? Sigh….how far-sighted our system is, implementing things without careful thought. I’m not saying that we make life hard for these HOs, but how are they even going to cope when they become MOs / specialists, when they are already whining away to glory to their parents and politicians about the ‘terrible workload’ and ‘inhumane working hours’ that they are supposedly facing? Well for your information, my dear juniors, your MOs and specialists are still doing on-calls, and have more on their hands than you do (including having to supervise you bunch of spoilt brats!)
When you already got HO who don’t know how to take histories and do examinations, shorter training periods, ease of passing housemanship rotations without much of an effort, medical students and junior doctors who enter the field with absolutely no insight, and on top of that, 16 Unis rubber-stamping MQE examinations, just imagine what sort of specialists are we training years down the line ? The system is so rotten and the politicians are just making the numbers nice because they don’t use the service themselves. I really wonder how many of the current HO/MOs are actually competent. Might be worth starting a list of juniors who are competent, and another list of those who are bound to be dangerous just for your own future reference.
Yes, that is exactly what I intend to explore. If a person is not interested or has low morale doing medicine, how can we make it better? We need to pursue internal drivers that determine this and sadly money is not the magic bullet. If you decide to leave the system as it is, then it is a defeatist sort of attitude. I am sure you have heard the saying ‘You can be the change that you want to see in this world’.
Anyway, I believe that this online argument is futile but nevertheless gives me an insight how people are still unwilling to budge and move forward. I will work towards what I believe is achievable. I’ll let the rest complain about something that they are not ready to change though it is a viable option.
Thanks for all your comments.
Yes, I wish you all the best! I tried and failed, I must admit that. The system is just too complex and convoluted to change.