Unboxing The Malaysian Healthcare System Crises — Part 2
Part 2 - About the junior doctor’s working conditions
5. Inhuman working hours
With medical officers working on average 5 to 8 of 36 hours oncall shifts in a month (varies between departments and between hospitals), they essentially work really long continuous hours. Even so, I recall as a house officer, my working hours ranges from 60 to 120 hours. On average, I had previously worked 90 hours in a week.
Among the medical officers in the medical department, they would sometimes do oncall shifts back to back. For example, Monday to Sunday, they could do, morning on Monday, 36 hours on Tuesday-Wednesday, again 26 hours on Thursday to Friday, morning on Saturday and finally a day off on Sunday. With oncall shifts, they will essentially carry out team/ward work up till office hours, then they may juggle with patients referred from ED on top of taking care of sick patients in the ward, then again with ward rounds/work the next morning with the team. Seen and witnessed, am I horrified? Yes. Particularly because I wouldn’t want someone who has worked more than 24 hours continuously to see a sick patient and is expected to make his/her best medical judgement. This doesn’t sound fair to either party.
6. Unfair wages
Scenario 1 - Unexpected situations in an unpredictable setting
In probably many parts of the world, wages are paid hourly. In the healthcare setting where it is often unpredictable, working hours will inevitably differ between doctors. For example, if a patient deteriorates in the last 10 minutes of your working shift, doctors cannot wait for the incoming colleague to come and treat, but rather he/she has to see the patient, assess and manage accordingly. Often, doctors end up working longer than expected and it is rarely their fault. The extra time we spent on resuscitating aren’t compensated unfortunately, they’re often viewed as unlucky and unfortunate. The perception of this is entirely wrong. Nobody choose to do during the last ten minutes of my shift, if I had stay back another hour to settle the patient, I shall have to, and I should be compensated, fairly.
Scenario 2 - The unpaid hours that nobody understands why
While junior doctors have rostering schedules, they are rarely followed. For example, while I am rostered to work 7AM to 5PM, I’m mostly expected to come at 5.30AM or 6.00AM depending on how venipunctures I have in the morning, and how many patients I have to review etc. Medical officers, registrars and consultants comes after 8AM. Sometimes, even medical officers are expected to come earlier than their consultants to ensure that all patients are reviewed (and also well, if their house officers haven’t finished reviewing, it falls on the medical officers). The only reason for this would be to present cases to their consultants. And it is generally expected for junior doctors to know all the cases by heart. While consultants see this as learning opportunities, many junior doctors nowadays see this as inefficiency (and I call tell you why in another lengthy post) and an impossible task.
I often arrive to the wards at 5.30AM in surgical postings and 6AM in medical postings, to take bloods and review all the patients. By 8AM, medical officers start their ward rounds. By 9AM, consultants would do theirs. This concludes with 3 morning ward rounds, possibly an afternoon ward round and likely a night ward round for the unstable patients.
And in none of this instances, am I paid for the extra few hours that I am in the hospital. Essentially, it is free service. For decades now, the ministry and the administrative office of all, if not most of the hospitals never seemed bothered about the hours that juniors doctors come in early for, and in this context, pay for those extra hours. And of course, there is the controversial RM600 flexi allowance that is supposed to accommodate those extra working hours. Sure, we get it, better this than none. Got it, thanks. But still though I would earn no more than RM18 per hour if I were to earn RM5000 per month with an average of 70 hours per week.
But if at all, If I am paid RM18 an hour and I work 100 hours per week. Multiply 4, I should probably earn at least RM7200 per month. This would mean that I am in deficit of RM2200 per month.
I’d probably be much happier getting paid by hours.
7. Burnout
In the context of unfair wages and long working hours, there also seems to be no regard for doctors who got off work at 12AM last night (for whatever reason) only to come back to work at 5AM again. We have got repeated statements from doctors stating they have experience microsleeping while driving, derailing, driving off course, and getting into accidents (I know I have). Yet, the people governing the health system could not care less to put policies or measures to protect healthcare workers. Safeguarding our safety is ensuring patient safety.
Doctors who work long hours tend to burnout, no surprise here. What are we doing about it? How are we rostering doctors? How are we safeguarding the working hours? How are we protecting our doctors?
8. Changing societal values, perception, and the great resignation
Perhaps, more and more people are starting to realise the downside of doctoring, and finally feeling the heavy duty burden and the sacrifices for a profession that doesn’t provide the right gratification (not in this part of the world at least). What do we want in life?
We want to love the work we do. It is simple, we want a job that we love doing and would do it all over again the next day.
We want a good work-life balance. It is not that hard to ask, while working is important, it is equally important to spend time with family and friends.
We want a good, if not, a fair pay. Who doesn’t love being rewarded? We work hard day in and day out for our patients, we do out best to ensure patients get the care they deserve, we deserve a better pay.
We want a healthy work environment. A healthy work culture is important to feel safe, to be appreciated, to be empowered, supported and respected.
Maybe these aren’t changing values, but rather values that are now heavily looked upon and emphasised.
“If you can’t give me that, then I will look for a job elsewhere (i.e Australia).” Truth is, I think, people are now empowered more than ever to leave the system, not because they want to, but because they can. And nobody wants to stop them (unfortunately?).
9. Exploitation of healthcare workers and unresolved issues on bullying, overworking, and underpayment
I can provide voluntary services by coming in early to take blood and review all my patients, and in that process I would learn to be an efficient phlebotomist, and a respected writer (with probably bad handwriting - Malaysia is still paper based, mostly). I probably would not mind staying a little longer because my senior is inserting a chest tube and I would want to learn how to and eventually do it myself. I accept that this is the pay and there is no point in asking for more, this is just how the public service works.
But I will not accept that bullying is tolerated. While there are agencies and associations to report to, it is wrong to be at bystander and watch the bullying happen. While Malaysian junior doctors are disempowered to speak up (and generally more timid, it’s true and you know it), it is even morally wrong for senior doctors to allow bullying to happen, and actually watch it happen. Often times I think, senior medical officers, consultants all know about it, but has something been done to help? Have we done enough to empower our junior doctors to speak up and advocate for themselves? Or have we shy away and choose to ignore the situation?
And it is not just the bullying, it is the harassment. It is the unacceptable behaviour of asking the houseman to take their Grab food or their McDonalds. Don’t they have lives to save? This is exploitation, and you know it at heart.
10. Lack of support for healthcare workers and no efforts for culture management
If you have a system with superiors that support the current one, you generally wouldn’t expect a positive change. And therefore, you wouldn’t expect the support for doctors who need the help. And of course being the asians we are, the cultural aspect of things are often overlooked and that is perhaps the biggest contributing factor to our failing workforce.
Mind you, many companies in the business, telecommunications, marketing, finance industry often hire experts in culture integration/management to help them set up a positive work environment. Malaysia should start looking into this if they ever want any hope to retain and empower their doctors at all.
No system is perfect, but the least any healthcare system should entail is to safeguard the welfare of the people that makes up the system. How does one advocate for their patients when they can’t even advocate for themselves? Our system has silenced us for years, if not decades. The new generation speaks very loudly and they should be feared. Not the other way around, not anymore.
To fellow Malaysian doctors who are participating in the strike on 3rd and 5th of April 2023, know that you’re not alone and your voices will be heard. I am hopeful that something good might come out of this. I wish you all the best. Cheers.
My last part is on administrative failure and this should hopefully come full circle.
