traditionally have brutal introductions to their respective fields of
profession. Everyone is expected to know what they are getting into. Medical
interns are no different.
The punishing training and taxing schedules are essential to
teach rookies, especially doctors, how to operate under pressure and achieve
quality. So there is no reason for junior doctors to relentlessly gripe they
are made to feel like a nuisance and a problem to be “got around”.
Fact is, present-day housemanship bears little resemblance to
the one that the senior doctors supervising juniors underwent.
They never tire grumbling about what they are paid to do.
Perhaps, it was too much for a junior doctor to have kept the service running
and working anti-social hours for up to 40 hours in a stretch.
Perhaps, they were not admirably acknowledged for covering gaps
in the rota and for ensuring patients received the high quality care they
deserved and expected.
It is unfortunate that this time-honoured tradition has become
dishonourable. Has the system let down junior doctors? Are they viewed as
dedicated professionals who embrace a difficult role?
A Being Frank enquiry showed dozens of primary care doctors,
mostly housemen, have been assessed for mental health issues in the last six
months — a worrying revelation that raises a provocative question:
Would YOU put your life in the hands of a junior doctor?
The most common mental illnesses among the doctors stem from
anxiety, emotional exhaustion, clinical depression, sleep deprivation and
Health Ministry and Malaysian Medical Association (MMA)
officials concurred but distanced their agreement to the death of Dr Lee Chang
Tat, 29, who last week was found dead in a toilet of the paediatric ward at
Kajang Hospital with a used syringe beside him.
Certain quarters had claimed the houseman had taken his life due
to work pressure. Dr Lee’s death re-ignited debate on “pressures” heaped on
doctors, mainly interns, that could impair their functioning capacity and
result in fatal mistakes.
The key factors for psychological disturbances among doctors at
all levels are consistent: long hours, lack of sleep, heavy workload, bullying
by senior doctors and making life and death decisions.
Isn’t it scary that someone who hasn’t even been working as a
doctor for two years makes life-threatening decisions?
While there might be poor implementation of the Graduate Medical
Officer Flexi Timetable system introduced last September, every doctor knows
upon entering the profession that a doctor’s job is never nine-to-five, and
health services and medical treatment have to be provided 24/7.
The quibbling housemen must also be aware that the timetable
requiring them to work no more than 60 hours a week, with two days off compare
favourably with the maximum 48-hour week for doctors in training set by the
European Working Time Directive. Or with the 80-hour workweek mandated in the
The “overworked houseman” groan is a tired issue and it’s time
the Government injects new enthusiasm in efforts to ensure the quality of
medical students who graduate from certain foreign institutions.
There is no proper scheme to assess foreign medical graduates
and detect weaknesses before they begin their housemanship.
Health Minister Datuk Seri Liow Tiong Lai’s announcement last
week that housemen in government hospitals nationwide will have a weekly
session with the hospital director or deputy director to iron out issues
pertaining to being overworked, bullying and depression is a cursory
approach to the problem.
The broader picture is: The number of medical housemen
undergoing clinical training in most government hospitals has increased and
this has given rise to concern that they may not get sufficient experience.
With new medical schools opening up locally and lower fees being
offered at new institutions abroad, around 4,000 Malaysian medical students are
expected to graduate annually from 350 universities all over the world in the
It has been suggested that while the number of doctors
graduating is increasing not all of them are able to perform well as house
officers due to lack of proper training and attitude problems.
If five years ago, one houseman looked after 10 patients in
hospital wards at any one time, now it is one to four patients.
The concern is that these interns are seeing fewer patients and
hence, have fewer opportunities to carry out adequate procedures.
In some hospitals, there are more housemen than patients.
Some lack responsibility towards their patients. There are also
those who did not know how to give an accurate diagnosis and relied too much on
investigative tools instead of clinical skills and getting the proper patient
The Health Ministry is aware of the issue but has been slow to
increase the number of training hospitals. As of last year, there were 38
hospitals providing training to more than 3,000 housemen last year.
Ideally, there should be one specialist supervising five
housemen with one houseman taking care of 14 hospital beds depending on
However, the number increased to more than 6,000 housemen since
the ministry increased the duration of housemanship from one year to two. This
led to most hospitals having an excess of housemen.
The doctor to patient population in Malaysia is now 1:920
compared to Singapore (1:620) and Japan (1:370-460). Malaysia’s aim is to have
1:597 by 2015.
The Health Ministry’s Competency Assessment Centre is aware of
the unflattering situation in public hospitals nationwide.
That being the case, why is the mental state of mind among
junior doctors worsening?
Why are they becoming increasingly disillusioned and quitting
the national health service before completing their two-year training?
Past president of the MMA, Datuk Dr Lee Yan San says the
Government must seriously look into the declining standards in the training of
housemen as the quality of medical care in the future depends on them.
Internship is crucial to allow graduates to put medical training
into practice under the supervision of senior doctors, he says.
“While good academic results are important, these alone are no
guarantee one will become a good doctor. Selection of candidates for entry to
medical school is therefore very important. Very stringent screening (via
interviews) to find out more about the personality and psychology of the
applicants is essential to ensure that the medical schools take in only
committed students who are likely to devote themselves to medicine in the
future and able to endure this stressful profession,” he said.
So, what does all this mean when it comes to patient care?
Nerve-racking, to say the least, because every day thousands of
newly-qualified junior doctors make decisions which could mean the difference
between life or death — and they’re often as terrified as the patient.
award-winning journalist Frankie D’Cruz is Editor-At-Large of The Malay Mail.
He can be reached at firstname.lastname@example.org