INTERNS 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 substance misuse.
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 United States.
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 coming years.
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 history.
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 discipline.
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.
Multiple award-winning journalist Frankie D’Cruz is Editor-At-Large of The Malay Mail. He can be reached at [email protected]