“Dear Malaysia, I am not giving up on you.”
Humans of Medicine #41
This publication is in conjunction with the upcoming initiative by MMI on contract doctors in Malaysia. Further information can be found at @mmi_social on Instagram.
Dr. Timothy Cheng is an orthopedic surgeon in Duchess of Kent Sandakan Hospital, Sabah as well as the MMA SCHOMOS Secretary. Underlying his outspoken advocacy to address the issues in the Malaysian healthcare system is a strong love for this country.
Negaraku, tanah tumpahnya darahku… “Psst. Look at that guy, he’s the only one actually singing!” “Can you believe it? Didn’t know anyone took “Negaraku” seriously.” “I know right, I just mouth along to the lyrics.”
Yes, “that guy” is me.
The way I see it, the Malaysian healthcare system is currently suffering from three concurrent afflictions: issues with (1) human resources, (2) infrastructure and facilities and (3) transparency at the government level. As diseases are wont to do, these issues break out of their neat little boxes — one consequence becomes another problem’s cause, perpetuating a vicious cycle that, if left unchecked, will see our healthcare system crippled and our people deprived.
(1) Human resources
Our country is struggling to retain medical talent and one of the main push factors driving brain drain is salary. The current weekend on-call claims for MOs is RM9/hour; in comparison, Singapore is paying double our rates at S$20/hour. Wait, some might think, I thought that doctors shouldn’t work for money? True, most doctors stepping into wards or clinics will be thinking of their patients instead of their pay, but that doesn’t equate to a willingness to work for free. It’s not an either/or situation, both commitment to patients and fighting for due remuneration can and should exist simultaneously. If you are paid more, you are then able to give more.
Understaffing, on the other hand, is brought about by maldistribution and the structure of the healthcare system itself. This problem is felt most strongly in rural areas and East Malaysia. The entire state of Sabah has 20 to 30 orthopedic surgeons in service while the same number might be found in one single hospital in Semenanjung. There’s also great variability in manpower at different points in time due to the HO rotation system. What happens if 90% of a batch of HOs fail their orthopedic posting and only 10% make it to O&G? Staff shortage in O&G. Say everyone passes the next round? Excess in O&G. Imagine these variations happening every four months across all postings and you’d understand the difficulties that come with a distributed medical workforce.
And of course, we have the contract system, which was introduced in December 2016 because there were too many medical graduates and “not enough jawatan.” Just create more jawatan then, some might suggest, but to do that, the government would have to take out their trusty government calculator and calculate all the income, paid leaves, extra benefits and pension afforded to those new posts, and these things share a commonality in that they all require money. So, when there’s no money, there’s no jawatan. But we still need doctors! The government’s response — don’t worry, have this contract system instead. And so existed contract doctors in Malaysia, who are disadvantaged and discriminated against. HKL was printing the word “contract” on doctors’ name tags. A state health department director in Sabah asked, “So do you need MOs or are contract doctors enough?” Well, some might wonder, it must be because there are some differences in the skill level or qualifications between contract and permanent doctors. I’d have to answer with a resounding “no.” In fact, the entry criteria into permanent positions is not known. You could graduate at the top of your class and be shuffled into the contract system while watching batchmates with less than stellar results get better pay and benefits as a permanent doctor.
(2) Infrastructure and Facilities
Either they’re not enough, or they’re breaking down, and when the brick and mortar of healthcare fails, patient care is compromised. A lift broke down in my hospital last year, and stuck inside for half an hour was an intubated patient, along with the HOs, nurses and the patient’s family members, all watching as the oxygen level in the tank decreased slowly but steadily. He survived, but that incident should never have happened in the first place. There are many other examples I can name: autoclave machines breaking down, subsequently delaying operations, or even four simultaneously ongoing psychiatric consultations in the same room — needless to say, everyone involved bid farewell to patient confidentiality that day.
Of course, there are the usual culprits, for instance poor maintenance and inadequate funds, but also of note is the attitude pervasive in Malaysian government service sectors where suboptimal standards are readily accepted. Bed rails rosak? Tak ape, let’s just tie it with some bandage and ignore the equipment damage report that we could send in to request to have them fixed. This particular sentiment among Malaysians — “tak ape lah,” “boleh lah” — makes for an understanding and forgiving society but, unfortunately, produces substandard care in healthcare delivery services.
(3) Transparency at the Government Level
Getting the government to provide us with data is like pulling teeth; we encounter resistance at every step of the way. Whether about salaries, costs, or the number of doctors that have left service, full transparency is expected, yet we have to contend with opacity or blurriness at best. The biggest issue is undoubtedly the unspecified entry criteria for permanent positions. If 100 contract doctors apply for permanent positions, how will they be ranked? Will the top percentile be selected? Will results be published? Is there even a criteria? The answer to our many valid questions: radio silence.
Problems need solutions. First of all, an on-call claim review is needed. Secondly, fix the contract system. We must realize that the contract system is not inherently a bad thing, it’s the way we are doing it — with poor planning and poorer implementation — that is bad. Fortunately, a lot of the disparities have been improved: flight warrants and special leaves have been granted, and the postgraduate pathway for contract doctors is now open. The remaining issues requiring immediate attention are pay grades, promotion schemes, and selection criteria for permanent positions. Some might protest: why are you even talking about the contract system, we should just focus on pushing for more permanent posts! Truly, it’d be nice if everyone’s a permanent doctor, but I don’t think that it’s possible considering our current progress. The glacial pace at which permanent posts are created notwithstanding, if 80% of our doctors acquire permanent positions, what about the 20% still left in the contract system? Who’s going to fight for them if everyone refuses to acknowledge that the contract system must be fixed, because it cannot be abolished? My word of advice to our contract doctors: get into a master program and become a specialist, then the contract/permanent status wouldn’t make much of a difference anymore.
Infrastructure-wise, we need a complete revamp. Let’s try to strive for quality instead of accepting second best and just “making do” all the time.
The solution to the third issue isn’t rocket science; a simple “be more transparent” should do the trick. To the new government, I say this: you won our votes, now please hear our voice.
For those interested in choosing Medicine as a career: you have to go into it knowing that the path ahead will be difficult. Apart from the stressful nature of the job as well as the structural problems highlighted above, we’re inundated with stories of burnout and bullying among the ranks. Nevertheless, we have to understand that efforts to improve working conditions aren’t going to be like flicking a switch and being instantly illuminated by a flood of light — it’s lighting up candle by candle to clear the darkness instead, all while a brisk wind threatens to extinguish the tiny, flickering flames. So, as we continue fighting for betterment, please enter the field of Medicine with a strong heart.
If the grass is greener on the other side, then why do I stay? Well, because the grass on the other side isn’t home, for one; because there’s still a lot worth fighting for over here; because I wish to give back what I’ve received; because I wish to make our patch of grass greener for the sake of all the junior doctors currently struggling in the system. I implore this of every citizen: don’t give up on Malaysia. We grew up and are now living peacefully here. We share this nation, this culture and this identity. Stay and fight; if you really need to leave, come back one day. The grass will surely be greener where we water it.
Dani is a third-year medical student at Monash University Malaysia.
Her circadian rhythm is often ruined by her inability to put down a book. Please note that stickers and gifs are her preferred mode of communication.
Consent has been obtained from the interviewee for the purpose of this publication. The author has rewritten the article with permission from the interviewee.
Humans of Medicine is a new initiative under MMI. We tell inspiring stories behind portrait shots of our everyday unsung heroes. Curated by Malaysian medical students from home and abroad.
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