Materia Medica Malaysiana

Rigidity that kills medical service

HIS first encounter with civil servants was spectacularly shocking.
When he presented his qualifications, they pored over the documents and then dismissed him by saying: "Go back. We can't pay you, so just go back." They were probably being realistic; the civil service does not allow for exceptions. You either fit in or stay out of the system altogether.

Still, their indifference was a stinging slap on TJ's face.

Even the most self-assured person would have been bruised by the rejection but the foolish young man persevered.

Friends thought he was mad. Top-rung clinics abroad were courting him but he remained resolute about working at home.

Amazingly, it is now four years since he joined the government service, a period so fraught with piffling obstacles created by petty officers that you would cry just listening to the stories.

TJ still receives job offers from abroad and he continues to say no — because he hasn't quite finished his work here.

"I love my job, it's as simple as that," he says, with no hint of bitterness or anger in his voice.

But friends say it is unlikely that he will hang on for much longer on the miserable salary he draws.

For now, Malaysia has him and you can be assured that his expertise is rare and his skills, first-class. When he leaves, we will be pushed back to square one.

Which is strange, really, given the loud exhortations politicians have been making over the last decade about bringing Malaysian specialists home to work in government hospitals.

In the UK alone, there are some 100 Malaysian specialists. If the Ministry of Health can get its act together, some of these individuals may seriously consider coming home.

But they may not stay long if structural problems are not resolved, if attitudes don't change and if rampant politicking is not reduced.

TJ's story is not uncommon; all those living abroad would probably have heard variations of it.

Indeed, why work in a system which, in TJ's case, adamantly places seniority above experience? Why succumb to a pay structure where even the most highly-skilled Malaysian contract doctor must begin at the bottom rung? And, why put up with small-minded bureaucrats when you know your expertise is needed elsewhere? Unhappiness, it turns out, is not limited to Malaysian contract doctors. Medical professionals who have served in government hospitals for decades are equally distressed by the treatment they receive.

Last week, a professor of medicine, unable to contain her frustrations, sent an open letter to the Prime Minister, parts of which were carried by the NST.

"My husband and I are fair dinkum Malaysian doctors who returned as medical specialists back in 1982 after our medical training and after working abroad for some 13 years," she wrote. "He served as a lecturer and later professor in medicine, planned and administered the Hospital UKM whilst I first served in the Ministry of Health as a kidney specialist before joining the department of medicine in UKM. "We have each contributed much of our private time to serve in our respective professional societies and in setting up or strengthening national patients' associations. We are among pioneers of both the undergraduate and postgraduate medical training programmes in our local universities as well as in paramedical training programmes." More than all this, said the professor who is about to retire, is the satisfaction she has gained from research and her interaction with trainees, housemen and colleagues. Seeing her patients get better by the day also keeps her going.

But all this, she said, has been soured by the way the Public Service Department treats government doctors, nurses, paramedics and other health professionals.

"To them, we exist as mere statistics within a group much like the unskilled and semi-skilled staff in the civil service who work office hours, 8am to 4.30pm, with all the public holidays and alternate weekends off." "Although some minor improvements have occurred in recent years, inflation, long working hours, the near-absence of career advancement and further training opportunities, the time-consuming and morale-deflating examinations (all of which are totally unrelated to patient care) have pushed doctors into a corner.

"Is it a wonder there are fewer and fewer of us left? Is it a wonder that waiting lines are getting longer at government clinics and outpatient departments?" The professor said if no one fights for the medical profession, good doctors and nurses will move on to greener pastures.

Which is not to say that money is the motivating factor for all doctors, but they certainly "cannot live on chicken feed and self-gratification" today.

The solutions she offered were: Keep the doctors we have by giving them equitable remuneration and training opportunities rather than enticing a few to return at exorbitant salaries or recruiting expatriate doctors and paying them higher salaries.

Facilitate promotion of government doctors based on professional merits and qualifications as this would help maintain and enhance professional standards to provide the best care possible for patients.

Remove red tape and stumbling blocks e.g. SSM-PTK examinations — these take away critical staff for two weeks at a time.

She ended her letter with a plea to the Prime Minister to "intervene before we lose most of our young medium-rank specialists and medical lecturers to Singapore and the private sector".

Ninety-five per cent of the rakyat, she pointed out, could not afford extensive private health care. This is why, a good, sound, comprehensive health care system staffed by sufficient, efficient and caring Malaysian doctors, nurses and paramedics is critical for the country, she said.

Since her letter was published, she has received the support of many. Letters in the NST attest to this. Interestingly, there are individuals in the Ministry of Health who recognise the problems.

"The rot set in a long time ago," said one anonymously.

"We have a bloated bureaucracy but any attempts to remove the deadwood will be met with resistance," he said. "At the bottom, we have clerks and junior officers suffering from power denial psychosis (where a little power gets to the head) and, at the top, we have senior people who cannot see eye to eye." As a consequence, he said, the people who matter most — the medical professionals — are trapped in between. Of course, not all medical personnel behave like hapless sheep; those who see the benefit of playing politics will jump into the fray.

But those who cannot stomach the nonsense and neglect, leave.

This is said to be another reason why certain units in teaching hospitals are almost depleted of critical staff. In one hospital, the cardiology unit is as good as dead.

If nothing is done to resolve this, we may soon be sending our medical students to be trained in Russia or Myanmar, even.

As it is, the minister is now thinking of getting doctors from Myanmar (who speak English and are better trained, he says) because doctors from other countries have not worked out as well as expected.

The main complaint has been language. As pointed out by a doctor from Sungai Petani in a letter to the NST last Friday, foreign doctors are not able to communicate with patients. The doctor said in most instances, Malaysian doctors who are themselves overworked, are being asked to train the foreign ones.

A specialist who travels the country to introduce new methods and equipment to doctors said he was stunned that some foreign doctors were not even able to conduct basic procedures.

He was asked by one Bangladeshi doctor whether he could recommend a book on some of the basic surgical methods.

More worrying is that many have poor medical knowledge. In the last few weeks, two operations were apparently botched up by Egyptian doctors. In one case, a young woman's bowels were completely ruined. Major reconstruction surgery could barely return her to normal.

"This is very scary," said the specialist. "We take them in without knowing what they've done before coming to this country and we send them to places like Langkawi, Sabah and Sarawak where it is hard to monitor them." The professor who wrote the letter to the PM says she has encountered foreign doctors who could not be bothered to remember patients' names — "if you see them many times, surely you would know their names, right?" — and who refused to turn up for night duty.

But not all is lost.

A sizeable number of dedicated, disciplined, caring and brilliant doctors — trained locally and abroad — are still plugging away in government service.

Whether they are on contract or permanent, let's keep the ones we have.