INTENDED to solve the woes of exhausted and overburdened housemen, the new flexi-hour shift system itself is turning out to be one of Gordian complexity.
One of the most vocal critics of the shift system has been Tan Sri Dr Ismail Merican, the former director-general of health.
He believed that while it might have improved the quality of life of housemen or house officers (HO), it might result in HOs being under-trained.
In an excerpt of his speech delivered at the Malaysian Medical Association Oration 2012, which was carried in the New Straits Times on Aug 23, Dr Ismail also expressed concern that with the shift system, there would be no continuity of patient care or accountability.
He also noted the lack of interest among HOs in attending professional development programmes because these were held outside their working hours.
"They may attend if their shift duty coincides with the programmes.
"Otherwise, they prefer to stay at home and rest than continuing their medical education," he said.
Medical education in Malaysia is indeed at a crossroads, said Dr S.R. Manalan, president of the Malaysian Medical Association (MMA).
"It has been much politicised and faces many unresolved problems, such as shortcomings in the selection of students for entry into medical schools, structure of undergraduate training, cost of medical education and the need for dedicated medical educators."
He said the apparent commercial interest in establishing medical schools because of the increasing demand to produce doctors was also not helping the situation.
In 2009, there were 3,058 HOs. In 2010, the figure rose to 3,252 and last year, there were 3,564.
According to statistics, Malaysia will reach the doctor-to-population ratio of 1:600 by 2015 and 1:400 by 2020.
"The question now is, why do we have to train so many to become doctors and is there a drop in the standard of knowledge and skills of these doctors?"
Dr Manalan said the shift system was implemented to replace the old on-call system. It not only reduced the long working hours of HOs, which was the main cause of stress for them, but also prevented too many from working in the wards.
Working in smaller numbers optimised their exposure to a wider spectrum of clinical cases.
He said following complaints from housemen about the shift system, the MMA ordered a survey and entrusted the Section Concerning House Officers, Medical Officers and Specialists (Schomos) with the task. About 908 HOs took part in the online survey.
"Overall results showed that 85 per cent felt they were getting enough rest in between work compared with the previous system.
"About 52 per cent felt the old system was better than the existing system. On whether there was enough teaching or ward rounds by medical officers and specialists in the shift system, 52 per cent felt there was," said Dr Manalan.
Not so positive was that 75 per cent of the HOs who felt that they were not getting adequate clinical exposure and were unable to complete enough procedures as required for their training.
Of the total respondents, 60 per cent felt there was no continuity of care for patients.
The MMA presented its findings to the Health Ministry in July. Dr Manalan said the ministry felt the results submitted by MMA needed more study and, therefore, it might do a further survey.
"In the meantime, the MMA executive council's recommendation to the health minister is that there be a moratorium on the number of medical colleges or house officers until we have enough training facilities in government hospitals and better supervision of the new doctors."
Equally concerned about the efficacy of the shift system was Prof Datuk Dr Kew Siang Tong, dean of the School of Medicine in International Medical University.
Although housemen were getting enough rest, Dr Kew was concerned with the MMA survey of HOs thinking they were not getting enough clinical exposure compared with the on-call system.
"That's very significant isn't it?
"But it's reasonable because they are spending less time in hospital, less time with patients.
"Then there is a question that asked if the housemen are able to log in more procedures than in the previous system -- a very important question -- and only 25 per cent of the respondents said yes. That's a very telling indication about the current system."
Another factor that pushed for the implementation of the shift system was the big increase in the number of HOs over the years.
"The Malaysian Medical Council used to register a few hundred house officers every year, but now, it's about 4,000 annually.
"If we follow the old system where everybody works the same hours, there will not be enough place for them."
But the major concern for Dr Kew, which she believed was shared by many of her peers, was the lack of continuity in caring for patients.
"Now, put yourself as a patient. You're seeing different faces all the time. You'd be confused and worried when different doctors tell you to do different things."
It also puts the housemen at a disadvantage, for if they didn't see a patient from beginning to end, they would not know the patients' progress.
When housemen don't get proper exposure, are not confident of their skills and do not know their patients well, this creates extra stress for medical officers as the work burden would be shifted to the seniors.
Another senior specialist opined that if we wanted quality doctors, we should control the number of doctors being churned out.
"If you count, the number of medical schools in such a small country is amazing. Yet, we are also sending students to Russia, Europe and other places. If this glut continues, we will soon have more doctors than nurses and end up like the Philippines. We will have to export our doctors," he said.
Although conscious of the fact that our doctor to population ratio has yet to reach the aspired 1:400 by 2020, Dr Kew thought the problem might be distributive in nature.
"There are more than enough doctors in the Klang Valley. But if you go to Sabah and Sarawak, there are clearly not enough. So, the medical and healthcare service planners have to look at the problem in its totality."
The sheer number of housemen had made the previous on-call system unfeasible, but the criticisms on the current shift system cannot be ignored.
Dr Kew, who has trained housemen for years, candidly admitted that she did not know what was the best way forward.
"There are only 37 designated housemen training hospitals in the whole country.
"On the other hand, there are some 4,000 new housemen every year. They need to be paid too and the government's coffers are not a bottomless pit.
"It's a difficult problem to solve. It may come a time when there'll be housemen without jobs because there are only so many vacancies."
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