Running on Empty

This is a difficult post to write. Simply because it attempts to address issues that are raw and painful to a segment of the medical profession – the junior doctors, i.e. the house and medical officers, residents etc.

There have been many instances of reporting of junior doctors finding life unbearable now in the public institutions. Many have purportedly quit or are in the process of quitting. Apparently, dissatisfaction is at an all-time high and about to get worse.

This Hobbit has provided links to articles on this topic found in the mainstream media at the end of this post. But these are only from the mainstream media. If you go beyond this, there are much more stuff found in blogs, memes etc.

What is the profession’s response to this? At the risk of stereotyping, the profession’s response can be divided into two groups. One group of doctors are those that share the view that things are really bad. Another group just thinks that well, today’s younger doctors are soft and just can’t hack it and things were far worse last time.

This hobbit will not go into whether things are better or worse now. For one thing, the Covid-19 pandemic has upended many things in the practice of medicine. PPEs cannot be that comfortable, especially with global warming. Taking consent now is a labourious affair. Unlike my time, you can’t just find a houseman to stuff a consent form into a patient’s face and instruct him gruffly in Hokkien or Cantonese, “Uncle, we have to operate on you, sign this form”.

Things are also better now, because you don’t have to give IVs and contend with performing 120-second hypocounts. And of course everyone gets paid decent money for doing calls.

So there are pluses and minuses between the past and present. It is pointless to debate ad nauseam whether things are better or worse between the present and the past from a material point of view. Of course if money is the solution, it would be simple for MOH to pump more money and pay junior doctors more. After all, MOH has the largest budget allocated this year by the Government, at some S18B, even larger than MINDEF. So paying the junior doctors say a bit more won’t really put a big dent in the budget. But life is more complicated than that. Of course, more money also helps, but money is not the cure-all or be-all.

It may be fruitful to look at abstract issues that drive morale. What is clear to this hobbit is that life in the past was bad too. But we had one thing that perhaps young doctors today don’t have very much – hope.

We knew that life will get better when we became specialists or when we serve out our 5-year local undergraduate bond. We knew there was an end to all this and things will get better. I am not so sure if young doctors have this optimism today.

Let’s take the example of being a specialty “trainee” (the old term for “resident”). We knew that when we completed specialty trainee, we will be appointed Senior Registrar or Associate Consultant. Senior Registrar was the term used when the Specialist Accreditation Board (SAB) and Specialist Register had not come into being yet. There will always be a job in a public hospital for you after exit. And on top of that, you know you are well-trained, having seen and managed many, many patients. That black name-tag (signifying you were a ‘senior’ doctor with at least a master’s degree or fellowship, i.e. at least Registrar) that was hanging off your chest or stethoscope gave you hope, satisfaction and a spring in your step.

Now associate consultants, let alone residents or senior residents, do not have this aura of positiveness around them. In fact, residents do not have any assurance of any job security when they exit. All this came about because a few geniuses in MOH decided to Americanize our specialty training system more than 10 years ago with ACGME-I Residency. The idea was that being a more structured system, the residency can produce more specialists faster. A good summary of this is that some geniuses thought they can produce more specialists like how the Clone Army was produced on the planet Kamino (Star Wars Episode 2), vis a vis the old system of apprenticeship, like Jedi (or Sith) training.

To this old coot, residency is a term used by Celine Dion when she is contracted to sing at a casino in Las Vegas for 2 years after Titanic. But like the Titanic, our young doctors are sinking in residency.

It starts with this ill-informed idea that training can be delinked from employment. This can be acceptable in a large country like the USA, where you can train in a Los Angeles hospital and after that the LA hospital may not offer you a job but you can get a job in a hospital in the state of Montana. America is a big country and life goes on. This cannot be so in a small place like Singapore. If you exit training in NUHS and don’t get a job offer from NUHS, the chances are you can’t get a job in the other two clusters as well. It is simply unwise to delink training from employment in Singapore. MOH should disabuse public healthcare clusters and hospitals of the idea that they can recruit many residents (i.e. cheap labour) and then hope someone else will hire them later on when they exit.

This is especially so because most residencies are confined to the same cluster and other clusters’ clinical leadership do not know the resident. This is different from the past when MOH controlled the postings centrally. Trainees rotated between different hospitals across the country and he has a chance of being hired by different hospitals after exit.

We then move on to what happens after one exits and cannot get a job in where he trained.

If nobody hires them as associate consultants then legally speaking, they can still set up shop in the private sector and practise as specialists in private hospitals, albeit somewhat lacking in experience and exposure.

But as of recently and in a practical sense, they cannot.

There are only a few private hospital operators in Singapore. Recently the largest private hospital group issued a policy stating that they will only accredit new specialists if they have been registered specialists for at least 5 years, of which at least 3 years must be of consultant grade (note: consultant, not associate consultant) in a public hospital. If you were promoted to consultant from associate consultant after 3 years and not 2, effectively you have to hold a specialist position in a public hospital for at least 6 years and not 5. Another private hospital has also followed suit with this policy.

Now back to these new specialists who cannot get a job in a public hospital. What are they going to do? Theoretically,  they can practise as specialists in the private sector with no practising and admission rights in at least 5 (some of the largest) private hospitals in Singapore. What kind of prospect is that? This may be OK if you are a dermatologist or psychiatrist but definitely not OK if you are in almost all other specialties that require a hospital setting.

In other words, from the start of residency to the time a specialist is able to gain practising rights in most private hospitals in Singapore, he needs to be employed for at least 10 years (5 years of residency + 5 years as AC and Consultant) if not more in the same public hospital that trained the resident. Yet, the young doctors are not getting any assurance it will be so from some public healthcare clusters and hospitals. Of course there are good residents and not so good residents, and nobody owes anyone a living for 10 years, especially if the resident doesn’t perform. Nonetheless, this kind of uncertainty is very unsettling for young doctors today, and a source of unhappiness that in our time many years ago, under the old traineeship system, simply did not exist. In the past, if a trainee was very bad, the hospital simply did not sign him up for exit. This is unlike today when we over-recruited, under-trained our residents and under-employed them after exit.

In the past, once you are a trainee in a certain department in a hospital, you are practically family. Of course, every family had its problems, but you are still part of the family.

The powers that are have recently addressed this by drastically decreasing the number of training positions offered in some specialties. This in turn has created another source of unhappiness. Newer batches of medical graduates now wonder why there are so few residency positions available when compared to their seniors. This is the typical sort of deep unhappiness and frustration that accompanies boom and bust, feast and famine cycles. And in this case, they are man-made, avoidable cycles.

Perhaps the only bright area for young doctors is in family medicine and this explains why its popularity as a training program is rising. Once you exit you are not at the mercy of private hospitals’ accreditation requirements. And with the emphasis on prevention, everyone having a regular family physician and Healthier SG, the future of family medicine looks reasonably bright.

There are certain things that are beyond our control, such as the demands of infection control and patient load brought on by the pandemic. But many things can be managed. Are we managing public expectations and patient expectations? Or are we content to just accept the inexorable climb in these expectations, and let the young doctors (and nurses) bear the brunt of it? Some expectations are reasonable and should be met but are all expectations reasonable? What are hospital administrators and MOH doing to buffer our frontline healthcare workers from some of these unreasonable expectations?

Another common phenomenon which is seldom addressed is that when every hospital and department attempts to manage their risks (a euphemism for covering backside), then invariably new and more complex policies are written which in turn lead to more work being created downstream for the junior staff like medical officers and staff nurses. Has anyone thought of saying “Hospital management will take this risk so that we don’t pile more work on the medical and house officers”? No. The usual answer is “we will implement a new policy to address this problem/risk”. Which almost always translates into more work for the poor guys at the ward or clinic floor.

The lack of opportunity for career advancement and the lack of certainty in career prospects have a pernicious effect on morale and undermines hope. Aggravating this situation is the junior doctor often has to bear the full brunt of unreasonable public expectations as well as get bogged down by an every-increasing array of administrative and policy requirements that are perceived to increase the survivability of hospital management but not that of the junior doctor.

Is it therefore any surprise that our junior doctors are feel they are running on empty?

Links to writings about junior doctors’ plight in mainstream media:

https://www.straitstimes.com/singapore/health/long-call-hours-teach-time-management-but-not-best-way-to-learn-medicine-say-junior-doctors

https://www.channelnewsasia.com/singapore/review-junior-doctors-work-hours-among-steps-improve-healthcare-workers-well-being-2551376

11 thoughts on “Running on Empty

  1. I would like to add some more.

    RHS and other public institutions and their admin frequently look at the manpower in terms of costs.

    1) how much does it cost to hire a AC/C/SC versus hiring resident physicians/bonded MOs/foreigner clinical associates.

    A good friend of mine told me some few years ago when he was newly minted an AC and got into a conference discussing admin, the above was frequently discussed. The cost of one AC is about the cost of 2 to 3 MOs.

    It will make perfect admin sense to have less senior positions and have the junior doctor do more tasks that these senior doctors use to do, and save some dollars in the process.

    2) MOH may not be in total control of what goes on in the policies of the RHS. RHS have a semi-private structure, they have autonomy in a lot of their processes.

    It is worse when you allow RHS to helm residency programmes, for them to dictate who gets to join this eventual “family”. Even more of what I mentioned in point 1) will take place. Cos again, it makes admin sense to do so.

    3) personal aspirations of the doctor come last place compared with needs of the RHS.

    Unfortunately, do not expect the RHS or even MOH to look after your well being. Rightfully speaking, these institutions do not owe you a living. I may sound cynical, but the fact is they really don’t

    It is high time we teach proper career management even at the undergraduate level, so that our medical students and doctors eventually know how to look after themselves.

    The truth is not every one gets to be a specialist. Very soon, maybe not everyone even gets to be a GP.

    Private sector? Both specialist and family medicine/GP are increasingly oversaturated.

    4) who looks after u during a strenuous night call or during the day when your going gets tough?

    It is actually your immediate colleagues, and even your nurses in the same ward. Start to learn how to work properly in the ward and rely on one another.

    After all you have a bond to serve if you are local grad. After the bond, you will have full right to decide your career path and whether you want to stay in the hospital or not.

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  2. We were once told to trust the process…
    And yet we see Dean Lister’s applying to family medicine as a backup option.
    *Laughs in millennial*

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  3. Also made worse when hiring ability is tied to patient load, with each new consultant position requiring an extra X number of patients to be seen in clinic- but this translates to an extra X patients being seen by the MO/registrar pool, which stays constant in size. Apparently now subidized patients no need consultant see?

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  4. Medicine in itself is a low trust kind of vocation. I can’t afford to trust anyone or anything or else my career gets messed up.
    How can I trust the bosses, administrators and politicians to ensure that my lifelihood and training is in safe hands?
    That’s why I left the system.

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    1. Good choice.

      Not that I’m beckoning others to do the same. But the fact remains is that the way it is heading now, no one should be surprised why people start leaving the public system once their bonds are over or when their bonds are bought out.

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      1. What happens when too many mopexes flood the private sector?

        Time to seriously look into studying for the property agent exam..

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  5. Fascinating that the author actually touched on the roots of the issue, and the related bigger issue, but didn’t connect the dots.
    Said author assumes that the US system is ‘working’ as it’s a big country and doctors can move around. Erm, nope. Every system that can be privatized, crappified and set up as rent-extraction scheme in the US gets that treatment. it is a feature, not a bug. Most medical practices are owned by private equity, including the big hospital chains – doctors are for the most part just ‘mere’ employees.. with many departments doctors working on contract terms. End result? Most US doctors start off with tremendous levels of debt, are basically slightly better-paid precariat folks and have next to no say in their career development / prospects. The societal outcome is a bloated medical sector, with high costs, crappy public health outcomes and ever decreasing life expectancy – even before covid hit. US was the first major industrial nation to ever experience that – the steady drop in life expectancy.
    Singapore blindly followed the US ‘system’ as that’s where most of the tendencies of our current elites lie… it affects the entire ‘industrial policy’ now… companies get run into the ground and then sold off for pennies into the private sector (remember NOL, anyone?) The ‘MBA” mindset is that owning some shares is good enough, forgetting that complex set of skills lie behind industry and its related supporting industries, how that capability has to be trained up over time and properly invested in. So shortchanging the current junior doctors in terms of their training, career prospects etc.. all that is just part and parcel of the neoliberal mindset. Again, a feature, not a bug.

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  6. Do u know of any good resident who has been denied AC position? More often than not it’s the dept not wanting to say upfront they don’t really think he/she is good.

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    1. Yes. I do know of good juniors being denied, cos the hospital positions are “already occupied”. So they end up waiting. (Which is foolish in my opinion, cos if they refuse you now, what is there to stop them from refusing you again – like what you have just mentioned above)

      I even have classmate who was offered HMDP in the subspec which was not preferred – also similarly because the initial choice subspec was already taken up and no intention for any more positions to be created in the hospital over the next few years. You can say the doctor has been sidelined and not preferred instead of another candidate. But the other side of the coin holds true too. No position, and hence no subspec/training/job offered for you.

      When you let the HR determine medical training and job employment, this is what you get. Getting eaten up from both sides. Does MOH or the RHS care? Seeing that this has been allowed to continue for close to a decade or maybe even slightly more than a decade, I will say no.

      Every single doctor in the country should not be in a delusion and fantasy that someone is going to look after you and your career progress. That’s bullshit and really no one owes another person a living. It is time every doctor starts to think and consider seriously their career options, right from the undergrad first year.

      If the organisation does not care much about your training, career paths etc, it’s a red flag and signal for the doctor to start looking elsewhere. This happens in every single occupation elsewhere. So don’t expect healthcare to be different.

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