Is it time for house officers in private hospitals?

 

Our most immediate health system crisis over the past few weeks does not seem to be abating. Stories on over congested, overcrowded Emergency Departments of public hospitals have been plastered all over the news; and social media on the other hand seems to be filled with complaints of similar conditions in private hospitals as well.

While in the public sector the complaints are in no small part due to the sheer volume of individuals seeking treatment, the issue is compounded by the shortages of healthcare professionals in both public and private hospitals.

Senior physicians and experts far more seasoned than me have written and commented at much length on this issue. Make no mistake; it is not an easily solvable one. The complexities around the shortage of healthcare professionals revolve around many issues including inadequate remuneration, challenges in training and retention of healthcare professionals even within the healthcare sector. Worse, this is not a problem limited to one type of healthcare professional such as doctors; but is woeful across the entire spectrum of healthcare professionals from nurses to therapists.

A multifaceted transformative solution is needed to fix the problem across many different levels; but over decades, Malaysia has been unable to gather itself together to put this into motion in one big, bold, step to transform the healthcare system.

Thus, for pragmatists like me, the only way to change the system is through small, incremental steps. One such out-of-the-box suggestion is to put house officers in private hospitals to undergo their housemanship.

How could this help? A perennial problem plaguing successive health ministers , the health ministry and successive governments is the placement of new medical graduates into the public system for training i.e. housemanship. Under current mechanisms, new medical graduates can only receive training within the public sector, and upon completion of this training, receive their certificate of full registration which allows them to practice medicine

Due to the inability of the government to create so many new jobs year on year (along with the large numbers of medical graduates completing their education each year), graduates wait for a few months to get a job, and in some cases this can even stretch up to a year or even more.

By allowing housemanship training in the private sector, waiting times can be reduced for house officers to get into jobs; and there will at least be a reduction in the costs in terms of salaries that need to be allocated for these new officers. This is not something impossible to do; as other healthcare professionals such as pharmacists have in recent years been allowed to do their internship training in the private sector already.

I can already hear some naysayers voicing out the perennial question of: Will they receive the training they require in the private sector? Will they be getting the experience they need in terms of seeing patients? Will they receive the supervision they need? My answer to that is: Why not? Our private hospitals span both the secondary and tertiary landscape of care; with many larger private hospitals already providing a volume of care such as deliveries unseen even in many smaller public hospitals. They are more than able to provide the volumes of cases needed.

In addition, it is an open secret within the medical profession that many senior distinguished clinicians who have moved to the private sector are interested and capable of supervising house officers. In fact, most of them used to perform these supervisory roles when they were in the public sector, with some even writing a book on how to do so for their particular specialty. Under current arrangements they have no manner of doing so and sharing their wealth of experience to their juniors.

Many of my colleagues in the public sector continue to lament on how their wards continue to be congested with too many house officers who then have fewer opportunities to learn; and how as overworked as they are they have little capacity or opportunity to be able to meaningfully teach or mentor them. Again, moving some numbers of house officers or ‘housemen’ into private hospitals will reduce the disproportionate ratio of teachers: learners within the public setting while also enabling more teachers i.e. private specialists to mentor and groom doctors.

We often forget that housemanship is still an educative phase for the young medical graduate and the rules of teaching and learning should apply within this context as it does for all other teaching: learning settings in medicine. If we want to produce capable and experienced doctors in the coming years, the housemanship period is as critical as a student’s undergraduate medical years in terms of the learning and mentoring they should receive.

The health ministry realises this, and has taken many important steps to structure the house officer training curriculum and its implementation, with the standardisation resulting in the Certification of Completion of Housemanship Training which is now in place. This goes a long way to ensure that any house officer being trained in the public sector is of a particular competency standard upon completion of their training. With such strong structural frameworks in place, it would not be too difficult to implement it in a private sector setting, filled with former health ministry personnel as mentors and supervisors.

Coming back full circle to my opening lines, moving house officers to the private sector will provide much needed healthcare professional capacity there. While house officers are not nurses or medical assistants, task shifting and realigning of responsibilities can ensure their capability and expertise is utilised in filling the shortage of these professionals. More importantly this will enable private sector institutions to take on more of the clinical load and thus assist in decongesting public sector hospitals.

A small step, but one capable of making a big difference.

Almost every single task force, commission and committee convened in Malaysia for decades has recommended that we need to integrate our public and private healthcare sectors in a closer manner. In a panel convened to look at how better to improve the care landscape in Malaysia for healthcare workers and people living with non-communicable disease patients in Malaysia, this was also one of the top recommendations that were put forward.

Opening up housemanship in the private sector will go a long way towards enabling such integration of both the sectors to occur in a meaningful, sustainable manner with positive effects in the entire health ecosystem.

We need to start somewhere, and we may have missed a golden window in the immediate post-Covid-19 era. Though we may already be late in taking small steps towards a systemic solution today, it is still better than the threat of the system collapsing altogether. - FMT

The views expressed are those of the writer and do not necessarily reflect those of MMKtT.