It was an honor for me to present a paper on physician resource planning at the National Conference on Redefining & Reforming Medical Education, held at the Putra World Trade Centre in Kuala Lumpur, Malaysia, on July 21, 2011.
The following is an excerpt of my paper entitled: “Eradicating incompetent medical graduates, leveraging oversupply of housemen, avoiding substandard doctors and nurses:- Renegotiating and laying the foundation for national healthcare reform.” I know… a pretty lengthy title (the longest of any presentation I’ve given in my entire career!). I wasn’t its author; the event organizers gave it to me. It didn’t appear I had a say in this matter, and because this was a paid engagement and the first time I was working with this group of people – I hadn’t even met them in person – I let this pass. I didn’t want to come across as a nit-picker.
The Problem: An Oversupply of Doctors in Malaysia
Over 6,000 fresh medical graduates enter the Malaysian health workforce annually; about 4,000 are from local medical schools and the rest from overseas institutions. Such a number is enormous for a country with about 28.5 million. In recent years, the alarmingly high rate at which fresh graduates have entered the workforce has caused concern in several quarters (see the list of blogs at the end of this blog post) because:
- The number of internship positions approved by the Malaysian Medical Council exceeds the capacity for supervision and training. There is an insufficient number of qualified senior physicians to oversee the training of housemen (interns); and
- Inadequate supervision of housemen leads to:
- Potentially compromised patient care at the 63 training hospitals approved for houseman training; and
- Failure to meet housemen’s training objectives has adverse effects on the health system both short- and long-term.
An often-cited reason for the rapid escalation in physician production is a shortage of doctors in the country’s public sector and target population-to-doctor ratios of 600:1 by 2015 and 400:1 by 2020. The government has not put forward any other argument that explains the methods used to forecast the country’s requirement for physicians.
Despite the government’s adamance that there is no surplus of doctors in the public sector, it imposed a five-year moratorium on medical programs in December 2010. However, the moratorium does not restrict the number of students existing medical schools can accept – this seems to defeat the moratorium’s purpose.
There are several problems with the current approach to physician workforce planning:
- Lack of strategic planning. Health workforce planning should be strategic, i.e., take a long-term view, say, 25 years (instead of a 10-year view), and be rolling. Short-term targets often yield unsatisfactory results, especially when coupled with quick fixes (as appears to be the case).
- Inadequate consideration of factors that influence workforce effectiveness other than physician density. Density, as measured by a population-to-physician ratio, is merely one determinant of workforce effectiveness. The other significant factors influencing effectiveness are skill mix, distribution, and quality. A health workforce with the desired population-to-doctor ratio may still fail to deliver the best possible outcomes. Further, suppose the mix of health workers (doctors, nurses, pharmacists, and other allied health staff) is sub-optimal. In that case, the production of health services might be inefficient, i.e., we could achieve more health services at the same quality for a similar cost, or we could achieve the same number of health services at the same quality at a lower price. An aggregate population-to-doctor ratio masks the relative excess of health workers, especially doctors, in the urban areas and their relative deficit in rural areas. In fact, a massive influx of doctors into the cities may exacerbate the maldistribution of physicians. We may also compromise the overall quality of fresh medical graduates because of a lack of supervisory capacity during their two years of housemanship, aka internship.
- Mismatch between the supply of housemen and postgraduate medical education capacity. The critical shortage of qualified senior physicians to oversee the internship of housemen is a serious issue.
A Possible Solution
Any strategy to address the current issues requires a tailored and collaborative approach. Indeed, the World Health Organization (WHO) states:
A blueprint approach will not work, as effective workforce strategies must be matched to a country’s unique history and situation. Most workforce problems are deeply embedded in changing contexts, and they cannot be easily resolved. These problems can be emotionally charged because of status issues and politically loaded because of divergent interests. That is why workforce solutions require stakeholders to be engaged in both problem diagnosis and problem solving. 1 1. World Health Organization. World Health Report 2006 (The): Working Together for Health [Internet]. World Health Organization; 2006. ×
Projecting Future Requirements for Medical Personnel
Besides density, skill mix, distribution, and quality, we should consider other factors when projecting the future requirement for physicians, including:
- Demographic trends
- Effects of economic development
- Affordability of healthcare services
- Demand for healthcare services
- Regional and international comparisons
- Recommended standards, e.g., WHO, World Bank
- Past trends
- Expert opinion
Because of the disparate interests and the considerable number of issues at hand, we propose a Working Group responsible for high-level planning and executive oversight. This Group would comprise at least the following parties:
- Policymakers and health planners from MOH, Ministry of Higher Education, Malaysian Medical Council, and National Accreditation Board;
- Representatives from the medical schools; and
- Representatives from the public and private healthcare sector, e.g., the Association of Private Hospitals of Malaysia.
Implementing national plans will require sufficient political will. We suggest several ideas that may form part of the overall strategy to address the aforementioned issues.
We may classify the tactics we employ into two major categories:
- Those that improve the quality of postgraduate medical training
- Those that control the number of fresh graduates entering the local workforce
Tactics that improve the quality of postgraduate medical training
According to WHO, “(s)trategies to improve the performance of the health workforce must initially focus on existing staff because of the time lag in training new health workers.” In brief, we suggest tactics to:
- Build education capacity.
- Harness the value of supervision.
- Leverage opportunities for “non-clinical” education, such as public health, clinical research, and risk management, and training methods that address the new paradigms of care, e.g., from acute tertiary hospital care to home-based team-driven care.
Tactics that control the number of fresh graduates entering the local workforce
- Continuous re-evaluation of future requirement for health workers.
- Controlling the number of Malaysians being admitted and graduating from medical schools, which we can achieve through:
- Creation of a body to oversee the quality of medical education, the functions of which may be like the Council on Medical Education in the United States.
- Introduction of standards to improve the quality of medical education, e.g., requiring a primary university degree before acceptance into a professional degree program (as in some parts of the world), establishing minimum expectations in a medical curriculum, and a minimum number of full-time medical faculty. 2 2. Flexner A. Medical education in the United States and Canada. A report to Carnegie Foundation for the Advancement of Teaching. New York: DB Updike. 1910. ×
- Following the Flexner Report, which advocated the following changes (and more) in similar circumstances to the present in Malaysia, many medical schools in the United States merged or closed. The average physician quality improved significantly.
- A standardized examination for all newly graduated medical practitioners entering the workforce.
- Review of requirements for admission and graduation.
- Review of school recruitment practices.
- Manage student and parent expectations.
We can only overcome the issues related to the oversupply of physicians in recent years by taking a more responsive approach to the population’s health needs. The solution needs to incorporate planning with a longer-term focus, appropriate planning methods, data-based decision-making, better coordination among the various stakeholders, and a shared intent to improve the safety and quality of patient care.
Commentary About the Oversupply of Doctors
- A doctor too many!
- Bernama – Health Minister: No Surplus Of Doctors In Public Sector By 2015 (Read the comments below the newspaper article.)
- Houseman Glut: Why should we be surprised?
- For Future Doctors: Housemanship Glut