The Ministry of Health (MOH) established the National Wellness Committee for Junior Doctors (NWC-JD) in December 2021 with the aim of improving the well-being of junior doctors (JDs) in Singapore. For this article, we invite the SMA Doctors-in-Training (DIT) Committee to reflect on their role in the NWC-JD, and the progress made since its inception.
Speaking up for JD wellness
When the SMA first learnt of the NWC-JD being formed by MOH in 2021, we wrote in to volunteer our time and services to the Committee, in hopes of being a voice for all JDs in Singapore.
After all, SMA is no stranger to helping DITs, having spoken up and acted on key issues over the past few decades, which include but are not limited to:
- Introduction of night call pay. There was a time when JDs were not remunerated at all for doing night calls.
- Removal of caps on female medical student intake. Up till 2002, there was a conservative limit on the number of females that the Faculty of Medicine in the National University of Singapore was able to accept.
- Strengthening financial support for medical students. To date, the SMA Charity Fund has disbursed 472 bursaries to needy medical students, totalling more than $2.1 million.
- Advocacy for the night float system vis-a-vis the full overnight call system. The SMA DIT Committee published the findings of a nationwide survey of JDs' perceptions of overnight duty systems in 2020.1
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Helping JDs through the challenging transition of starting work. The SMA DIT Committee runs workshops and provides resources for incoming house officers (HOs) and newly minted "baby" medical officers.
It has been nearly two years since the formation of the NWC-JD, with the Committee's final recommendations to be announced in the coming months. Hence, it is timely to reflect on where the SMA stands regarding several important JD matters.
JD work "redesign"
The healthcare landscape has become more complex over the past few decades, and has understandably led to an increased workload, both in clinical matters and administrative tasks. The demand for healthcare services and manpower will continue to increase with Singapore's ageing population. Given the significant JD manpower supply-demand mismatch, our primary concern was whether JDs had the appropriate capability, competency and capacity to undertake their current and projected slew of responsibilities.
SMA supports the move toward a more needs-based manpower allocation approach, and the avoidance of protracted working hours exceeding 24 hours in a single stretch (the impact of which is equivalent to having a blood alcohol content of 0.1%; ie, surpassing Singapore's legal drink-driving limit). We believe this approach enables our JDs to provide safer patient care. We understand and appreciate the competing considerations that need to be taken into account (eg, the time needed to improve proficiency in specific skills or procedures) as we continue to advocate against confounding work hour caps with clinical training requirements.
We strongly advocate for the right-siting and automation of personnel support services (eg, manpower management, night call claims and work hour tracking), to allow JDs to spend more time on their primary task of providing meaningful patient care. On the subject of work hour regulations, it was mentioned in Parliament that approximately 15% of JDs continue to exceed their stipulated work hours,2 raising concerns regarding lack of rest and patient safety. SMA specifically advocates for a passive work-hour surveillance approach (eg, automated tracking of daily electronic medical record use or hospital access timings), as this would reduce (1) the administrative burden of manual reporting and (2) bias and compliance issues inherent to self-reporting, providing more objective, verifiable data to aid in designing policies and monitoring their effectiveness.
Strengthening "generalist" training
With regard to career and training opportunities, Singapore has moved toward improving JDs' family medicine training and created new paths for our JDs to take on generalist roles in public healthcare institutions. SMA supports this approach and continues to advocate for improved access (eg, scholarships and subsidies) to existing robust training programmes, such as the Graduate Diploma in Family Medicine and Master of Medicine in Family Medicine, in line with Singapore's shifting emphasis from hospital care to community care.
JDs remain uncertain about their career and training options. Despite the recent introduction of the hospital clinician (HC) scheme, which provides another viable career path alongside the resident physician and residency tracks, there is still information asymmetry regarding entry requirements and progression prospects, and JDs remain concerned over the consistency of implementation across departments and clusters.
The SMA's position is that there is a need to improve the credibility and competitiveness of the HC scheme. In addition, for JDs who have yet to decide which scheme to apply for, SMA hopes that there will be increased opportunities for training as well. Such training opportunities may be related to research, healthcare informatics, medical education and more.
Supporting and engaging our JDs
With regard to improving the engagement of and support for our JDs, SMA agrees with the move to improve the quality of support provided to healthcare providers. This is in particular for JDs who remain especially vulnerable to abuse and burnout in the face of (1) a rising disease burden nationally, (2) an increasingly complex patient demographic and (3) a progressively more litigious environment of practice.
On this front, the SMA DIT Committee advocated for a review of the whistleblowing process against disruptive behaviour, as well as a zero-tolerance approach for abuse and harassment of healthcare workers and in particular JDs. We advocated for a pivot from mitigation to prevention of disruptive behaviours and appreciate the engagement with the Tripartite Workgroup for the Prevention of Abuse and Harassment of Healthcare Workers. We also broadly support the Workgroup's findings published in 2023. Additionally, we welcome the appointment of chief wellness officers in each healthcare cluster, aimed at the development of institution-specific measures to provide accessible and transparent support systems for junior staff.
SMA continues to engage various stakeholders involved in the development of policy changes pertinent to JDs, providing channels for those in the system to raise concerns and provide feedback (such as the SMA JD Helpline on Telegram). During discussions with MOH and Ministry of Health Holdings (MOHH), SMA raised issues of feedback and survey fatigue, miscommunication regarding mental health conditions and fitness to practise, and the lack of face-to-face engagement opportunities between JDs and their employer MOHH. One development on this front was the SMA-MOH-MOHH engagement sessions which have taken place since February 2022, and further small group discussions with JD representatives in early 2023. These discussions directly involved JDs in redesigning our healthcare system and improving JDs' well-being. SMA will continue to work with MOH and MOHH to meaningfully engage our JDs longitudinally and to provide support, particularly during difficult transition periods (eg, transiting to HO training or "baby" medical officer training).
Concluding thoughts
SMA is appreciative of the movement to improve the well-being of our JDs and is glad to contribute to the NWC-JD. We look forward to the final recommendations from the NWC-JD as well as the implementation of these recommendations. Within and beyond the NWC-JD, SMA will continue to carry the torch and run the race for all our JDs.
Acknowledgements
We would like to acknowledge the contributions of and thank the following SMA representatives to the NWC-JD: Dr Aaron Goh, Dr Calvin Tjio, Dr Goh Kang Shiong, Dr Goh Ying Xian, Dr K Sri Karpageshwary, Dr Lim Ee Jean, Dr Ng Chew Lip, Dr Raj Menon, Dr Thaddaeus Tan and Dr Wu Hong King.
About us
The SMA DIT Committee advocates for JDs and medical students, and runs a wide range of initiatives to support them in becoming competent, confident and compassionate healthcare professionals. The Committee has spoken up about on-call allowances, leave for National Service call-ups and the float system, among other issues. More recently, we have provided recommendations on key issues such as working hour caps, postgraduate training opportunities and JD engagement. On top of this, the Committee operates the SMA JD Helpline, publishes the SMA HO Handbook, conducts workshops for JDs and co-organises the SMA National Medical Students' Convention.
If you are keen to get involved with SMA DIT efforts, please write in to ilj@sma.org.sg. You can visit https://bit.ly/SMA-DIT to find out more regarding the SMA DIT Committee, and join our Telegram channel @HelpOurJuniorDocs to stay up to date regarding our various initiatives.
