On doctors working abroad

(warning: another long entry) I started my university life by studying medicine. After three years, I realized that I did not want to be a doctor but my sponsor disagreed. They insisted that I complete the medical course even though I repeatedly told them that I would probably not survive doing something I did not enjoy. After four years in medical school, I (perhaps luckily) failed in one of my exams and, to my delight, this then allowed me the opportunity to change course. I moved from medicine to management, gladly paying my own way and even arranged with my former sponsors to re-pay the money they gave me while I was doing medicine. Now that everything is in place, and arrangements have been made with my former sponsor, I am greatly enjoying what I do. But I pity my Malaysian colleagues in medical schools, especially those who are still studying or have graduated from medical schools in the UK. Medicine itself is not an easy subject. It takes at least five long years to complete, which is much longer than most other courses. You have to understand complete textbooks, many which are hundreds pages thick. You have to learn an array of Latin words especially for anatomy (why can’t they use normal English words when naming muscles and bones?). And the expectation on them is high, especially when they graduate. Just take a look at the letters and articles recently published in Malaysian media about Malaysian medical graduates working abroad. They are accused of being greedy, unpatriotic, selfish and ungrateful, to say the least. I am lucky again in that sense. Having not continued with medicine, and after sorting out the finances with my former sponsor, I am not tied to any of these predicaments. Since I paid for my own studies right up to postgraduate level, I am free to do what I want without people calling me ungrateful or greedy. Ethicality of professional training Many of the doctors I know, who are working in the UK and / or Ireland, give relatively similar reasons on why they want to continue their stay in the UK. Contrary to popular belief, money is not the prime motivator among the doctors I know personally. Yes, money is relatively good over here, but most would say they are here because the better post-qualification training. Training is the primary factor. The crux of their argument, usually, is that it is better for a doctor to return home as a consultant rather than just as a junior doctor. Thus, if they are being trained in the UK without the need for Malaysian taxpayers to pay for their training, surely they must be doing all Malaysians a huge favour. While I can sympathise with that argument, I must question the ethicality of the reasoning. Being trained in the UK, paid by British taxpayers, raises serious issues of ethicality. The amount of taxes paid by these doctors while they work in this country almost never equate to the amount of money used for their post-qualification training. Thus, they are effectively using local taxpayers’ money. Is it ethical for Malaysians to use local taxpayers’ money with the aim of using their expertise in a different country (e.g. Malaysia)? The Malaysian doctors working in the UK should realise that they are actually contributing to some of the problems faced by British health services. For most junior to mid-level doctors here, they have to renew their training contract from time to time. Many contracts have to be renewed in August every year. Just last week, the British Medical Association reported that many young doctors are being left without jobs due to the stiffest competition for training places faced by the NHS in years. It was reported that more than 200 applications were received for every training position, with some posts attracting more than 1000 applications. The presence of junior and mid-level doctors, like the Malaysians, who (as they claim) are not planning to stay in Britain permanently are without doubt contributing to this problem. Those Malaysians who have taken up training posts are crowding the system and are preventing doctors who actually want to permanently remain in Britain from taking their rightful training places. Is it ethical for Malaysian doctors (though perhaps not that many) to take up the spaces and the money meant for training doctors who are supposed to remain permanently here? Human resources projection Another issue that these doctors need to consider is Malaysia’s own human resources projection. (In writing this, I am going to assume that the Malaysian Ministry of Health has made a long-term projection on how many medical personnels are needed and this projection is the basis for sending students abroad) Responsible governments would not use the public coffer to sponsor just anyone to go study abroad. I hope the Malaysian government, in sending students abroad, do so based on careful planning and projection. For example, if they send 100 students to do medicine in 2005, this should be done on the projection that at least 90 (assuming 10% drop-out) would return home in 2010 as junior doctors. I want to reiterate my intentional use of the term ‘junior doctors’. When I signed my contract many years ago, it clearly stated that upon graduation, I have to return home to serve for at least 10 years. This must mean they expected me to come back within five years as a junior doctor, not as a specialist. If they want me to come back as a specialist, surely the contract would state that I should come back with an MRCP or FRCS after, say, ten years, not just five. And here is the problem with the doctors’ argument that they want to gain from the ethically questionable ‘free’ training abroad. Who gave them the authority to neglect the country’s need for junior doctors who can be sent to rural areas to be (what Ida Bakar called) ‘workhorses’? How come these once-sponsored students suddenly become too superior to work in rural areas? I would say that once we sign the sponsorship contract, we are morally and legally duty-bound to return to Malaysia to be junior doctors. Yes, becoming specialists may be ideal, but the contract says that you are supposed to serve as junior doctors in Malaysia first. And you signed that contract. Since when does a sponsored student get the moral high-ground to demand and insist that they would only do what they want, without due regard to the commitment they made when signing the contract? I have even heard some say that the government should not sue Malaysian doctors working abroad for repayment. Rather, the government should ‘entice’ them with better pay and better career prospects. This is a sham! To give a simple analogy, if you borrow money from the bank, you have to repay it under the terms agreed in the original loan agreement. The borrower can never say “Now that I have taken the funds, I will repay it whenever I want. The bank must not sue me but it should give me preferential treatment instead”. The receiver of funds cannot dictate such terms, let alone claim the moral high-ground or claim the right to preferential treatment when they fail to observe the terms. Worse still, some of the students who originally said that they are here to exploit the free training have continuously and repeatedly failed in their professional examinations. How many times does one need to fail before admitting that perhaps it would be better to return to Malaysia? Surely there must be a limit for otherwise the contract may never be properly fulfilled. Thus, the argument that they want to stay to be trained does not hold water. Firstly the ethicality of their stay is definitely questionable as they are abusing the British taxpayers’ funds. Secondly, these doctors are legally and morally bound to serve as junior doctors after graduating. They do not have the rights nor the authority to claim otherwise as most responsible governments would sponsor students based on specific projections of the country’s human resources needs. By staying abroad to be trained as specialists, they neglect their obligations to fulfil the terms of their contracts to return as soon as they graduate. Way out Of course there is a way out. The most obvious one is for them to re-pay the money they have received as per the terms of their initial contract. Better still, the graduates can negotiate with their sponsors and sign another agreement to allow them to stay and work / train. Some have done just that. They signed a new agreement with their sponsors, and postponed the date by which they have to return to serve Malaysia. These are the ones who must be admired as they know their responsibilities, and have opted to make formal arrangements to pursue their career and ambition. It is the ones who blatantly breached their contracts that cause irk. Nevertheless, I would suggest that the best way forward is for the government to scrap funding by scholarships altogether. There is absolutely no reason to give free money to anyone, especially if that give-away is racist in nature. A better way forward is to make all funding as loans, rather than scholarships. Repayment can be either by paying back the full cash amount in instalments, or by serving for a fixed period of time. In either case, the agreement must be a loan agreement, not scholarship. The loans must be offered to all Malaysian citizens regardless of race or religion, and the agreement must be enforced in full, without fear or favour. The difference between what I am suggesting and the current system is in the implementation. Firstly, the current scholarship system clearly expects students to serve, not re-pay. If they breach this understanding, they would have to repay only a percentage of the funds. This is ridiculous. Why should those who breach their contract, and refuse to serve, be rewarded with a bulky discount? They should be made to pay the full amount. Secondly, since it is a loan, it is available to anyone regardless of race. The current system clearly favours the Malays. Why should the Malays continue to be favoured when good doctors can come from any race or religion? The current scholarship system is unfair and racially biased. The benefit from this loan system is that everybody becomes obliged to repay by one method or another. If they refuse to pay or to serve, then they must -not ‘could’, but ‘must’- be taken to court, just like any other loans. Yet, they are also not obliged to serve if they do not want to since they can re-pay the money in full if they prefer. This would create choice, and the Malaysian health system itself would naturally be forced to improve if they want to attract the new doctors. If they choose to re-pay the funds, then the same funds can be used to sponsor another student. The Malaysian taxpayers can rest assured that their money is not lost or given away freely. And the doctors can choose where they want to work so long they pay back every sen they have borrowed. By providing loans rather than scholarships, Malaysians of all races stand to benefit. And most importantly, if the terms are observed, Malaysians who graduated from abroad will not be under the moral pressure to work in places they do not want to (e.g. in Malaysia). Government’s responsibility One thing that must be stated is the government has a lot to do. They must enforce contracts properly, without fear or favour. Looking at the current situation, it wouldn’t be excessive if we were to say that the government does not take doctors who are in breach of their contracts to court because mainly they are Malays. This needs to change. Those who defaulted and breached their contracts are guilty of a criminal offence, regardless of their race or religion. As a Malay Muslim, I am ashamed of this unjustifiable favouritism to an extent that even criminal offences are looked at negligently. Unless the doctors have made an alternative arrangement post-graduation, they must face the music if they choose to breach a legal contract. By making all fundings as loans rather than scholarships, it should be clearer and more obvious to everyone that they need to repay the fundings, or face the consequences. There will be no more dilly-dally. The government must also address the problem of doctors resigning from the public sector to work privately. Lengthening the period of compulsory service is one thing that must be considered. If they want to do something more radical, then perhaps they can consider nationalizing the whole medical service (I personally do not favour total nationalization but it should not be discarded without due consideration). One thing the government needs to do immediately is to clarify their expectations to those who are still studying abroad. Does the government want them to return as specialists, or as junior doctors? Some of those working here now assume that it would be better for the country for them to return as specialists. Hence their stay post-graduation. If this is what the government wants, then students should be asked to sign another contract outlining how long they can defer their service to the country and what exactly their professional targets are. But if the government wants them to come back as junior doctors, then this should be clearly explained so that they no longer have the mistaken understanding on what is expected from them. I know that the government is also currently sending senior doctors for further training abroad. This is good and must be continued. But I want to suggest that if these senior doctors receive salaries while training abroad, then their Malaysian salary must be freezed. I do not see why they should be paid twice, one for the job they are doing abroad, and another for a job they are not doing in Malaysia. After all, the foreign salaries are generally much higher than the Malaysian ones. I want to end by emphasizing that we certainly need to change the Malaysian health provision system. (In fact, I want the whole government to be changed!). But that does not mean those who have received public funds can ignore their legal and moral obligations. Imagine what would happen if sponsored students from all fields do what is being done by the doctors and refuse to return home by using the same arguments the doctors are giving. Law graduates do not want to return until they become senior barristers; lecturers do not want to return until they are professors; management graduates do not return until they are CEOs; etc. If the non-medics were to copy the attitudes and the excuses given by the so-called crème de la crème, Malaysia’s human resources planning would be in deep trouble.