SINGAPORE, June 24 — It was during her 19th consecutive day of work as a junior doctor at a public hospital three years ago that Dr Faith Choo, physically and mentally drained, first considered breaking her medical service bond.

She still had a long way to go until the end of the bond she had signed with MOH Holdings (MOHH), the holding company for Singapore’s public healthcare institutions. The agreement requires her to work in the public healthcare sector for five years upon graduation. This does not include a year of internship, or housemanship, which commences right after graduation.

To break the bond, she would have to repay around S$100,000 (RM348,000) for each year of service she did not fulfil.

However, barely a year in, the then 24-year-old was already mulling if it would be worth forking out that hefty sum if it meant freedom from constant scrutiny at work while being perennially sleep-deprived and physically unwell.

Dr Choo, now 27, said: “It got me wondering whether it was worth it in the long run, sacrificing so much of my health and my youth. Because if you do it for five, six years, you don’t know — maybe you’re shortening your lifespan by a couple of years.”

She broke her bond in 2022 and now works as a locum doctor in the private sector, covering the duties of regular doctors who are on leave or unable to work.

Dr Choo’s experience was far from unique. The high rate of burnout among junior doctors led the Government to set up the National Wellness Committee for Junior Doctors in December 2021, to look into the issue and recommend ways to promote the well-being of junior doctors in the public healthcare system.

Last month, the Ministry of Health (MOH) said in response to a parliamentary question that this committee, which comprises both senior and junior doctors, had finalised its recommendations.

These include “setting clearer work hour guidelines for junior doctors, enhancing career guidance, and promoting a safe and supportive environment for junior doctors”, the ministry said, without giving specifics.

TODAY has reached out to MOH for further details, but have yet to receive a response at time of publication.

Even with the committee working on this, doctors have in recent months turned to online forum Reddit to vent about their long working hours.

One Reddit user, who identified as a Singapore doctor, specifically bemoaned the traditional “call system” at public hospitals. While on call, a doctor may work up to 30 hours straight — a full day of work followed by the night shift, and up until the following afternoon.

Commenting on this, Dr Choo said that this call system has repercussions for patients as well.

“I realised it’s quite dangerous for patient safety, because (the sleep deprivation) really reduces the quality of care that I could provide to them.”

Dr Koh Poh Koon, formerly Senior Minister of State for Health, said in 2022 that although Singapore Medical Council’s guidelines state that junior doctors may work up to 80 hours a week, surveys showed that 20 per cent of them exceeded this.

TODAY spoke to seven junior doctors in Singapore, most of whom did not provide their real names for fear that speaking out would affect their careers.

Although work hours and workloads differed based on where they are posted, all said that they were burnt out and many are considering leaving the public sector.

In March 2023, MOH said that the attrition rate of all doctors in the public healthcare sector had “remained stable in the last three years”, ranging from 3 to 5 per cent, but did not specify the rate for junior doctors.

Data on the proportion or number of junior doctors who break their bonds are not publicly available either.

However, those who spoke to TODAY said they believe that more junior doctors are planning to do so.

The feeling of being overworked lies at the heart of their complaints. What makes the lifestyle harder to bear are the comparatively “better” lives that doctors in the private sector appear to have.

Bryan, a medical officer in his late 20s working at a public hospital, said that it is “tempting” to break his bond early and work in a private clinic, in spite of the large amount of liquidated damages he would have to pay MOHH.

He earns a monthly salary of around S$5,000, not including the allowance he receives for working weekend rounds. In contrast, a locum earns an average of S$10,000 a month.

One 27-year-old interviewee, who took a loan to break her MOHH bond and then work as a locum in the private sector this year, said that she now earns S$14,000 to S$18,000 a month by taking on more locum gigs.

This is up from the S$5,000 a month that she earned in the public sector.

Bryan said: “You’re not getting paid as much compared to working as a locum in the private sector. Their hours are way better, they get more flexibility, and they get to pursue things outside of medicine, too.”

And those who choose to break their bonds may not even have to fork out the penalty themselves. Bryan said that private clinics have approached several of his peers to offer them jobs as locum doctors, effective immediately, and even offered to pay off their bonds for them.

Several other doctors said that this form of headhunting is a common practice in the medical industry. TODAY reached out to several private healthcare companies but all declined to comment.

The attraction is not just about the money. For many, the pull of the private sector is the level of autonomy and control that they would have over their lives.

Tom, a former medical officer in his early 30s who broke his bond in 2021 and now works in the private sector, said: “If I earn more money, it’s because I choose to work more hours. If I have more patients that follow me and consult with me, it’s because I deliver good service.

“So now, I wield the power to make a difference that actually matters.”

In response to TODAY’s queries, Member of Parliament (MP) Yip Hon Weng, who is part of the Government Parliamentary Committee for Health, acknowledged that the public sector, while essential, is often unable to match the remuneration offered by the private sector.

“Moreover, junior doctors often feel like ‘cogs in a machine’, with their personal strengths and interests overlooked,” Yip said.

‘Faceless bunch of manpower’

Another gripe that junior doctors have is with the residency system.

To become a specialist in Singapore, a medical officer must be selected for a residency programme, such as for anaesthesiology, neurosurgery and ophthalmology, which can take three to six years to complete.

However, applications for these residency programmes open only once a year and can be incredibly competitive.

Certain specialisations have much higher demand than there are slots available. This means many applicants inevitably miss out on their preferred programme and have to try again the following year.

Interviewees said that some junior doctors, after failing in their initial applications, decide not to try again and cut their losses by breaking their bonds. This is because their career “runway” as a fully fledged specialist becomes shorter, and they would have to rethink plans for their own personal lives.

Tom, who now works in aesthetic medicine, said this is one example of how junior doctors end up feeling disillusioned.

“A lot of us have different passions, different callings and different abilities,” Tom added.

“But instead of being developed and nurtured for our strengths, we’re being fit into a mould — we’re told we have to fill this need and that need, and therefore whatever else you can do does not matter.

“It’s like we’re a faceless bunch of manpower.”

Measures to improve well-being of doctors

Anna, a 29-year-old medical officer working in a public hospital, said that she appreciates the initiatives that have been introduced over the years to better care for junior doctors.

One is the allowance given to doctors who work weekends, which came into place in February 2023.

At some hospitals, there is also strict end-shift timings for staff members and a night-float system to replace the traditional call system.

In a night-float system, a dedicated team of doctors take over the care of patients for consecutive nights in a week, and a different team of doctors resume care of patients the following day.

This usually entails an overnight shift of 12 to 15 hours. It eliminates the need for prolonged working hours and allows junior doctors more rest.

The National University Health System (NUHS), one of three healthcare clusters in Singapore, said that it has put in place the night-float system in some departments in the National University Hospital since 2007 and Ng Teng Fong General Hospital since 2015.

“To manage the manpower required to support this system, the night float is hybridised with doctors who also perform traditional night calls in a 24-hour shift until 8am the following day,” NUHS said.

However, interviewees noted that the system has not been set up at all public hospitals, and junior doctors are not in control over which healthcare institution they are posted to work.

And even with these initiatives in place, Anna said that “it doesn’t mean it’s great or ideal now”.

Others pointed out smaller initiatives that have been introduced to help them, such as the offering of occasional snack packs and online seminars on how to manage stress, but they said that these are far from adequate and do not tackle the problem of overwork.

Efforts by Singapore’s healthcare clusters

Since 2017, Singapore’s public healthcare system has been organised into three integrated clusters. They are the National Healthcare Group (NHG), SingHealth, and the National University Health System (NUHS).

TODAY reached out to all three to understand the measures and initiatives they have taken to ensure junior doctors’ well-being and address their concerns.

1. National University Health System (NUHS)

With the night float system, a dedicated team of doctors take over the care of patients for consecutive nights in a week, and a different team of doctors resume care of patients the following day.

Besides this, NUHS said that the cluster has also introduced parallel career tracks such as the Hospital Clinician scheme for non-specialist doctors who anchor inpatient care services in a role complementary to specialists.

Additionally, NUHS has rolled out the following measures:

• Formal feedback sessions at certain milestones of each posting, where suggestions and feedback are recorded and acted on, where feasible

• Monthly “Mind-Body Medicine” sessions to introduce the concepts of mindfulness and reflection to help junior doctors cope with work-life challenges

• Proactive counselling and psychosocial support, with access to confidential counselling by an independent psychologist working outside the hospital system

• The formation of an NUHS Wellbeing Office that develops and spearheads the NUHS community’s holistic well-being strategy

• The Get Rid of Stupid Stuff (Gross) initiative, which encourages workers to provide suggestions to eliminate unnecessary processes and improve efficiency

• Confidential counselling services are also provided to all employees to support mental health and well-being

2. SingHealth

Professor Terrance Chua, who is the group chairman (medical board) for SingHealth, said that strong support for healthcare professionals, including junior doctors, is fundamental in enabling them to provide the best care they can to patients.

To help do this, SingHealth said that it has put in place the following:

• The formation of a SingHealth Junior Doctor Well-being Committee at each of its hospital campuses in 2020 to foster a sense of community among junior doctors

• Two targeted workgroups at cluster-level to look into ward-round practices and work hours to address clinical and operational issues that may affect workers’ morale

• Post-graduate training programmes, courses and workshops to enhance junior doctors’ knowledge and skills

• The Hospital Clinician Scheme, developed to provide an alternative standardised career track for junior doctors who wish to work in public hospitals

• Regular engagement sessions for feedback and career support and development

• Dedicated employee care helplines manned by trained and experienced volunteer medical social workers, counsellors and psychologists

• A SingHealth-wide peer support network of about 480 peer supporters among its workers who are trained to extend emotional support to fellow colleagues

3. National Healthcare Group (NHG)

Associate Professor Faith Chia, who is the designated institutional official for NHG Residency, said that the cluster recognises that the well-being of doctors directly affects patient safety and care quality.

NHG said that it has introduced initiatives such as:

• An Annual Career Day held for all junior doctors to share training, career and research opportunities

• A well-being committee that oversees a curriculum to build resilience and well-being, titled Managing Self, Others and Building Resilience. This includes self-care strategies and management of fatigue, conflict and negotiation

• Having external experts provide confidential counselling for its junior doctors, when necessary and appropriate

• A Medical Officer Well-being Committee in 2022 to focus on the well-being and professional development of its medical officers across the cluster

• Regular welfare and well-being programmes available to all doctors, such as sports and physical activities, mental wellness programmes and bonding sessions

• The peer-elected NHG Resident Council, where members advocate for residents’ and junior doctors’ interests and welfare, and facilitate feedback to senior management

Assoc Prof Chia added that NHG would also be launching a new career guidance counselling portal and mentor-matching system in the coming academic year.

What else should be done?

Yip, who is the MP for Yio Chu Kang, said that while MOH has made some adjustments to improve the situation, “there is more to be done”.

“Medicine is more than a job; it is a calling that requires dedication and sacrifice,” he added.

“The public sector must strive to provide a supportive environment that recognises and rewards these sacrifices while ensuring the sustainability of our healthcare system.”

To that end, Yip offered several suggestions of his own, including:

• Introducing shift work with a fixed number of hours a week, similar to the system in Australia, to help mitigate burnout

• Providing significant pay increases for those working in demanding specialties such as vascular surgery, cardiothoracic surgery, renal medicine or neurosurgery

• Making service work meaningful by allowing junior doctors opportunities to upskill in areas they are passionate about

• Increasing medical school intake to ensure a steady pipeline of junior doctors to help alleviate the workload, while simultaneously managing expectations during the selection process to ensuring prospective medical students are aware of the sacrifices involved

• Introducing significant pay differentials for rotations in demanding specialties, commonly known in the industry as “hardship postings”, in order to help attract and retain junior doctors in these fields

To prevent an exodus to the private sector, Yip said that MOH could consider extending the period of a doctor’s conditional registration and re-evaluate the need for certain specialties.

Louis Ng, MP for Nee Soon Group Representation Constituency who had asked MOH for an update on the review of junior doctors’ welfare in a parliamentary question, told TODAY that there may be a huge impact on the healthcare system if the issues that junior doctors face are not resolved soon.

“I think it’s a vicious circle. As more (doctors) leave, the remaining ones have to work more. When the remaining ones work more, the attrition goes up — and we have seen that first hand during Covid-19 with the nurses.

“I think it’s a sad problem that we have such young doctors who are burning out so fast.” — TODAY