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They say Malta’s medical graduates are amongst the best trained but now that they have been lured elsewhere, most of them may never come back to the island that nurtured them. Matthew Vella reports
The men and women being trained to diagnose and treat the nation’s illnesses are setting their eyes elsewhere. They say they have to get better academic qualifications if they want to do specialist work in Malta, but then find there is nothing paying them well enough to work for the state, the community, their family. Why? Why are so many young Maltese doctors and healthcare workers leaving friends and family behind to go to the UK and work in their national health service?
Last summer, the Polish newspaper Gazeta Wyborcza reported that an 83-year-old man had died from complications said to have been caused by an underqualified anaesthetist. The anaesthetist had failed to empty the patient’s stomach and provide enough oxygen. The man had a severe choking fit, which was stopped by a more senior anaesthetist. The operation went ahead but the patient died as he left theatre. The headline read that there were not enough anaesthetists, after 10 of the hospital’s 13 walked out after rejecting a pay offer, probably deciding to leave to the Czech Republic or Britain where pays were as much as 300%.
The death could illustrate the impact of Poland’s brain drain, where 5,000 doctors left over two years. Malta’s brain drain to richer EU countries, namely the UK, has caught up momentum since the Medical Association of Malta sent out the alarm some two years ago that 70 per cent of new graduates had left the NHS. And in the greying corridors of St Luke’s Hospital, doctors complain they are finding it hard to cope with a growing demand for their services, hours-long queues, and waiting lists which have patients waiting for five years for a hip replacement. The working conditions are poor, the pay is low, workloads heavy, and little opportunity to further one’s career.
Such is the pressure on doctors, that they end up working 60 to 70 hours a week, while authorities insist that health centre doctors should see one patient every four minutes. One former senior house officer, 27, who today works in the UK in orthodontics says he worked six days a week for long hours for a “largely unreceptive public who were unaware and uninterested in the range of treatments I was trained to provide for them.”
He left behind his “abysmal” salary to work with people whose textbooks he had studied, involving himself in research and postgraduate training and career development. “For the first time in my working life I had a two-day weekend – which had hitherto been an alien concept for me.”
Now he has a postgraduate qualification and is seeking a second degree, all paid for by the NHS.
Another doctor, Kurt Buhagiar, 27, who works in Belfast, affirms the lack of advancement in training in Malta. “It stops at medical school essentially. After two years under supervision working as a pre-registration house officer, which essentially means getting everyone’s dirty work sorted with the ultimate aim of getting registration with the council, very little can be gained by staying in Malta within the hospital setting. Basic speciality training is essentially non-existent – although one can sit for Royal College exams for medicine (MRCP) and surgery (MRCS) by staying in Malta, passing them doesn’t make you a specialist anyway, although in the old days, doctors in Malta did in practice get consultants’ jobs by just obtaining those exams; in other words some consultants are not qualified to work as consultants.”
The MAM says the demand for services is on the rise while the number of experienced and specialised doctors is decreasing. “A newly graduated doctor cannot do the work of a doctor with years of experience,” the MAM says. One medical student who’s reading for her postgraduate degree in London says young doctors leave because there is no further advancement, academically, to actually reach the heights they are expected to.
Kurt confirms that higher specialist training can only be acquired from overseas as only those exams confer entry to higher training. “This means there are far too many people than needed stuck at senior house officer level holding such qualifications but who cannot progress further in their career. Even worse, doctors pursuing most other specialties such as psychiatry are not even able to sit for entire stages of the exam while working in Malta, as posts are not approved.”
David Galea, 30, a senior house officer at the Assertive Outreach Team in Chichester left the island because he could not sit for the psychiatry exams and further his studies. “I wanted the experience of working abroad where the concepts of recovery and treating people in the community are at a more advanced stage.”
Today his workload is lighter and safer. “In Malta I would see over 15 people in a morning outpatient clinic. In the UK I see a maximum of five, allowing to give each patient the appropriate time and attention.”
Despite the lack of advancement opportunities, they praise the medical training they received at the University of Malta. “Malta gave me a fantastic education and my undergraduate degree at university was absolutely first-rate with excellent training and I constantly sing the praises of the training I got as a student in Malta,” the orthodontics specialist says.
But when he graduated from university, there was hope to advance further but little postgraduate education was available in the first place. “The little there was consisted of evening lectures by local self-proclaimed ‘experts’ with little or no postgraduate qualifications of their own.”
“Because the only postgraduate training in Malta comes in the most rudimentary of forms, career progression comes to a halt,” Kurt says. “Those not interested in hospital work of course can get into family practice, which for some illegitimate reason is considered as a subordinate speciality in Malta. This is unheard of in the UK, as GP training is treated akin to other specialty training, and this just explains the sub-standard level of practice by family physicians in general.”
In fact, education remains the paramount concern in the UK. David Galea says that as a trainee, nobody can make you fill in at the clinic if you are scheduled for a lecture.
“At the risk of sounding too presumptuous, the system does feel totally different and almost completely flawless,” Kurt says. “I get a whole day off for studying every week, there’s informal teaching in the ward, formal one-to-one teaching once weekly. Study leave on top of that is encouraged…people just start looking at you suspiciously if you don’t make use of that.”
And there’s the annual leave (“an inviolable right”, Kurt says), reasonable patient loads, and other plusses. “Only evidence-based medicine is administered, rather than merely consultants’ preference and anecdotal treatments. There is better interdisciplinary cooperation between doctors and nurses, and ‘bullying’ by senior doctors towards subordinates is unheard of, unlike what happens at St Luke’s, everyone seems to get a kick out that.”
As Malta’s young doctors take to the UK, morale among Britain’s junior doctors is actually falling to a new low, with a survey by doctors’ pressure group Remedy UK saying that almost half of them think they chose the wrong career. That’s because under the Modernising Medical Careers scheme, due to be implemented in August, all senior house officers’ posts will be abolished, leaving many junior doctors facing uncertain futures. Almost 1,000 could struggle to find work when applications open in February. With 2,000 doctors churned out into UK, more trusts are cutting costs and restricting the number of posts created. But although the UK loses up to a fifth of its doctors to the US, the MAM states Malta is losing more than half of its doctors to richer EU states. That is a frightening figure, especially when considering that the drain is encouraged by the UK’s inducements of better pay. Doctors’ basic wages range in the UK from around GBP22,000 (Lm14,000) for a first year postgraduate, to around GBP90,000 (Lm59,000) at consultant level. With on-call work, a doctor’s salary can be doubled. In Malta, a consultant earns Lm10,811, a senior registrar Lm9,560 and a house officer Lm7,827.
“Which of course explains why consultants have to necessarily resort to private practice to get an income in accordance with their level of responsibility,” Kurt says.
“It’s disheartening when you talk to colleagues who remained in Malta,” David says. “I realise how overworked and underpaid they are. And this is not about paying doctors more – it is about patient safety and ensuring a better service. You wonder whether you should ever go back.”
Although our young doctors became highly-paid specialists abroad, and make their families proud, Malta is losing elite workers, and one could only wonder at the adverse effects of losing some of the most productive individuals for a small island like Malta. MAM secretary-general Martin Balzan already knows that Mater Dei hospital will never be staffed to the complement which its operations will require. “I don’t know how we can cope with all those theatres and new surgery rooms there are.”
So will they ever come back? The orthodontics specialist says that despite leaving behind his girlfriend and the Maltese lifestyle, his only regret is not having made the move sooner. “It is such a shame that we can train people up to that level and then let them go. I don’t know the answer to keeping people behind but something has to change.”
“You miss friends and family,” David says. “Each time you visit, it can be harder to go back. I miss the island and our lifestyle, which is difficult to match anywhere in the world… I hope to return to Malta eventually, because I am Maltese. However the work opportunities and conditions are a major drawback.”
For Kurt, leaving Malta behind was not a hurdle. “Might be for some people, not so much myself. It feels somewhat of a relief to be away from the over-intrusion back home. Would just dread the thought of having to come back.”
mvella@mediatoday.com.mt
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