When asked about work-life balance, many junior doctors respond with a knowing smile and a change of subject. This silence speaks volumes, not of satisfaction, but of a complex web of challenges that extend far beyond the traditional rigours of medical training and defies simple answers. As Singapore's healthcare system evolves to meet unprecedented demographic and technological demands, junior doctors find themselves navigating an increasingly turbulent landscape.
In public healthcare, the junior doctor workforce is the foundation of the clinician corps. They are at the forefront of patient care – through managing the wards, organising the patient lists, supporting senior clinicians on call – yet they are often absent from the forefront of our minds. In recent years, medical circles in Singapore have been abuzz with pressing healthcare issues: healthcare workers' compensation, the ageing population, rising insurance premiums, artificial intelligence (AI), and pandemic preparedness. But rarely have we paused to examine the junior doctor psyche and the evolving challenges they face.
In South Korea, 19 February 2024 marked the start of what has been described as "one of the world's longest medical strikes". In a dramatic turn of events, thousands of junior doctors submitted their resignations, escalating into a massive walkout the next day. While media coverage has rightfully focused on the issue of junior doctors' concerns about inadequate pay in essential specialties, long working hours and a highly litigious medical malpractice environment, we believe the root of the problem runs deeper. At its core, there is a fundamental disconnect between the presence of a dynamic epidemiological landscape (due to an ageing population, worsening lifestyle habits, etc) against a static healthcare landscape whose policies have not caught up with global trends. This highlights the importance of putting the challenges that junior doctors face at the forefront of our policy and advocacy efforts, so as to identify and address issues early before they boil over. Thus, we reflect below on some of the global trends we consider to be particularly pertinent to the challenges and experiences faced by junior doctors today.
Technology: A double-edged scalpel
The phrase "ageing population" is often cited as a looming challenge in healthcare, but what does it truly mean for junior doctors? In a word, workload.
Singapore stands at a critical demographic juncture. The nation is projected to become a "super-aged" society by 2026, with 21% of the population aged 65 years and above. This transformation has significant implications for healthcare workforce planning as our old-age support ratio is projected to decline from 3.5 as of 2024 to 2.7 working age adults for every citizen aged 65 years and above by 2030. Healthcare workers already struggle with higher workloads and stress, with risks of fatigue, burnout and attrition. These in turn multiply the remaining workers' workloads, perpetuating a vicious cycle. The implications extend beyond mere numbers as older patients typically require more complex and time-intensive care.
In response, technology has been positioned as the solution to this "soon-to-be overwhelmed" healthcare system. Economically, technology promises improved productivity by enabling fewer employees to produce more healthcare services. But for junior doctors, this promise is proving to be a wolf in sheep's clothing.
In reality, junior doctors' well-being or workloads are often overlooked during the implementation of new technologies. Junior doctors may be expected to support pilot projects that inadvertently increase their workload instead of alleviating it. These projects, while well-intentioned, may siphon away manpower from clinical duties, further straining already stretched teams. The result is a mismatch between what junior doctors expect technology to bring and its actual impact on their present workload.
The irony is stark: we deploy cutting-edge AI for patient diagnostics while junior doctors still navigate painfully manual processes for roster planning, call claims and other administrative workflows. While there is hope on the horizon that AI may simplify routine tasks such as documentation and administration in the future, such benefits have yet to reach most junior doctors in their daily practice. For now, the more visible gains of such technological initiatives are often higher in the clinical hierarchy (eg, surgical technology, latest oncology drugs). As with all promises of progress, the proof of the pudding is in the eating.
Globalisation of the medical workforce
Among junior doctor circles, questions such as "Should I join residency?", or "How long more before I serve out my bond?" are frequently discussed. Finding the optimal career path that provides work-life balance is a concern for some junior doctors. In recent years, the available career options have expanded from residency, becoming a resident physician, and joining a GP clinic, to joining the new and highly publicised Hospital Clinician scheme. However, with more choices comes choice paralysis. Many may find themselves needing more time and clarity to make these pivotal career decisions.
To add another "differential" to this expanding list, the global junior doctor job market is becoming increasingly permeable. Medical licensure is increasingly transferable, with international examinations and credential recognition enabling greater mobility of junior doctors across international borders. This may present exciting opportunities to those who find local options limiting, but it also fuels competition and uncertainty. For some junior doctors, overseas training pathways can offer better alignment with both their professional and personal aspirations. However, this could signal a troubling shift that the current system is losing its ability to retain top talent.
These shifting dynamics raise questions about the kind of medical careers offered in Singapore. Is it one where doctors feel empowered, valued and invested, or is it one where early burnout and disenchantment are normalised as rites of passage? Instead of having systems that disincentivise emigration, can systems be designed to incentivise retainment instead?
The weight of societal change
Today's patients arrive with unprecedented access to medical information and misinformation. The traditional monopoly doctors once held over health knowledge has been democratised through Internet access and now AI-powered "health advisors". This empowerment is undoubtedly a positive development for population health, but it also fundamentally alters the dynamics of clinical practice, particularly for junior doctors.
As frontline healthcare providers who frequently interact with patients and families, junior doctors often grapple with the realities of increased patient empowerment and health literacy. This information abundance paradoxically increases rather than decreases the communication burden on junior doctors as patients and families search deeper to reconcile conflicting information sources. It is not unheard of for junior doctors to be doing "7 pm communication rounds" where they go around updating patients and families until the late evening. With greater empowerment of patients and caregivers also comes greater fear of litigation. This creates the dangerous cycle of fear fuelling the practice of defensive medicine. In such an environment, are we inadvertently engineering a more distant, less relational cohort of junior doctors? This also begs the question, have we done enough to equip junior doctors with the skillsets and support they need to navigate this increasingly empowered patient landscape?
Looking ahead
Healthcare transformation must not come at the expense of those who sustain it. Much importance has been placed on healthcare expenditure, hospital systems and research, but these rarely capture the perspectives of junior doctors in planning, funding, services and human resource transformation. This needs to change. Junior doctors are not just workers; they are leaders, educators and architects of the future of healthcare, and they need to be a part of the equation and given a voice.
We do not claim to have all the answers, but we believe in the power of recognition and open dialogue. By surfacing these less-discussed patterns, we hope to inspire readers to observe, question and ultimately contribute to conversations that place junior doctor perspectives at the forefront of healthcare transformation planning. This conversation continues through your engagement. Share your thoughts with the SMA Doctors-in-Training Committee through our Instagram page (@jrdocs.sg) and learn more about what we do by joining our Telegram group (t.me/ helpourjuniordocs). Your participation can surface ideas to help shape a more sustainable and supportive journey for junior doctors.