This blog
has been abandoned for a while. It is not that I don’t want to write anymore. I
know a few of my colleagues have stumbled upon this blog and I don’t want to
make my private thought public especially at my work place. But, I am now at
the point of ‘TAK TAHAN LAGI’ and desperately need an avenue to vent.
I have been
working here in this district hospital for a year and a half now. In
the first few months, it was immensely enjoyable. The learning curve was very
steep. I would come to work early and leave late to help around, get that extra
bit of practice or to see the interesting patients. My colleagues would make
silly joke all the time and made me laugh everyday to the point my cheek and
belly hurt from exhaustion. The experience was so good that I declined an offer
for a paediatric medical officer post from my old teaching hospital.
Now, it is
just the opposite. I feel unmotivated. I feel work is routine. Every morning
when I wake up, I contemplate faking an illness to be absent from work.
My upbringing, education and training made me expect a high standard
of myself. It is not good enough to do just enough, it has to be better than
that. Similarly, I expect my teachers to be better than me. I am trained to
always keep an open mind, always ask why, always to look at an issue from different
perspectives.
The problem
with training in this hospital now is that the specialists in charge of the
wards are new specialists, fresh from passing the exams, having been medical
officers just like me a few months ago, sent here for a stint of gazettement.
Hence I do not find their rounds as worthy for my training as compared to, say,
a ward round with my previous consultant who was near retirement age. I do feel
arrogant writing this, and I have tried to think of it another way. But there
is no other way of putting it. This is how I truly feel.
The feeling
is exactly the same like when I was a house officer having to do round with a junior
medical officer, who did not having the experience to make any meaningful decision,
whose basic knowledge was shaky at best and not only was unable to teach my anything
useful, I found myself having to fill in gaps in their inadequacy. With this
type of medical officers, I found that registrars and specialists often like to
hear from me or convey their management plans to me directly, without going
through the medical officer. That made life a lot easier for me without having
to go through an intermediary.
In
Malaysia, this is considered close to unacceptable. Respect for the people
older than us, people who are considered our senior, people who are more
experienced, had been drilled into every Malaysian kids by the time they finish
school. My mere thought of the kind mentioned above would have me labeled as
someone disrespectful. Biadap, they call it in Malay.
Of course,
most housemen in Malaysia are not like me. Most are obedient and do not judge
their medical officers like me. Most just follow order, get the job done, and
that’s good enough. And that work routine carries on when one becomes a medical
officer, who follows orders, who doesn’t judge their specialists.
Once
mastering the basics after a few months at work, I began to think about
our current medical practice, to read up more broadly. And I became more
unsettled with a few things on the way we work. I started to ask questions. It
wasn’t received well. They were often met with silence when I discussed them
with my colleagues, and when brought up to the boss, occasionally ended with
heated argument.
It
frustrates me very much when I am forced to practice medicine in such old
fashion way. When I asked why, I get vague answers. I am not stuck up. If there
is a plausible explanation, I can accept it. The logic around here probably makes
as much sense as the logic of witchcraft. I don’t know. Maybe I have not enough
grey matter to understand. Maybe there are extenuating circumstances why we
cannot follow the standard practice and in accordance to the best available
evidence.
I am critical of the way we manage things here. I feel things could
have been better. But no one else would speak up. Sometimes I feel I am leading
a rebellion, trying to convince my colleague of a different point of view from
what the bosses think. And they do not take it well. They all asked me to tone
down, not speak up. ‘Just follow, no need to think.’ I was told, and
my soul would be at peace. She was too kind in her words. Another had harsher
words: ‘She thinks she is smarter than the specialist.’
Paediatrics appealed to me because I feel
paediatricians are proper clinicians. During housemanship time, I was most
unimpressed with doctors from adult specialties, whom after only a quick
cursory interview and examination, often order a battery of tests and imaging
without much consideration or justification. In contrast, I liked what I saw in
paeds. Answers were often found in a thorough history and examination. In
teaching rounds, professors often encourage us to make accurate, confident
diagnosis, to fine tune management. Yes, the child has been having fever for 3
days, but if it is a viral fever, there is no need for antibiotic. In those
days, there cannot be such a thing as ‘antibiotic just to cover’. They pay attention to teach us clinical judgments – how to differentiate a viral vs
bacterial pneumonia and the likes. And they pay attention to explanation and
education to the parents. I believe this is how medicine should be practiced.
But it is not the case here in this district
hospital. Not to say that histories and examinations were bad, but I just do
not understand why it is so different. I cannot count how many children we
‘empirically treat as pulmonary TB’ without much as a shadow of lymph node on chest
x-ray. There has been even more children, maybe in the thousands, subjected to
antibiotics they do not need for viral illnesses. There has been too many
unnecessary lumbar punctures evidence by the overwhelming negative results (I
have never seen a culture positive CSF). Sometimes even myself as a junior medical
officer, am able to tell with confidence that a fever is viral in nature, hence
do not need antibiotic, only to have my decision overruled by the specialist
later, adding antibiotic with the reason ‘just to cover’. Our head of
department wants us to be safe, by over-treating rather than be perfect. I
disagree. Every x-ray is radiation, every ultrasound takes up time (and every
negative ultrasound makes the radiologist think less of us in paeds), every
drop of blood is precious in a little human, and every poke is a trauma to the
little one’s childhood. Overuse of antibiotic breeds resistant organisms.
Over-investigation and overtreatment increase anxiety in the parents. If we are
going to overtreat everyone, what is the use of learning clinical medicine? We
only need to take a single sentence presenting complain, take a look make sure
nothing obviously wrong, then proceed to all investigations, wack some antibiotic 'to cover', like how they do
it for the poor adults. I am not learning much clinical acumen here as you
probably can tell. Hence, I feel my time is up here in this district hospital.
This is a shame. The myriads of disease presentation here is amazing and I
could have seen the best of medicine here.
During university days, I used to run workshop
convincing other students to join my cause for the right of refugees, fighting
the policy makers, with a motto of never taking no for an answer. Here, nobody feels
righteousness is something worth fighting for. In this lonely battle, I have
lost confidence and motivation. I am tempted to give in, to quit thinking, to
be comfortable and just follow like a robot.
