Becoming robot

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.