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. 

Weary

I suppose it happens. I ask too much too often. But it isn't fair that I blame everything on myself. It is all about work. After all, for the past year, other than the 20 days or so of annual leave I took, I spent at work. That is more than 340 days at work in a year. We are required to work everyday including weekends and public holiday. It does take a toll and wears one off. Ward round is mundane, even for the patients and parents on short stay, and there are plenty of those in a working day. There are problems to be solved everyday and certain amount of distasteful jobs to do every few days. There is no scope for life outside work here at this place. 

I try to do my best at work though, I really do. It is not please the boss, not at all. I am privileged to be able to be in such position to help, to make a difference. The fortune teller said it is because in my past life, I had saved a drowning man. I am not particularly superstitious or religious, but I believe in karma and morality. Whatever good or bad things I do will eventually come back to myself or my family. But due to my inexperience and ignorance, sometimes, no, often, even doing my best is worthless. I make mistakes sometimes, including few medication errors, and that had been quite upsetting. Quite often I do become frustrated if I know things could have been done better for my patients, because of the action and decisions made by myself or others. But I have never and would never cry for my patient. There has to be professional distance. But I feel I ought to set even wider distance, never to allow patient issues affect me at all. Yet I do not see how that is possible - my life is work, and only work at the moment. Erasing feeling aroused from work equals no feeling, or so my logic says. Unlike in the west, the medical profession do not reflect much, we do not discuss feelings. That is just the working culture here. 

I do long for an acquaintance. Not necessarily a male counterpart. Just someone I can relate to and talk and vent for hours, a nice company to have dinner with. I spend most of my time outside work (for necessities like groceries shopping and dining) on my own. I am not embarrassed by that. But it does get a little lonely. Colleagues are nice enough, but I am not getting along well with a few. My wavelength and theirs are simple different.

You can say in some perspective that I am depressed. I cannot see the future. All very dark. I cannot see myself passing the next paper. I cannot see myself taking the next step getting out of this place.

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Excerpts that were left out

There were many pieces I have written in the past that have been left unpublished for the blog, for many reasons: unfinished, considered inappropriate for public reading, too frustrated to continue etc. Two of which made me laugh when I look back.

'The more you put in, the more you get out of it. You don't even have to know a lot, you just have to be keen!' One of the consultant said this to me one day. I reflected upon it. Did I not seem very keen? Did I give him the impression that I was bored? 

This is the most difficult thing about studying medicine. It isn't the vast medical knowledge that we are expected to learn. It isn't even the extraordinary hard work that we have to put in. It is having to appear enthusiastic, keen, energetic all the time. 

You'd realise the fact on the very first day you set foot into the hospital in the third year. Hospitals are very busy and unfriendly places. Doctors and nurses have 1001 things to do already and routine is very important to be efficient, so more can be done in a shorter span of time. Doctors and nurses tend to cope with the madness of hospital chaos by sharing a strange a camaraderie. Because we don't work within the circle, medical students are not included in.

I suppose I am awkward compared to my fellow friends because I like to work. I love being in hospital, I like helping doctors and nurses, I intrigued that I learn new things everyday. I hate laziness and I cannot stand being idle.  

In my third year, on our very first placement, one of the consultant tried to get me doing jobs as part of the medical team, and that was such a rare thing. 

However, even for me, I feel that sometimes I just have not any energy left to pull up that keen face that we are suppose to show all the time. 

This was written when I was nearing the end of my fifth year. I suppose the exhaustion had started to kick in, exhaustion of being a student. I was the model student. I wanted to make good impression of every senior person I met, and that took quite a bit of effort. 

1. Staff nurse - don't be angry if i don't entertain your request stat. because I have more urgent things to do first.

2. Patients - i am not a mi-si. please don't ask anything about toileting, linen, spillage - i haven't a clue.

3. Relatives - talking to mi-si is so much better than talking to me - they know useful things like where is the parking,  etc. i'm only a houseplant.

4.

This was written two months into my housemanship training, at the time working in excess of 100 hours a week, mainly due to my inexperience of prioritising tasks and trying to please all the mi-si and patients who also called me mi-si. I used to think they call me mi-si because I did not appear confident (and I was probably right), hence the use of 'I' in small letters 'i'. Clearly I had more to say in this piece but now I cannot remember who else I have had resentment towards.
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New job

It is now coming into my third week working in a district general hospital in Sarawak. I always have thought of working in East Malaysia embracing a whole new experience, perhaps not yet having the guts to accept a job at remote places only accessible by boats and helicopters, but being actually here now on this side of the world is a good start.

Moving was daunting - all the fuss with finding a house and car. Luckily I had help from a friend's parents, without whom I'd be so stuck.

I am lucky enough to be accepted into Paeds. The first week was tough. Besides having to get used to the new system in general, I quickly realised that despite having done paeds just half a year ago and having recently passed an exam, my knowledge is minimal and sort of have to start from zero. I like the bosses here because they are strict and have high expectations. It is a steep learning curve but I am enjoying paeds more and more everyday. I like micromanaging baby's nutrition, manipulating baby's ventilation, working together with parents. Nurses are so capable here than the ones I've worked with before. I couldn't ask for better colleagues than this bunch who had been kind enough to include me in every meal and every outing they've planned. It's been interesting interacting with Sarawak people, whose accent I absolutely adore.

It's all looking positive. Who knows, I might actually stay.

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Paeds Ortho

Some update. I passed MRCPCH Part 1a and 1b. With good scores if I may add. I did work hard to prepare for this exam and I am so glad that my effort had paid off. I am proud of this achievement.

I am now 'floating' in the Orthopaedic department. I was actually unclear of my role. I am in the HO roster, assigned as the Paeds Ortho team's HO, as I have promised to help out since we are short of HOs at the moment. The difference is that nowadays I consult my seniors less and tend to just go ahead with what I think is appropriate in terms of clinical management. But I do not sign MC as I have not obtained my full MMC registration number, and I avoid signing on operation consent forms. Last Friday, we were chatting and I accidentally let slip to prof, who is also our head of department, that I am actually neither doing shift work nor oncall. On Monday morning, prof delivered the news that I will be assigned to do the MO calls. It was a mixed feeling. I am happy that I am upgraded to do MO's work and would be able to earn some extra cash. On the other hand, my luxurious ways of working office hours would be sorely missed. On the next day, we had a visiting professor from Indonesia joining our round. Prof introduced our team to the visitor and a sense of pride overwhelmed me when prof introduced me as 'one of our new MOs in our team'. I actually smirked uncontrollably. So embarrassing  Now I feel I have to really up knowledge and improve to live up the standard of being an MO. 

As opposed to my expectation, I really enjoy being in my team now. The main reason is the bosses. The two professors heading my team are great old school doctors who give much emphasis on how a patient is clinically to determine diagnosis and treatment, as opposed to fancy tests and scans. A 7 month old boy came in with high fever, not moving the left hip, all the signs pointing at septic arthritis but because the ultrasound concluded that there isn't one, the MOs did not treat for the condition. Prof listened to the story, took one look at the child and sent the boy straight to OT. Impressive enough, needle into the hip, pus poured out. It was septic arthritis. Unlike the MOs, prof trusted the clinical presentation rather than technology, and he made the correct diagnosis. I could have gave him a salute. There were other examples. In general, there is less unnecessary referral and requests for scans in Paeds Ortho team compared to the other Ortho teams because our profs are more sensible. I like learning proper medicine from these sensible old school doctors. It also reinforces my believe that Paediatric doctors (physician or surgeon) are simple cleverer and more conscientious doctors. Even though I am the most junior in the team, I have never felt the hierarchy preventing me to ask questions and express my point of view. In fact, prof would always ask what I thought I would do before he suggests his management.

However, ortho is ortho and I cannot deny losing interest when conversation starts to veer towards operative technique, anatomy... I am in the process of trying to continue floating in the real Paediatric department, where my real interest lies. We will see how this pans out. Should be interesting. 

There is a previously-known-to-be-stubborn kiddo in the ward now. Prior to this, we needed to change his dressing under GA or sedation every time as he would scream through the roof when anyone touched his foot. But, as of yesterday, I have managed to tackle him and we are good friends now. With me he was so cooperative that he held his hand out still for me to poke him to take blood, not making a sound and concentrated on his breathing just like I told him to. So cute. After that he even gave me a pack of his sweets. Today was not the greatest day. I messed up a case in my presentation. Prof wasn't happy and I felt disappointed with myself. But after that, I went back to the ward and played with this kiddo. He cheered me up and made my day.

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Exam mode

I have foolishly signed up for the Paeds Part 1 exam to be held in Oct 2012. I am so not prepared and it has cost a bomb. O well. I will just have to do my best. At the moment, progress is ever so slow. The palpitation and sense of urgency, worryingly, has yet to set it.

I am now doing my last posting as a house plant in the Orthopaedic department, on my third week with the rehab team. It is really one of the most depressing attachments I have been through. The impression I get is rehab review = expensive equipments = cannot afford = refer welfare = chase welfare. I am on first name terms with the sales rep who provides these equipments. I feel like doing a daily round at the social work department.

It will end very soon!

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So illogical I am speechless

I attended a meeting as a Paediatrics house officer representative with other specialist coordinators for housemen from all specialties and representative from the health ministry (KKM) to discuss about the implementation of the flexi hour system (working in shift).

Before I start, let me just say that in my hospital, unlike the KKM hospitals, there is no problem with excessive and overcrowding of house officers. We have just the right amount of housemen that at any one time so no one is idle. We have no complaint over the oncall system. We get to be attached to a team or a ward, our MOs and specialists see us every morning, we know the patient well and they can teach us something. Patient receives good care as the same house officers in the team who look after them from admission till discharge through to clinic follow up sometimes. We may be tired post call and might whine slightly, but we are happy with the current system as we are getting good training and patients are well looked after.

Then, in the meeting, this lady from KKM announced that the flexi hour system has been decided and all hospitals in Malaysia HAVE to implement it – there is no choice over this matter. It is an order from the Director General of Health – with a full stop written in permanent marker. No matter what we say now, the matter is closed.

Fine. In order to implement the flexi hour system, we will need more housemen to join us – at least 25-30 in each department. So, this hospital, which does not have a problem of overcrowding of housemen, will have such problem in the future, as we will be forced to take in more housemen just to fulfill this directive from the top. Rather than having the system to resolve a problem, we are creating a problem just to serve the system.

Nevermind that training will be compromised (even though the position house officer is created primarily for training).

Nevermind that patient care will be compromised.

Nevermind that the house officers themselves and their consultants who are immediately affected by this directive are all against it.

Nevermind that the mortality and morbidity rate will increase.

Nevermind that in the future the nation will be looked after by a generation of poor quality doctors .

As long as the flexi hour is implemented.

We argued at length. KKM wouldn’t budge. KKM said she receives letters from parents of house officers regarding their children working too long hours in the oncall system and those letters are often conveniently forwarded to the top shots like the health minister and the prime minister. On why these top shots think that they should entertain these parents, I am at a lost. (Separate post coming soon regarding this issue)  

I asked if I, and many other housemen who are against the flexi hour system, can also write similar letters to the KKM to counter these overprotective parents. The specialists and professors warned me not – fearing that my action would annoy the DG and I might end up not getting my full registration.

I became speechless at that point. Now I cannot even exercise my right to freedom of speech.

I am now more acutely aware that I am back in Malaysia. Sigh. Yes. Welcome back.

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