Friday, 2 December 2011

Houseman shift system - it's not all bad as portrayed

There is a lot of talk about the houseman shift system lately, and I heard a lot of feedbacks be it from the mouths of the doctors, the newspapers, social media like facebook, twitter, and blogs. I am one of the lucky few houseman who has got chance to experience housemanship in two ways; first half of my housemanship doing oncalls and second half doing shifts, equally divided three postings each. And I have the privilege to make a comparison between the two.



Since the beginning of an era, the main complains of doctors anywhere in the world are that they are being overworked and underpaid. Now that houseman are not overworked and underpaid anymore, why do we still complain? We should have been grateful that the whines of the past 50 years have finally realized in 2011! I really really bet you that all those who have been thru housemanship would really wish that their work hours were less back then. Heck even I wished for lesser work hours when I was in 1st till 3rd postings, when the oncall system was in place.

I was quite opposed to the idea of the shift initially. But as I go through it, I don’t think it’s all bad. As I mentioned in my previous post, the number of houseman is increasing. The government cannot possibly increase the number of patients to cater for the increasing number of houseman. To force us do more frequent calls will not increase the frequency of the patients we see as we are forced to do calls with few other houseman, about 3-4 houseman in one ward. Shift system makes us see more patients more frequently albeit in a shorter period of time.

The result of lessening the work hours are inevitable; we shall see much less patients and thus allegedly lacking clinical exposure. The good old consultants may claim that in their olden days they saw much more patients, they did more oncalls, they had more horror experience with their bosses, they managed the ward, the clinic, the operation theater alone as houseman while their bosses came in to work late, some even play golf.

With due respect, in the olden days the mortality rate is much higher, in the olden days you could not possibly be taking care of 40 patients and finish your work perfectly, in the olden days the diagnostic investigations were not as available and lavish as the current days, in the olden days there were not so many treatment options and patient care guidelines, in the olden days the nurses were damn good and efficient not having to call houseman for a simple IV line, in the olden days time is not wasted on petty documentations, in the olden days there is much less medicolegal cases, in the olden days you don’t even know what HIV is, some subspecialties were not known to mankind, some recently classified diseases were not even disease yet. Really, I do not think of anything to be proud of back then. And we do not appreciate horror tyrannic bosses as we do not appreciate a hostile working environment.

I do not mind listening to the tales of the specialists on how it was during their good old days. It actually gives me more inspiration to strive harder. But you can not, really can not, expect things to be as same as the olden days. Things change. So should the working attitude.

This lessening of work hours have implications on houseman clinical exposure as well. Some specialists have been proposing for entrance and exit exam of housemanship, with continuous department level assessments. I do not mind that at all, given that it is somehow true that clinical exposure has been much less and some HOs bring quite the worrying attitude, even to the other HOs. If the higher ups are really keen towards producing safer medical officers at the same time lessening the work hours, they must find a mechanism to assure the public that we are safe doctors.

So yes, we work lesser hours. That gives us more quality rest time and social time, like any other normally functioning human being. Apart from physical health, mental health is also very important. We do not want any doctors to be fatigued or psychotic or depressed. If you think that the current medical officers and specialists are really great with their mental health, try to be more observant. Few of them are really just making other people’s lives more miserable! No, they are not teaching or scolding houseman at a clinical error. They simply swear, they yell, they degrade and humiliate their juniors, they make people feel awful all the time. Do you think a normal human being would do that? I understand that as a houseman in the good old days you were also being constantly harassed and insulted, and claims that made you a better doctor. But does it make you a better human being? Does Allah almighty give you the rights to insult your juniors? I don’t remember He gave those privileges to His prophets.



Previously housemen are just being scorned within the walls of the hospitals, but now they humiliate housemen in newspapers and social media. The reason is they want the public to know how lousy we are, and watch out for the graduates of this and that countries. I do not know what good that can do. They mentioned that housemen are being spoiled and mollycoddled, but in fact the public should be more worried about the mental health of some medical officers and specialists as they are the clinical decision makers who are fatigued and psychotic. Lucky I only met few people like this in my hospital. These people ask respect from us and yet they treat houseman like idiots. And we have to respect them, how??

Some of medical officers are not without irresponsible attitudes. I remembered there was one patient who was seen by neuromed in Emergency Department the day before, but I mistakenly referred to another neuromedical MO as a new case. After she did her 3 page review, she yelled at me “Why are you refering this case to me? This case was refered yesterday to another MO! Why didn’t you call him? Why do you waste my time doing all this useless shit?!”… Excuse me, a patient is a useless shit?? I admit my mistake for the wrong referral, but to say that a patient is a useless shit??? Some other MOs did not even come when called for help or opinion. Some even said “ask your houseman friend lah how to manage.” Some MOs become over-apprehensive when a case is refered to them. They specialists mentioned about a lot of houseman with lackadaisical attitude, but what about your MOs? Irresponsible MOs with attitudes are far more dangerous, don’t you know that? Some of them are just psychotic beyond borders because they are allegedly stressed out.

I have worked with some MOs and specialists who really teach houseman. It is long and tiring rounds but the rounds are brain stimulating. The problem is some of them prefer resting time or doing administrative works over bedside teaching, and scorn us for being low in quality. Ironically they work in a teaching hospital. Yes it’s annoying if a houseman doesn’t know the basics, but if you do not even teach, you can’t put blame on them. I am not proposing breastfeeding, I am proposing tighter supervision. Some houseman even get the basics wrong that you must really correct. If you are concerned that housemen are of low clinical quality, then you should do something about it. If not concerned, please take your rest time, and make peace about our quality.

I do feel shame that my bosses (the medical officers and specialists) are working harder than me. There should be a mechanism to limit their working hours as well. A fatigued medical officer and specialists are more dangerous than a fatigued houseman. A fatigued houseman after an overnight call can still function like a robot, following orders from the superior. But a fatigued medical officer and specialists will endanger patients as they are the ones giving orders and supervising the juniors, and they are bound medicolegally.

I am two postings away from becoming a medical officer. I do not mind doing oncalls all over again as I had done it before and I enjoyed doing oncalls. But as more of my batch of houseman are becoming medical officers, I hope that the government revises the working hours for medical officers as they are currently the most hardworking group of doctors, covering the houseman’s works especially when the housemen go home after their shifts. As I mentioned, I do feel embarassed that my medical officers are working harder than me.

Why am I writing this? Because I find it true, to myself at least. When I started my first posting as a houseman in surgical department, I always dreaded coming to work everyday. There was once I had a sleepless call due to multiple emergency operations. I couldn’t help my colleague at 4am to take morning bloods in the ward as I was still in Operation theater till 7am. The next morning rounds, I was so screwed by the specialist for not taking LFT of a patient post op. He pulled my tie to him and threatened me with extension, in front of patients, nurses and my colleague. I explained to him I was in operation that time, but he just said you houseman are making lame excuses, so stayback till 11pm tonight. Mind you I was postcall and it was a weekend! And that kind of things did not happen just once.

My temper back then was very unimaginable. I honked on the roads all the time, I was really a reckless and fast driver, I yelled at waiters and customer services, and I was swearing curses like I don’t care, even to my parents. I slept dreaming of my dreadful bosses. I look tired even when I am not oncall or postcall. After starting shift system at my fourth posting, I found out that I have been much less stressful, even I forgave a driver who accidentally hit my honda city quite easily. And frankly, I feel happier coming to work each morning, and I do not feel like quitting medicine as much as I have posted in this blog before.

I now love my job as a doctor. I want to brush up on my clinical skills, though I know it takes some time. And I do care about my own health, physically and mentally. Change in the working attitude really needs a paradigm shift. Few specialists already on board for lessening work hours. We hope the other majority follow suit. Please take note that a physician burnout is no small issue. I am sure those who are medical officers and specialists now wished their housemanship in the past to be less tedious and less dreadful.

For further reading

http://www.kevinmd.com/blog/2011/10/life-medical-resident-mexico.html

http://www.kevinmd.com/blog/2010/08/burnout-doctors-stressed-physicians-hurt-patients.html

8 maklum balas:

:D... I'm in the same boat as you 100% about the golden quote of-- "during my time as a houseman we used to bla bla bla" ...

anyway, lousy houseman would make lousy MO so the MO who shouted at you was probably a bad HO as well. So it's a continuity of lousiness and I feel their actions are somehow well justified if they keep on bringing the issue of our lack of quality. Wallahualam.

Thank you so much. It built more confidence in me.

breastfeeding? lol nice article nway ;)

here writer, you not even been pay single cent since the start of shift system. some centre even force their HO to work more than 70hours and it all can't even claimed a single cent and no place to complaint!! with the shift system, you have more resting time(perhaps) but some centre even not allowed to have PH off as promise. so, i disagree some of your view and the shift system shouldn't start without a full proposal and legislation!! it causing mentally and physically exhausted to some HO (somewhere around M'sia)

Whether u r in shift system or oncall system, it is all depend on your attitude actually...

In oncall system, u'll put on tagging for abt 1-2 wk before u r being eligible for oncall. Bcz u know that u'll be oncall alone and u r the 1st liner, u make ur best to learn as much as u can and to do all the procedures. But with the shift system, there is no word of tagging anymore, n even there r, it has no use. The HO doesn't seem to bother much to improve themselves neither in term of knowledge nor clinical procedures.

I can see that u r a good HO when u do feel bad seeing the MO during more work than u. But it is sad to say that some of u don't even bother. Once their shift is finished, they just want to go back. Some of u even left the work not finish. When the pt is admitted about 30 minute or 15 minutes before the shift end, they already don't bother to clerk the pt anymore as afraid that they will go back late.

What make me more frustrated is when we ask about the pt whether in term of progression, drugs, etc, everybody simply gives an answer that they don't know about the patient bcz they have not been on previous shift or previous day. Being in shift system doesn't give u an excuse of not knowing your the pt. Since u work in shift, u should find an alternative way so that u know ur patient. Most of the time, the ward round are delayed bcz the HO didn't know the case. So, we spend our time doing other things i.e. re-clerk the pt, checking the medication, etc, thus don't have much time to teach the HO.

Bcz the requirement in the shift system said that all HO can only work 60hr with 2 days off, thus there r less HO in ward. Bcz of the less HO, the workload become more per person. So most of them just end up doing technical work like taking bld, write referral, doing discharge summary, etc. In some hosp, even the MO are doing the clerking bcz the HO end up doing other work. Bcz of that, they don't have time to learn about the pt and mx of the disease. Since we the MO need to compensate for the lack of the shift system where we also do the HO's work, it also gives a reason why we don't have much time to teach the HO. Unless u made ur effort to do so, then we have no time to ask whether u want to learn or not.

With this type of HO, I don't dare to imagine what would happen when they become a MO later. With the lack of competency and knowledge, how would they manage the patient... They didn't feel anything right now bcz they are not bound to be responsible. But once they become the MO, then they will feel the consequences. U r the one who made a decision and u r bound responsible for any mistakes if u r incompetence and mismanagement d/t lack of knowledge. If u r being posted to district or KK, u r the boss, so u cannot ask help from ur senior anymore as u r the only one there. So, think carefully....

They are good HOs, but I seen only a few nowadays... Most of the good HOs that I've seen is the one that come from 2 system like urs, where they only being in the shift system during their 2nd year of HO. They faced the hardship before, so they appreciate the easy life better... The 1st and 2nd posting HO who started their HOship with shift system are bad, in term of mx of pt, clinical skill and sadly the foremost is the attitude...

Shift system depends from hospital to hospital. Your view is mainly from your hospital. What rubbish for you to say "And I have the privilege to make a comparison between the two" and only depends on your hospital. Some of us are working >100 hours a week because of not enough HO's and keep rotating the same houseman. We are exhausted. We are not paid as well, that's why some of us not keen for shift system, at least when we are oncall we working the same hours, more concentrated and getting paid! While our shift only spreads out the working hours.

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