Thursday, 26 January 2012

Housemanship - My Two Cents

I was an IB sudent studying in Kolej Mara Banting when I first heard about the three types of medical teaching philosophy that are in existence.

Those are namely:
3) Problem Based Learning (PBL)

Each of them stem from different school of thoughts, different opinions on how best to study medicine.

I am the product of PBL who at times wished to go traditional. And I have heard of the traditional med students who wished for integrated or PBL.

Yup, the field always seems greener on the other side, folks.

But the point of my bringing up the whole issue is to demonstrate that our teaching is not static. There will always be someone who thinks that we could have learned better when we were students if only they had implemented this or this or that. So they come up with ideas, all for the sake of making it better. The ideas will be examined, analyzed, shredded to pieces by discerning eyes. Once the ideas are found to be able to stand the test of logic, reasons and rationale, then plans will be made to carefully and gradually implement the ideas.

The key to on-going civilization is ideas! Innovations!

Being static is not an option.

Do you have any idea on how to make housemanship a better learning experience to prepare us to the real battlefield of diseases once we attained the rank MO-ship?

Previously, it was taught that putting a lot more hours into housemanship will increase your exposure to diseases and management, and thus would prepare you into becoming a good MO. Thus, the on-call system (sometimes EOD), the exhaustion, the denied physiological state of drowsiness and sleepiness, the GUILT of being made to believe that you won’t be a good enough MO if you don’t do on-calls.


I have other ideas. I am not saying that my idea is the best and it SHOULD be implemented. I am just using this medium in Blogger Ubat Muda as a sounding board to test what sorts of training would make a good MO. And I would like to hear ideas from others too. I am sure a lot of us have some ideas of what would make housemanship a better training program.

Let’s discuss it.


I was quite incredulous when I read the opinion of a houseman who thought that we should bring back the on-call system because he felt that housemen need the hours.


Let’ s say he was right.

Let’s say we do need the on-call hours.

But to do what?

To do more Brannulas?

To do blood taking?

To be informed by staff nurse that Pak Cik Ali has some temperature so that we can then order T. PCM and tepid sponging and then start taking Blood Culture?

To be informed by staff nurse that the patient in the acute cubicle has low BP – so that we can then run some fluid fast and then do hourly BP and then KIV start some inotropes if indicated after informing MO?

Granted we also clerk some new cases that come into the ward, but most of the time we just carry out the plans already ordered by our MO who was on-call in casualty.

Well, of course setting brannulas is important for patient who is on IV antibiotics. Of course blood taking is important when the patient is suspected of dengue and you need to monitor her/his FBC.

But when they said that we need the extra hours to be a better MO…are we supposed to devote those extra hours to be doing the above in the wards? Or to go to casualty and clerk new cases, and come up with a diagnosis and then decide on investigation as well as appropriate management plan for this patient?

Doing brannulas/ blood taking/ and order simple things like ‘run fluid fast’ or ‘T. PCM stat’ during oncall would not make us a better MO. It would not even make us a better houseman because we would already be doing those during office hours anyway! If you are already an excellent blood sucker, sucking more blood during on-calls would not make you more excellent than you already are. Like wise, if you are already an excellent brannula setter, setting them for an extra 100 times won’t make you any better. So what is the necessity of rendering our housemen exhausted and lethargic by hiding behind the reason that ‘they need the hours to become a good MO.’ The hours that they put in – that you say they need – should be devoted for doing something that will make them become a good MO, right?

Be smart!

If they need the hours, put them in casualty! Make them come up with diagnosis and appropriate investigation and make them come up with proper management plan from casualty! Make them use their brain because that’s what they will be doing once they become an MO.

If you want them to be tired, AT LEAST, make them tired for the right reason.

However it’s true that we need housemen in the wards too. It’s true that Brannulas still need to be set. It’s true that someone still need to take routine blood investigation from a dengue patient. It’s true that someone should be around if patient collapse.

But you see, my point is, the houseman can do all that without you hiding behind the reason that they need the hours to be a good MO. Why do we have to make them so tired going on-call for doing something that is YES! NECESSARY! – but won’t make them a good MO. Let them feel fresh to learn the most during office hours. If they are too tired from having worked for more than 24 hours on the previous day, do you think they will be able to absorb as much the next day, during office hours, when they need to maximize the use of their brain.

Don’t just work hard. Work smart!


Imagine this scenario.

Imagine a teacher who teaches add maths to a class of 25 students.

The teacher knows that at the end of two years, she needs to make sure that the 25 students will all be ready to answer the add maths questions in SPM. At least ready enough to pass.

So she reasons that in order for the students to pass Add Maths, the students need to do basic things ; multiplication, division, factorization, quadratic equation, differentiation, integration. They spend hours memorizing formulas that they know they will need to use when solving mathematical problems.

The Teacher spent the whole two years asking the students to practice all the concepts that they need to master in order to be able to pass SPM at the end of two years.

The exam day arrives at last.

The students are shocked! They are shocked when they find out that the questions come in the form of long paragraphs that they need to ponder and decipher and APPLY the concepts that they have learned. They are confused because the question is not as straightforward as ‘Do differentiation’ Or ‘factorize this equation’.

And at last only two students out of 25 pass Add Maths that year.

The teacher is very angry. “I teach you for two years! We even have Kelas Tambahan for you to keep doing quadratic equation and differentiation and integration bla bla.”

“But the questions in the paper were DIFFERENT than the one we are used to.” One student answered back.

"Ah alasan! How come these two students Ahmad and Ali pass? It’s because they have the initiative to study beyond what is taught in the classroom.”

Ahmad and Ali smile. They have a secret to their success. They both went to a tuition centre for ONLY two hours per week. In that two hours, they were taught how to apply the concepts that they learned. They were given past year questions and they were given questions in the form of long paragraphs just like what came out in the SPM.

Silently they want to say, “Oh teacher, we don’t need to spend all those extra hours in the classroom doing repetitive stuff on basic concepts. If only you had just spent 2 hours per week doing the real thing that we need to face during SPM, we would all have passed.”


We need to be able to set brannulas

We need to be able to do blood taking.

We need to be able to do procedures.

But we don’t need to do them for two years (siap sampai tak tidur and on-call lagi!!) to be good at those. In fact, that would NOT help us to become a good MO

What we need to do:

-interpret ABG – come up with possible Differentials.
-interpret CXR - come up with possible differentials
-interpret ECG – come up with possible differentials.
-interpret CT Brain – come up with possible differentials
-interpret MRI – come up with possible differentials.
-Decide on which antibiotics to use after patient is not responsive to one.
-Come up with management plan for all those differentials.

It doesn’t matter how many times we do on-calls….if we don’t spend the extra hours doing the right thing, we will never be a good MO. Might as well we don’t do the extra hours and come to work fresh and smiling and more receptive to learn by ourselves.


This is only my humble opinion on the current housemanship training. We should spend extra time thinking the way our MOs think!

Not everyone is like Ahmad and Ali who has the initiative to seek outside resources. Besides, by rights, the teacher should have recognized from the very beginning what sort of training is beneficial and what sort is not so necessary. By rights, regardless of anyone having extra initiative, the teaching should be successful simply looking at the amount of hours the students already put in to study. Work smart, remember?

I am not entirely convinced of my ability to become an MO even after 1 year of housemanship now. I am very scared to be all alone out there.

And I am discussing this issue not for the readers to agree with my opinion. If anyone disagree with what I have written, please say so and give us a solution. I would like to hear them. Maybe…we can make a few suggestions to the ministry.

What does everyone else think?
Let's discuss this.

7 maklum balas:

extra hours so we all can do enough wound dressing and nursing care..hahaha.. although i don on call only for 1 month, i found it interesting because O&G here very busy and many case where HO getting chance to manage it.. but once i entered ortho, kind of hate the whole thing.. hahaha. after all, so thankful for the shift system.. at last manage to go n see the world

-interpret ABG – come up with possible Differentials.
-interpret CXR - come up with possible differentials
-interpret ECG – come up with possible differentials.

May I ask who is it that is suppose to arrange for them to be done and also review them first as soon as the results came back? Aren't these common investigations that HOs are suppose to order with many of the new admissions, especially in Medical? HOs only need to know what they are 'supposed' to have learn in medical school to read and interpret them. With practice it will very wuickly become second nature to them. However, if the HOs themselves do not want to use theri brain while at work they will not be good at it no matter how long they are kept in the department.

Too often I have seen that the HOs don't take the trouble to:

1) Think through on why a patient need those investigations done in the first place, rather than just simply accepting them as 'routine' investigations.

2) Review investigations early and as soon as the results arrive back in the ward. They only do so when the MO or specialist ask for it. In fact, there have been many times that the HOS actually forgotten that they have arrange for the investigations to be done in the first place. Even more sad when some HOs simply 'forgot' to have the investigations ordered/arranged/done till the next ward round or, God forbid, the next day!

3) Treat urgent investigations as URGENT, especially when the MO/specialist said so during the ward round. This oft times happen because the HOs don't even understand the urgency of the situation. This can only happen because they are STILL unable to apply their basic medical science knowledge to each and every patient that they clerk and look after in the ward. In this instance I find it surprising how they got through their clinical years at the medical school in the first place. And I can never understand why an URGENT investigation results will only be reviewed by an HO at the end of the day when the results for the rest of the (non-urgent) investigations ordered during the morning rounds came back. be continued

-Decide on which antibiotics to use after patient is not responsive to one.
-Come up with management plan for all those differentials.

The above are also taught during medical school days but will need to be tempered with the policies and SOPs specific to the hospital or department that the HO is working in. Only experience and practice will make the HO be proficient enough to decide and implement them on their own. By right HOs would have an excellent opportunity to practice on which antibiotics to use and what sort of appropriate management is required with each patient that they clerk since they will need to present (at least a summary) to the MO/specialist during the rounds. It will not work when HOs themselves refuse to apply the knowledge taught during medical school days in their day-to-day activities in the ward. This arises because 1) The HOs graduated from medical school without the necessary knowledge to do this, or 2) The HOs just don't want to use their mental faculties while at work. Some will even do their utmost to avoid clerking patients. Makes you wonder what they were doing as a medical student previously.

-interpret CT Brain – come up with possible differentials
-interpret MRI – come up with possible differentials

CT brain and MRI results interpretations will actually require specialist training for someone to be proficient at. I don't think HOs and junior MOs are ever expected to do so. That is why HOs are expected to get the films and reports for these investigations from the radiology department themselves, especially for URGENT cases, and bring it around to the specialist to see and interpret before further or new management plans can be made by them.

At the end of the day, what I am trying to say is, it is actually the attitude and personality of the HOs themselves that are important to ensure that they can become proficient MOs, regardless of whatever system is being implemented during their HO training. Without the right attitude or willingness to use their mental faculties to the utmost during their time at the hospital HOs will continue to make mistakes and bad decisions. Sooner, rather than later, it will be one that will come at a high cost, either to the patient's well-being or to the HO him/herself.

As more and more HOs start working at the hospital with the wrong perceptions and a negative attitude towards their training they will always complain about what is not available, rather than what is available to make their time more rewarding for themselves and also everybody else. And, personally, I find that these HOs are those who portray the wrong attitudes and character from early on during their medical student days.....

My 2 cents.

Try not to look at the mx planned by casualty. Clerk the patient without even looking at dx from casualty. Then make your dx and ddx. Then lay up ur plans of mx. Then present it to your MO. then see if he agrees
With you. Only then you'll learn. Thats what the hours are
Meant for you do. If you work like 'operator pengeluaran', doing things without reasoning it; then thats all you shall be.

My 80 cents.

I dont get your rant but i do agree that we dont need any extra hours. Since this is my 5th posting, i got the taste of both on call system and flexihour system and obviously i am for the latter. everything you said about cannulas, blood taking and procedures are probably true for freshman, and often the newbies get told off for being 'incompetent' (what an oxymoron!). for what i believe, newbies being incompetent is absolutely normal. and being at newbie level during your first posting and stays at such during your 5th is no doubt unacceptable. Having said that, being competent takes time, rate of which is different among individuals. Regretfully, this aspect of training is overlooked, hence the unnecessary stress faced by most of us earlier when we joined in the system; the stress of being scrutinised and ?humiliated, and ?shouted at. The reason given as such that we are dealing with patient's welfare and life and short of senior medical attendees to this patient in acute settings make us HO dependable (due to our ?numbers). Ironically, we dont get the respect due to this 'competency' issue. true that a portion of us maybe deemed incompetent, but lack of supervision and dedicated walkthrough, is what makes things stagnant. not only that, lack of self motivation and initiative from us HO is what making the healthcare system looked bleak from our own perspective.
Contrary to what you mentioned;
I interpreted ABG – and came up with possible differentials.
I interpreted CXR - and came up with possible differentials.
I interpreted ECG – and came up with possible differentials.
So when the idea of abolishing oncall system was made aired, i was jolly. SO now i can go to the bank during office hour, i can have a nice breakfast at 8 am in the morning on certain days without the fear of patient collapsing in ward or an infinite line of patient queuing up in the clinic to be seen. When a good friend of mine said, flexihour is going to cut the hour he will be in contact with patient hence exposure, i said YOU WORKAHOLIC BULLSHIT!

there is nothing wrong with the system. Any system at all has its shortcomings. But you plough your own path, initiate. Learn and train yourself. Seek guidance. Be stern and motivated. THINK.

With the influx of medical students now, current situation is, doctor is just another job opportunity. nothing noble about being a doctor, in fact i refused any association of that title to my name. No offence to the senior doctors in existence. i think you guys are obsolete. a goody goody doctor is now a rare breed. we are money making zealots, semua jaga periuk nasi sendiri. Medical degree for show off on the wall.

So fellow HOs, do your job.

When I entered housemanship I forget how to be kind... well people just continue making money..because no use be kind and touchy feely in your one is nice to you anyway..MONEY is nice to you..i used to be very touchy feely about wanna save lives and all but the nature of our system is just some kind of mafia with no make money..and more money money..and fuel ur greed oh DOCTORS..

Housemans they are like the juniors of the system..some of them from totally different system namely the HSE ireland or the Uk takes time to adapt... I entered housemanship with a determination to learn but when I see a total crap bullshit HOD asking me to sit in the toilet, a crazy MO yelling like post natal psychosis.. I began to lose interest in the whole thing... think back superiors..when we juniors first come to YOU giving U 2 Hands to help U out in ur busy U treated US?? .with public humiliation and yelling..and U complaint that houseman are not being NICE to YOU??...we were very nice when we first come to U..and who first started to Carik Pasal? -pastu tuduh juniors tak baik etc...patut superior tunjuka teladan elok...

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