Response To : Housemen Need The Hours

Salam

This is a response to a letter by Dr Johan Ariff Juhari to The Star, published on 17th December 2011.

I praise the positive attitude to learn, shown by young doctors like Dr Johan. But I believe that as a house officer in his first posting, it is too early for him to make a fair judgement on our training system in Malaysia. What more in Orthopaedic Department, my colleagues would agree that his view doesn't reflect the reality on the ground.

We young doctors who demand changes are wrongly portrayed as pampered with bad attitude, due to unfair selective descriptions perpetuated in the media. On our talk with Dato' Dr Hassan, our current Director General of Health, I as a sixth poster house officer at that time, urged him to make the change to the system, even though there were people who were against it, especially the senior doctors. We would like to thank him for his courage to enforce the shift system.

We believe that the sudden influx of young doctors is compensated with the introduction of a longer 2-years housemanship training programme comprising of 4 months stints in six departments. These experiences have made us a more all-rounded young doctors. Senior housemen are more calm in handling emergencies and more well trained in doing manipulations such as rapid sequence intubation(RSI) than a minority of senior doctors, in my observance.

Not belittling the importance of exposure to patients, we have observed senior doctors, handling pediatric or pregnant patients, who had not had experience working in Pediatric or Obsteric & Gynecology departments, within the previous 1-year housemanship training programme. We as senior housemen sometimes do feel that we are in a better position to manage these patients.

Young doctors hope that we stopped looking at patients as mere 'intermediary' for training, but rather their health and rights as the central pillars of our healthcare system. We need to admit and remind ourselves that overworked doctors especially trainee doctors are hazardous to patients.

Rather than defending the status quo, I urge my fellow colleagues to use that extra hours to sharpen and deepen their knowledge to what they had learnt during their working hours. This is a change to a routine work-exhausted-home-sleep-work daily cycle.

As my colleagues who worked in university hospitals, where housemen intake are less and work are more, said, "I just do the work, but sometimes I do not have the time to learn what I am doing."

With the new shift system, we hope our fellow generation of doctors would strive and push themselves to become better doctors than the previous generation in terms of knowledge, skills, ethics and profesionalism.

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Patient's Story 1:Pak Cik's train..

As doctors,we spend a lot of time talking to patients and some of them have such interesting stories and habits that made them more memorable than the usual "cough and cold"

I have the habit of telling the most memorable ones to my wife during our long commute to Kuala Balah and one day she said"I think you should write them"

So here goes,it may be nothing to others,they may not learn anything from this..but I think..should write this..

Pak cik's train...

When I was in my medical posting, I was attached for a few months at hospital Kuala Krai along with two buddies of mine.

Our usual workday consist of doing rounds in the ward,with the MOs or specialist,doing the chores they ordered,then going down to the clinic to see outpatients.

There I met an interesting patient,a pakcik with heart problems and was admitted to our hospital a few months before.

He lives in a rural village deep in Gua Musang and the only way he can come for follow ups is by a train after trekking for a few kilometers from his village.

The problem was that the train will go through his village only in the morning and later in the evening.

If he takes the morning train,he would arrive near midday to the station in Kuala Krai and after taking the bus/taxi to the hospital he'd arrive at noon,when the clinic was already closed(we only open till 1 pm).

So, still keen for our follow up,he decided that the best way was to take the evening train 1 day before his date,spend the night on the hard aluminium couch in the waiting area of the clinic(he can't afford accommodations and have no relatives in Kuala Krai)!

He never complained and in the end we only noticed what he was doing after a few follow ups...

Some of us collected money to help him with the commute even though he never asked for it.

A few months ago,I met a friend still working in Kuala Krai and asked her about the pakcik,she told me that they now made an exception just for him,the doctors will see him at 3-4pm so that he can catch up his both of his trains...no more sleeping on the couch

So busy doctors out there..You may be tired with a throbbing headache from the sleepless night before,but remember when a patient comes to you,he may be spending the cold night on the couch spending rm40 for the trip while he makes only rm5 perday...ask him..

Wallahualam

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Kebahagiaan Doktor Di Tangan Anda

Semua jadi teruja. Ada kaki yang menari mengetuk lantai. Ada tangan kiri dan kanan saling berpaut. Ada yang mulut terkumat-kamit membaca sesuatu. Ada yang tersenyum seorang diri. Ada juga yang termenung.

Saya pula memang tidak senang duduk sejak tadi. Kaki dan tangan tidak seirama. Berdebar-debar menanti nama dipanggil.

“Doktor Yuliana.”

Terus saya bangun dari kerusi dan bergerak beberapa langkah ke hadapan. Sampul surat berwarna putih itu saya ambil dengan kedua belah tangan dan digenggam erat di sisi kanan tubuh. Sesampai di tempat duduk, semua sudah riuh. Saya terpinga-pinga.

“Yu, sampul surat putih ini kualiti murah. Boleh tembus dalam.”

“Ha?” Saya menyahut dengan kening terangkat.

Seawal tadi pihak urusetia program induksi ini telah memberi amaran supaya membuka surat tawaran penempatan bekerja setelah selesai semua nama dipanggil. Tetapi nampaknya kemampuan berfikir di luar kotak oleh sesetengah pegawai pergigian yang baru dilantik ini sedikit sebanyak mencacat keterujaan.

Saya memandang sampul putih itu. Tersenyum melihat nama di depan beserta alamat rumah. Nafas ditarik dalam sambil mata tertutup kemas, mulut saya berbisik,

“Akhirnya.”

Lantas sampul surat putih itu diangkat tinggi melepasi kepala. Cuba dihalakan ke arah lampu terang di siling dewan ini.

“Aish, tak nampak pun!”

Sampul itu diletak kembali ke atas meja. Suara-suara keterujaan rakan-rakan semakin menjadi-jadi. Saya sedikit tidak tentu arah. Hendak buka tidak diberi kebenaran. Arahan itu dihormati. Perlahan-lahan saya menekan sampul putih itu dan tertembuslah tulisan yang lebih 2 bulan saya nantikan.

***

Keesokan paginya. sekali lagi saya menerima sampul putih. Kali ini keterujaannya sedikit berbeza. Kali ini tiada pula amaran untuk tidak membukanya. Namun, saya berasa cukup berat hati untuk melihat isi kandungan di dalam. Dengan kalimah doa, akhirnya terteralah ayat-ayat yang tidak dinanti-nantikan.

TUAN/PUAN,

DENGAN DUKACITANYA DIMAKLUMKAN RAYUAN ANDA TIDAK DITERIMA.

Penyataan ini cukup menerangkan segala isi kandungan surat tersebut. Saya tidak mampu menatap keseluruhan isi surat. Titik demi titik air membasahi pipi dan bertambah deras dengan perasaan yang berkecamuk. Mata menjadi kabur dan segala hiruk pikuk dalam dewan diabaikan. Kawan-kawan mendekati dan memberi pelukan semangat, beserta kata-kata pemangkin untuk jiwa yang lemah. 

Hanya satu perkara yang menekan saya daripada untuk terus berfikiran positif dan menerima ketentuan Allah dengan redha.

Keluarga.

***

Pagi berganti petang, petang berganti malam, malam berganti pagi membawa kepada putaran masa yang tidak pernah berhenti meninggalkan kita. Ia diibaratkan sebagai nyawa kerana terlalu berharganya masa itu kepada kehidupan seseorang bernama manusia.

Sudah hampir setengah tahun saya di sini. Sudah 5 bulan, sudah 20 minggu, sudah 140 hari, sudah 3360 jam, sudah 201 600 minit dan sudah 12 096 000 saat.

Kinek tok, kamek udah pande kelakar Melayu Saghawak! (Sekarang ini, saya sudah pandai berbahasa Melayu Sarawak!)

Makna kata, benih yang baik jika ditaburkan di tanah yang bukan kebiasaannya pun dengan keizinan Allah pasti boleh tumbuh dengan baik. Semuanya terletak atas diri kita. Bak kata pepatah melayu, masuk kandang kambing, mengembek. Masuk kandang harimau, mengaum. Itulah adaptasi yang kita perlu lalui. Jika tidak sekarang, mungkin suatu masa nanti.

Jika dahulu air mata menjadi pengiring kepada sebuah perjuangan di perantauan, kini tiada setitis pun yang jatuh di kepulauan borneo ini. Tidak setitis pun sejak kali pertama kaki saya menjejakkan di sini pada Julai 2011.

Menyorot perjalanan kehidupan kita, semuanya mempunyai kisah yang berbeza. Kisah-kisah ini wajar diteladani untuk manfaat bersama. Memang pada awalnya negeri ini tiada langsung dalam senarai penempatan bekerja yang saya idam-idamkan. Memang ia jauh. Sejauh beribu kilometer dari kampung halaman.

Tahukah anda bahawa Sarawak adalah negeri terbesar di Malaysia juga pulau ketiga terbesar di dunia yang mempunyai kepadatan penduduk lebih 2 juta di atas tanah seluas 124,449.51 kilometer persegi? Tahukah anda bahawa Sarawak mempunyai lebih daripada 26 kumpulan etnik termasuklah Iban, Cina, Melayu, Bidayuh, Melanau, Kayan, Kenyah, Lun, Bawang, Penan, Kelabit, Kedayan, Bisaya, Berawan, Lahanan, Sekapan, Kejaman, Punan, Baketan, Ukit, Sihan, Tagal, Tabun, Saban, Lisum dan Longkiput?

Saya tidak dicampakkan di sebuah pulau yang terasing. Sebaliknya saya ditempatkan di sebuah pulau pelbagai etnik yang tidak terdapat di mana-mana negeri di semenanjung!

Allah ada mengingatkan orang yang bersyukur kepada Allah akan diberi nikmat yang berganda-ganda. Orang yang rugi adalah orang yang tidak tahu bersyukur dan menganggap setiap sesuatu yang berlaku adalah musibah yang menjejaskan keharmonian kehidupan mereka. Sebagai hambaNya yang serba daif siapalah kita untuk mengandaikan bahawa kita tahu nasib kita di masa hadapan. Dia tentu lebih tahu.

"Jika kamu bersyukur maka Aku (Tuhan) akan menambah (nikmat) itu kepada kamu.” (Ibrahim:7)

“Boleh jadi kamu benci kepada sesuatu padahal ia baik bagi kamu, dan boleh jadi kamu suka kepada sesuatu padahal ia buruk bagi kamu. Dan (ingatlah), Allah jualah Yang mengetahui (semuanya itu), sedang kamu tidak mengetahuinya.” (Albaqarah:216)

Justeru, selaku pekerja di bidang profesional, kita perlu sedia maklum bahawa ilmu yang kita timba selama bertahun-tahun perlu sedia dipraktikkan dan berkhidmat dengan mana-mana hospital atau klinik di seantero Malaysia. Anda perlu bersedia untuk dihantar kemana-mana sahaja di kawasan-kawasan yang kekurangan pegawai perubatan dan pergigian terutamanya Sabah dan Sarawak dengan masing-masing memiliki nisbah 1:2248 dan 1:1709 untuk pegawai perubatan(1). Bagi pegawai pergigian bilangannya agak kritikal iaitu Sarawak kekurangan 50% tenaga profesional(2) ini manakala Sabah memiliki nisbah yang besar iaitu 1:20,000 berbanding 1:7000 seperti yang disasarkan(3).

Saya sendiri melihat betapa ramai sahabat-sahabat saya di bidang perubatan mahupun pergigian tidak dapat berkhidmat di tempat yang mereka inginkan. Ada yang membuat rayuan sehingga sanggup tidak berkhidmat lebih 2 bulan kerana menanti keputusan rayuan oleh Kementerian Kesihatan Malaysia.

Ini baru cubaan pertama untuk kita yang baru mula bekerja, belum lagi yang lain-lain. Cubaan penempatan yang sebenarnya patut lebih mudah kita hadapi bagi seorang pelajar di bidang perubatan dan pergigian jika hendak dibandingkan dengan pelbagai cabaran yang telah kita harungi semasa belajar dahulu.

Andalah yang memilih untuk menjadi bahagia. Anda ialah bakal doktor ataupun sudah bergelar doktor. Kebahagiaan doktor di tangan anda.

Bahagia hanya untuk anda yang redha.

Doktor Yuliana kini berkhidmat sebagai doktor gigi di Hospital Umum Sarawak.

Rujukan:

1. http://www.mstar.com.my/cerita.asp?sec=mstar_berita&file=/2010/4/23/mstar_berita/20100423143752
2. http://www.bernama.com/bernama/v3/bm/news_lite.php?id=496663
3. http://www.utusan.com.my/utusan/info.asp?y=2010&dt=0427&pub=Utusan_Malaysia&sec=Sabah_%26_Sarawak&pg=wb_05.htm

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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

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Kenapa Nak Jadi Doktor?

"Kenapa nak jadi doktor?" Rasanya itu soalan skema, skrip standard mana-mana tempat dalam Malaysia.

Serasa sejak sekolah rendah, kalau disuarakan yang cita-cita hati nak jadi doktor, mesti soalan "kenapa?" menyusul.

Kalau zaman muda, berhingus dulu, pastilah jawapan sebegini yang keluar.

"Saya nak tolong orang yang dalam kesusahan."

"Saya nak jadi kaya."

"Doktor disanjung masyarakat."

Kalau kini soalan itu ditanya pada rakan-rakan pelajar perubatan, skema jawapannya masih sama. Cuma ada tambahan, mungkin.

"Mak ayah suruh."

"Saya minat biologi, Tak pandai matematik."

tak kurang yang menjawab " im born to be a doctor. WOW!"

Walau apapun sebab luaran anda, pastikan sebab dalam anda kukuh


Kerana bidang perubatan tak seindah yang kita nampak secara lahiriah atau superficial macam dalam drama atau filem.

Kata professor saya, tak cukup sekadar hasrat nak membantu orang. "Bagaimana nak membantu orang, kalau diri kamu sendiri kelak tidak terbantu?"

"Kamu bersengkang mata, tak cukup tidur. Kena herdik dengan pesakit, kena marah dengan doktor pakar lagi. Staf tarik muka dengan kamu, betul kamu rasa niat kamu nak 'membantu manusia lain;' itu dapat menyelamatkan kamu? Keluarga kamu terabai, makan pakai suami entah terjaga entah tidak? Betul kamu jadi doktor hanya atas sebab mahu tolong orang, disanjung, atau kaya?"

Professor senyum sinis, pelajar-pelajar perubatan yang mendengarnya ada yang termenung panjang, ada yang tersipu-sipu. Tak kurang ada yang mencebikkan muka.

Jadilah apapun yang kamu mahu. Jadikanlah ia kerana Allah, kerana agamamu.


Lalu professor itu tersenyum lagi. Diajaknya semua pelajarnya berfikir.

"Ayuh kita betulkan niat."

Dalam hidup kita, akan ada banyak perubahan. Contoh senang.
Tahun ni kita suka makan kuih cara, tahun depan mungkin kuih lapis pula.

Bagaimana minat kita boleh berubah, jadi jangan disandarkan pilihan kita pada minat semata-mata. Minat boleh berubah. Pada bila-bila masa. Teguhkan minat dengan niat.

Pekerjaan ini merupakan satu ibadah. Ya, menjadi doktor satu ibadah, menjadi tukang kebun juga ibadah, menjadi pekerja kantin juga ibadah. Betulkan niat anda.

Jom! ^_^

Dr dah ramai, dr muslim, belum ramai lagi. - Konvo UiTM 2011

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