I am a UK graduate and I’ve been working in Malaysia for almost a year. On my first day, I called my MO by her first name (respectfully) to ask her a question, and she did not answer, so I asked again, and she said to me ‘I would like to be addressed as Dr xxx’. For someone who has been calling all doctors, even my consultants in medical school by their first name, how lame that is, I thought. But I’m used to that now. Just because I am addressing them by their title doesn’t mean that I respect them all of them, especially ones who are obviously empty tins. If I disagree with something, I will say it out.
In Malaysia there is this thing that HO should round early in the morning first, then the MO will round again (which we are suppose to follow and write), then again with the reg and the specialist. I have never encountered anything like this where I studied. There is just so much repetition here. What is the problem with everyone just arriving at the same time and then we do ONE single round together? Are consultants too mighty high to be asking questions or examining patients? Yes, the juniors should know and present the cases, but so should the specialists and the consultants. Here, we come at 6:00-6:30am in the morning to see all the patients, then there will be another 2 or 3 rounds with people more senior than us so we can ‘update’ them patient condition so that they are able to add on their own management plan. Most of the specialist/consultant would just stand at the bedside listen to the juniors present, bombard lots of question, dictate some plans then move on, without even saying a word or looking at the patient. Then when the intimidating boss-like figure is finished, the patient would rush to ask me what had he just muttered before I had to rush off to tail ward round. In the UK, junior doctors come half an hour earlier than the consultant to get the investigations results ready and find out if anything happened overnight/over the weekend, then wait for the consultant to turn up to start the round. If it is a non-consultant round, everyone would get on with the round as a team. There is no such thing as HO to see the patients before the reg. There, the registrars, SHO and HO help each other out so they finish their work as quickly as possible. Isn’t that a much more efficient use of everybody’s time? Once, my nice MO was helping me with a particularly difficult IV line, and another MO asked him ‘why are you doing HO’s work?’ You see the attitude? Don’t get me started on the TDS round. Yes, they do rounds three times a day here (in most specialties), sometimes x 3 due to the hierarchical arrangement as I have mentioned above.
The worst part is having to play the servant for MO/reg/specialist/consultants. In my hospital, HOs have to regularly to go the record department to trace files for the reg’s case presentation/ write up. Last week, my friend had to go to my specialist’s car to fetch a stack of photo frames to her office. In departmental census, the HOs does all the data collection (trawling through the case records) not knowing the end results whilst the boss gets to present and publish. We call patient up to inform op date, cancelled op, rearrange op so often I thought we sounded like a professional telephone operator. You can’t blame me for cursing under my breath whilst performing these stupid errants.
In Malaysia, HOs are unappreciated slaves. Everyone, senior and junior figures in the medical profession, should rethink the way we are doing things here. You may say the practice has stood the test of time but is it really worth wasting so many hours for sometimes so unproductive as three morning ward rounds in a day just because of hierarchy? Is it fair to treat HO as your servant doing your secretarial job? Are MO/Reg/Specialist incapable of occasionally helping your new HO make some referrals or write a prescription or ask for a CT scan, or God forbids, take blood? Are we not in the same boat to make patient better? I foresee that it will take another 10-20 years for us to change the culture, if it ever will. The seniors always have their ‘back in those days’ or ‘you have to learn’ excuses
The above comment was posted in my blog by a houseman. I must say that he was right on certain issues that are ingrained into our system. It is a culture here that you must address a senior by the title and not by his/her name. I know that in western countries, you can call a consultant by his/her name but in Malaysia, you will be considered as disrespectful. It is part of the Asian culture and you just to accept it. It will take many more years to come before it chances. It is the same for all Dato’s and Tan Sri’s. When I refuse to address them as Dato so and so when they come to see me as a patient, they will look at me differently but I do not give a damn. It is not a God-given title for me to address them by the title. At least if you are a Professor or something, I will address them as such. Same goes to the community who are so enthusiastic to make their children a doctor by hook or crook just to get the title “Dr” infront of their names.
Let’s come to the ward round system in Malaysian MOH hospitals. The system that the HO is talking about has been around for many years, even when I was a houseman. In fact, even I use to ask the same questions when I was a houseman. It is really a time-wasting situation. That’s the reason when I became a specialist; I made sure that I am in the ward by 8am every morning unless I am stuck in a meeting or jam. I usually walk into the ward around 8am and wait for the houseman to finish taking blood by 8.15am. By 8.15am I will start my rounds and the houseman must join the rounds by then. It is mandatory for them to finish taking blood by then. My idea is always to finish the rounds by 10-11am so that the houseman and medical officers will have all the time to do what that has been ordered.
Then, when I went to a hospital in Klang Valley to do my subspeciality training, I entered the ward at 7.50am and noticed that I was the only one around!! I asked the nurse where the housemen and MOs are; and they smiled at me. It seems the HO comes at 8am, MO comes at 8.30am and the specialist only comes at 9.30am!! WTH!! Sometimes the specialist comes only after the MO/HO has completed the rounds and starts all over again. Of course, the specialist who does a consultant round has all the right to start the round again BUT I always felt that it is counterproductive. By the time they finish the round will be around 12-1pm and you are just left with another 4 hours to settle everything else! Sorry to say but most of the current specialists in government hospitals are in this category. Majority of the good ones have left the service not due to money but due to frustration with the system. No matter what you do, the system will always frustrate you. As someone said: either you join them or leave!
Now, housemen doing office boy’s job? Well, no matter what you become or what job that you do, you always have to start from the bottom, unless you are self-employed. It is common for all profession. Even fresh law graduates have to work as an office boy when they do chambering. There is no such thing as easy way to learn. You have to go through tough times and even be a slave to become a better person in the future. That’s why you are known as government “servants” ! But of course, I think it is atrocious for the specialist to ask the housemen to do the data collection and tracing of notes for something that the consultant is going to publish. If they do so, then the houseman’s name should be included as one of the author. When I was a houseman, the Head of O&G department challenged me to do a study on maternal weight gain during pregnancy for the 3 different races in the hospital. I took up the challenge and completed the study just before I completed my O&G posting, which was my last posting as a houseman. On my last day, I submitted the report to him and he was shocked. He never expected me to do it. The data supposed to be presented at the state scientific meeting but I was transferred before that.
I know that not everyone will be interested in academic life but the houseman should take the opportunity to get involved in the study and learn something. I am sure most specialist or consultants will be happy to welcome you into the group. Having said that, I must admit that most of the good specialists and consultants are not in MOH hospitals anymore. That is the sad part! And also, please remember that no one appreciates you in government service. You will always remain unappreciated. Your job is to serve the community, paid by the government/tax payers. Before 1994, there was no such thing as “oncall” allowance and then we were offered RM20 for every call! pathetic.
Pagalavan's Avatar 
Just feel sad and frustrated when I reading through this article… esp. as a new graduate who is going to work in the government hospital in 2 weeks. I dun mind becoming a “slave” but I want good, proper training to make me become a better doctor. However, from the sound of it, it seems that it is unlikely to get that in the government sector as majority of the good doctors have left the service. T.T
Hi GCG,
Don’t be too despaired. If you wish to work hard and learn, I am sure you can gain a lot of experience. There are still many good doctors in government hospital who are willing to teach. Identify them and learn from them.
Regards,
Guek
Three morning ward rounds? That’s just bloody absurd.
GCG, a good friend once told me: “a diamond will shine no matter where he end’s up”… She told me that in Malay, and she now has a successful career obtained by merit and perseverance in another country.
This culture has to change, and you are going to be the consultant one day… dont let it get to you.
The system should be geared to allow interns/HO’s to grow their medical knowledge:
1) Path/bloods should be done by dedicated pathology nurses who take bloods every morning, leaving HO’s more time to actually take proper histories and do more comprehensive examinations.
2) Ward rounds should be done as a team, with relevant hx and ex presented and management plans discussed…not dictated.
3) Consultants should actively teach/pass-on important mental processes used in making clinical judgments.
The last consultant I was with actually paused in the middle of a discussion regarding pt management with the registrar, turned to me, and said: “You know why XYZ is important right?” and proceeded to explain why the decisions had been made. This happened maybe once or twice every consultant ward round. I got him a bottle of wine as a gesture of my gratitude the day after he sent in my feedback forms (im a student).
Humble, brilliant people will go far in medicine… and you do not have to be an arrogant dick to show that you are smarter than everyone else to treat patients.
This change in culture will no doubt be gradual… and to all those involved: it’s up to you to make changes…no matter how small… to the culture that has existed for ages. Even if you are HO, you could tell others to call you by your first name.
Friend, do not be deceived by such type of ‘kind’ specialist during your time in medical school.
When you are students, they (government specialists) will show you their best face and attitude and you can be friend / brother with them, some of them wanted to be hired by the private medical school before leaving officially.
But once you become his houseman, your hierarchy is the lowest, worse than the student nurses. My friend encountered such kind of specialist / HOD last time. He was the best teaching staff in the medical school but hated most by the houseman and he treated houseman like labor and scolded houseman in front of the patients usually.
Some HOD also come late and asked houseman (who got car) to go fetch his son from the school (dun follow, you will get assessment and risk of repeat posting).
My friend last time got to present the ward cases 5 times everyday.
First to MO in the morning
Second to Ward Specialist (because both come at different time)
Third to HOD (come later after the round)
Fourth to other ward specialist (because during on call, other ward specialist need to know the ward cases)
Fifth to HOD again (who used to come at 11pm) – (why want to present again?, the HOD just walked in and HO presented the case and finished ward work at 11:45pm and had dinner at 12am)
The above not counted ward work, tracing result, observation and others.
I agreed that a phlebotomist should be present. As sometime, houseman need to be ‘order’ by the staff nurse to do work.
(oops, should’ve stated im in Australia atm)
The consultant I spoke of was a genuinely nice guy. I’ve never heard him say anything even remotely nasty to anyone… though my HMO (PGY2) dislikes the number of referrals he requests – he takes time to explain to me, the HMO (and occasionally the reg) why the referrals are made.
“I think we need a haem opinion on old Ms Jane Doe’s anticoagulation after her DVT last week. She’s a wanderer and often refuses bloods so warfarin titration and monitoring would be difficult. She also had a few falls with headstrike and keeps taking off her hip and head protectors due to her dementia (BPSD). In this scenario im not sure given her risk factors … … the OT also said … … … Therefore i think it’s best we liase haematology for an opinion on how to proceed given she is slated for discharge in three days.”
I have never seen him order the HMO or reg to write up a referral request without stating clearly the reasons for it – and discussing the patient with the team.
Should i return in the future (for personal reasons), I will try to do my part in changing the culture in Malaysian hospitals. Meanwhile, got to shine first… *fingers crossed* 7…maybe 8 years?
Private,
You should have picked up that he did not study in Malaysia. Hmph.
MBCrunch – got job already? =D congrats.
Yup =)
Was a close one… but thankfully yeah.
Really cant wait to start working.
Hello everyone we acknowledge the fact that our system is not as good as in UK in some ways. It is very good that Dr Paga and the readers of this column have highlighted problems in our healthcare system – first step forward!. Having done that the next step is to push for reformation which I agree is hard but it is our responsibility to do it. Running away from problems is not the way. I mean migrating to or working in other countries will not solve the problem. I am sure the system in UK & OZ was improvised over the years by their people!. So what we need to do is bring up the healthcare issues to the public in whatever ways and means. Only we can change our system. Bring it up in media I mean websites for the public to know the problem we are facing. Hopefully civil societies and NGOs will pick it up. So that we can move forward and improve working environment and future for our medical professionals and a better health care system for all of us.
Its part of our culture that we address our colleagues by their tiltle, i.e. Dr or prof so and so rather than their first names. I don’t see why we have to adopt the ang mo way to address our colleagues by their first name.
I’m working in one of the tertiary hospitals in Melbourne, and I usually address my bosses by their title and last name, unless they insist that I should call them by their first name. If you are to sit for the postgrad exams (MRCP or FRACP) we were taught to be professional and never address our patients/ colleagues by their first name as well.
Its funny how some people make a big fuss out of it. We are asians and we must not forget our culture and values. I’ve seen some locals here calling their parents/uncle/aunties by their first name, may be I’m too conservative, but thats totally unacceptable. What a disgrace.
5x ward rounds are a bit too much. Well, unfortunately we cant make a change unless we are at the top. Have to work hard and suck it up I guess. Life is unfair.
I would like to return to my tanah air one day. Hopefully things will get better eventually. We’ll see.
I agree with silverfox. Western culture and Asian cultures are significantly different. And don’t look down upon Asian value either. China, Taiwan, Hong Kong and India are sticking it up the PIGS’s (portugal, ireland, greece, spain) ass for our long term-orientation in economy and business.
If the system has never change since the days of Dr. Pagalavan’s HO years, why do you think it will ever change in the future?
Usually it all depends on the consultant of the team. If he’s a good leader and very respectful towards their subordinates. More likely that they will work with mutual respect. Help each other out.
But if you have a very bad team leader, shouting n screaming at his subordinates, more likely you’re gonna work at a hostile environment. And usually, the one at the bottom of the hierarchy receives the worst kind of treatment(HO).
Bad bosses are the norm. Good leaders are hard to come by. Gen Surg teams are the worst.
It’s not about calling people by first name, it’s about the MO’s, registrars & consultants attitude towards each other. Always playing the hide my ass game and blame it on the HO. take credit on others people hard work and generally being the a jerk. Threatening to extends HOs posting, verbally abusing them, even worst lifting their hand as if they’re about to slap you. It can all happen and I had quit.
Now I’m in a better place and will never come back to Malaysia until I’ve become a specialist. perhaps.
So if you’ve never work in public hospitals in Malaysia, you don’t know what you’re talking about. Believe me, it’s true about the worst thing you’ve ever heard.
“It’s not about calling people by first name, it’s about the MO’s, registrars & consultants attitude towards each other. Always playing the hide my ass game and blame it on the HO. take credit on others people hard work and generally being the a jerk. Threatening to extends HOs posting, verbally abusing them, even worst lifting their hand as if they’re about to slap you.”
what you said are indeeed TRUE!!!!!!
they never know because they never experienced.
they treat HO like dog!!!!!!!
I accept taking blood as part of our job, no prob.
Sending bloods to the lab, tracing results from the lab, refer pt to social worker, getting quotations for pt’s flights, measuring TED stockings,etc etc is rubbish la.
I used to think, if one day, all the HO die of depression, we can slot in Indonesian workers to send and trace blood.
and by the way dr paga, i went to work 5.30am sharp every single day, to do my am review. Do u really think it is possible for houseman to review say 10pts in 1 hr.
Yes, of course it is possible. BUT what is important is not how long you spend to review a patient , it is the quality of review that matters.
I agree with both authors, HO as well as Dr Paga. The hierarchy is there, and it has always been. BUT…we are the people of the future! What makes it so difficult to change things? I am a new MO, and having been through the above as a house officer, I try not to put the same burden on my HOs.
I come early to do my rounds, but if they have not finished reviewing the patients, we do it together. And if they’re busy, I do not hesitate to do admission clerkings and draw bloods myself. My colleagues post the same question to me, “Why are you doing the housemen’s work?” I often do not answer to avoid argument about how the training of the current HOs are deteriorating, or how pampered they are now. We are all a team, and as long as the work is done and the patient has benefited from our care, why start calculating who has done more or who has done less? Is it not the patient’s wellbeing that is in question?
As for running errands, well, it is always a tough argument. As long as I don’t need to go out of my way to do something, what is wrong with lending a little help? I’ve been asked to pay my superior’s bills, but I see it as a friend, asking me for a favour. And in return, I am guilty of asking my colleagues for small favours, like sending me to the airport. A little hard work has hurt no one, nor has it hurt your interpersonal relationships. Of course, blatant bullying or taking advantage is a different issue altogether!
Just because we have been through hardships, it doesn’t mean that we need to pass on the same mentality to our juniors. We can still improve on the system, only by working as a team, and not as an individual. A leader can demand for respect, but only a good leader gains it unspoken. It is up to us, the new generation to change the future.
I really like your attitude.
People first…title’s or whatever second.
Professional relationships and your patients.
I have a feeling you will go far in Medicine.
All the best to your future career =)
Well wishes
MB. Crunch.
May God bless u
And…in reply to angchoonseong, pray please be thankful you have ten patients to review and to learn from each day…because from where I come from, the ratio is perhaps ten house officers to one patient! Well that is an exaggeration…but I foresee that happening in the near future. As it is I have already seen 2-3 HOs sharing one patient.
While it is not possible to review 10 patients in an hour, it is also not feasible to take 30 minutes to review a patient. Some address this issue as time management. I call it prioritisation. Kudos to you for coming early to do your reviews, but with the current shift system, the burden has fallen back on your MOs to do most of the work! At least, I do feel so.
change? i doubt anything will change in the next 50 years…. because we are brought up using this tradition. So far i have only seen one department in my hospital that actually have something close to what the HO posted, where if the reviews in the morning is not completed – there isn’t a fuss by the specialist, but the specialists themselves would approach and the review is done together.
Life as a HO in Malaysia is bad. We are worst than dogs, more often we are at the end of the problem… if the nurses is not doing it, we have to do it. If the blood isn’t sent, it is our fault. If the temperature isn’t taken, it is our fault. And we have close to 20 patients shared within 2 – 3 HOs. Not including reviews, carrying out the management, and knowing each of them in and out. What’s worst, when we tell its not our fault, some how or rather it will end up being out fault!
I have accepted our fate. Call for change is good. But there is no one to champion our cause. This is just how sad life is…
I feel its only respectful to call your seniors/colleagues their Titles unless asked otherwise. why do we have to follow the western culture? we are asians we have our own cultures.
and
YES venepuncture, IV line setting, ABG, central lines, intubations, chest tubes other procedures etc r HO’s job!!!! seriously man, what r u on?!!! generally speaking, its part of your training, if u just want to be a clerk only then by all means go ahead, just dont be a Doctor if u just want the title. i dont feel that im being enslaved. so far in my training there’s only some isolated cases where my MO/specialist’s shouts for no reason (i blame special personalities) otherwise it is all done for a reason. and i’ve seen only people who r blind to their own faults and r unwilling to learn who grouches when they r given criticism.
i’ve seen some of my Dr colleagues got angry for being corrected by others Nurses, ward Sisters, Pharmacists etc even if they r in the wrong. Psshhht…oh my R u soo happy u hv title Dr? grow up lerr, your world is too small, your scope is too constricted….go eat healthy serving of humble pie.
HO’s r the frontlines (also part of the training). u learn from experience if u complain too must there will come a time when Malaysia will have doctors who cant draw blood, set iv lines, take ABG, decompress tension pneumothorax, intubate etc…….and later they will progress to become ill-equipped MO’s and so on. this isnt a joke in an emergency resuscitation situation u need these skills!!
~6th poster HO in Sabah
Dear All, RE: Titles
Hmmph, seems like this is quite a controversial issue. Well let me present the view that runs contrary to the mainstream in this thread.
The use of titles promotes an “us vs them” mentality and creates sort of a class barrier to interactions. It’s subtle, but introducing yourself like this: “Hi, my name’s Joe Blogs. Im one of the doctors and i’ll be taking care of you. Just call me Joe” … and like this: “Hi, Im Dr Blogs…” and proceeding to do a hx/ex standing all high and mighty with your white coat and stethescope over a patient. Have you ever put yourself in a patient’s shoes?
I know this is going to sound waaaay idealistic and unrealistic and in a way self depreciating: but at the end of the day being a doctor is not about status or authority… It’s about helping people… and there is no need for a class barrier between doctors and patients (or consultants and interns). There’s nothing wrong with patients seeing doctors as fellow human beings. How do you interact with a fellow human being whom is your equal? well you call each other by first name for a start. That seems to be the norm here in Australia…and most consultants do not even identify themselves as consultants to patients. Respect is earned by merit and by breath of knowledge… and is given where it is due. The removal of the “class barrier” encourages discourse about patient management and genuine teaching goes on in the wards as a result of this.
Some say “It’s culture…“. Well, it’s also culture in india to judge people by cast. It’s also culture to work HO’s like dogs in malaysia. It’s also “asian culture” to spoonfeed. It’s also culture to be subservient (eg. “acting as scribes”) as opposed to being inquisitive and engaging. Yes i agree some HO’s are probably not up to scratch…but it’s not entirely their fault.
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salimah
You guys get to do central lines as first year interns? Jealous…
I’ve not seen anyone more junior than a HMO3 (third year out) pop one in (Melbourne). It’s usually done by the anaesthetic reg.
Pls do not mistake my comment about having a path nurse for bloods. The ratio of interns to patients should be around 1:15-20 IMHO… This allows greater exposure… and having a path nurse saves time for more thorough examinations and histories to be done. It seems to be the system set up in just about all hospitals here.
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angchoonseongSending bloods to the lab, tracing results from the lab, refer pt to social worker, getting quotations for pt’s flights, measuring TED stockings,etc etc is rubbish la.
Sort of agree with this. Much of what you said is the job of allied health. The social worker should ensure a safe discharge once medically cleared…along with whatever benefits the pt is entitled to. While the TED stockings are usually administered by nursing staff. Chasing bloods from the lab is bog standard intern work….and I dont see anything wrong with that.
I’m one of the modern doctors you refer to who goes happily by first name with most of my patients. The ones who steadfastly persist in addressing me by title are typically the elder patients who still hold strongly to traditional values.
Being east asian, I always feel a small sense of irony when a patient twice my age addresses me by title. I say to them that as my elder, it is they who set the terms of address between us.
Believe me, most of them insist on calling us “doctor” not so much out of respect for the person, but for the fact it is a title earned through 5 years of successful medical studies.
Several years ago when I was a specialist registrar in training, one of my consultants took me to task over my choice to go by first name with my patients (something I have done since the day I got my MBChB).
He said, “Your patients are not your friends. The have not come to see you out of a need for social interaction. To them, you are the one who is going to treat their illness. When you choose so casual an address as your first name, it is not only inappropriate to your profession, but you dilute your position of authority. They have come with hope that you have the skills and knowledge to treat them. They have faith that you are an authority in your specialty. Do not deny them that comfort.”
Being that he is not only an excellent Consultant but immensely kind and well liked by his patients, I gave his opinion much greater weight than if it had come from some arrogant sod.
Today, I am a consultant, and unusual amongst my peers for the fact that I run by first name with *everyone* bar those who insist on the title. These include my patients, the domestic attendant on the ward, nursing staff, medical students and trainees of any level. I do not feel that I am any less respected, nor do I believe it makes my patients any less confident in my capacity.
However, I have no major issue with anyone who insists that their medical title is used. They earned it, so IMHO they deserve at least that much respect for that fact – and to me, this applies even if I can’t stand them!
Here in the UK, most consultants will make it a point to identify themselves to patients of their position. Nothing to do with being high and mighty. It’s just that in the UK National Health Service, each patient is allocated to a named consultant with whom all final responsibility and accountability lies. From the moment that person is enters the hospital, final duty of care from inpatient admission, treatment and through to outpatient clinic follow up rests with that specific consultant. Most patients want to know who that person is!!
@MB Crunch: yup we do central lines IJ & subclavian and femoral cath also. but then the workload here is crazy (i’m finishing ED as my last posting in 2 weeks) so of course more exposure. if we have to wait for our anest to set the CVL for resusc, the pts might not make it :p
didn know you cant do central line in melbourne. I am in US as first year any procedure we will get to do it first as long as paatient can tolerate it.
Well, it’s not about not being able to do things like central lines… but in teaching hospitals there will always be an anaeasthetic reg or senior clinician who could do it in place of you.
It’s just like CT/MRI…and all the Xrays with contrast: Interns arent even allowed to order them. CT in particular needs a senior clinician to sign off.
HO is not frontliner but emergency MO/specilist and outpatient doctor. HO is the first line receiving personal from the respective ward. If you have a good frontliner, they will do all the investigation, procedure and pt stabalization before admission. So basically u just take history and trace result only.
If HO need to do blood taking (should be done in ED) and others means that the respective ED is not efficient. In Singapore, eveything will be done in ED like emergency op and each dept will station one respective doctor on call in ED. ED even have their own CT scan, OT, xray machine and CCU. In Malaysia, I think might need another 20 or 30 years.
With the emerging of ED specialist now. I hope they can change the situation. If it happened. I think no need so many HO oncall. I hope I can see it in future.
Hi salimah
Just wondering if i missed something. Did anyone say venepuncture, IV line setting, ABG, central lines, intubations, chest tubes other procedures etc r NOT the HO’s job? (did i miss reading someone’s entry, if i did, i humbly apologise)
Personal opinion: ED dept in Sabah…. teeming with HOs; it use to be a mad house with just MOs about a couple of years back. In the 6 years that I’ve been here…. I’ve noticed alot of ‘interesting’ changes. It’d be great if you managed to do any procedures now.
I think for those of us who value a life in which we can serve people and fulfill our passion (in a humane way!)… start making alternative plans to just sticking it out with the local masters.
Local masters: recipe for depression/ anger/ self destruction and (self)hair pulling. The bureaucracy is ridiculous, the ‘back in the day/ during our time’ speech makes you want to vomit.
Yeah right. Back in the day there was no automobiles, no internet and no fire. wanna go back? Obviously not. Grr
Malaysia = Brain drain. (serious problem)
Jon J “They have come with hope that you have the skills and knowledge to treat them. They have faith that you are an authority in your specialty. Do not deny them that comfort.”
Interesting food for thought =)
I’ve been attached to the ED for the past few weeks, and i cant remember exactly how things went in the wards (what consultants actually say to patients), but I do know that patients sort of figure out who the consultant is, usually by sheer seniority – or the unofficial dress code for consultants – a suit. They are also routinely told “The consultant would see you on tuesday and thursday”… for example. And he/she’s the extra person on the ward rounds that day.
Either way, it’s always reassuring that someone of authority is looking after you.
M.B. Crunch “patients sort of figure out who the consultant is, usually by sheer seniority”
For the male consultants, it’s pretty obvious from their grey hair or (lack thereof!). For the females, dowdy dress sense in all likelihood!
i’ve been through 5 postings, for me we really can’t change the enviroment. but i’ve seen few new generation of MO trying to change all of this stupid environment. They really want to teach the HO, no unncessary scolding. But, having said that, it’s all depend on your HOD. What i can concude that, if your HOD is really nice consultant, and the department will be really peaceful and you can enjoy your work. But if your HOD is really bad, always cursing the HO, and the department will be in bad shape. Even, 1 of my HOD said that, she like to be an evil consultant. Bad attitude.
exactly, but that is missing!
Personally, I do feel that it is up to the person to decide he/she wants to be addressed by their first name or their title. I don’t see anything wrong with both as long as the person is happy and comfortable with the name.
It is just like whenever we approach a patient, we will ask them how they want us to address them….. whether Mr. Tan or Ah Bing (1st name). As long as, the patients are comfortable and happy with the name we address them.
I believe the same should be applied to doctor too.
In the end, it is the inter-person relationship that matters the most (patient-doctor or doctor-other healthcare professionals).
In the end, it is the inter-person relationship that matters the most (patient-doctor or doctor-other healthcare professionals).
^ Couldnt agree more.
Everyone who graduates from medical school needs to realize that they possess only very limited skills in payment management in real life. Things like history taking, physical examination, differential diagnosis, suggested management can be learnt from books and 3hour long case conferences. But in real life, we never have 3hours of talking and debating one single case. Medical graduates must realize that upon graduation-there are a million things they need to do, to learn how to do, to learn how not to do, and to learn when not to do it. You must see yourself as a brand new very large insatiable sponge waiting to absorb as much information and knowledge and wisdom as possible; medical graduates must get away from a very limited dependent mindset, where things have to be taught TO them. They must take ownership of their postgraduate medical education and training, decide what you want to do (make sure your plan is sound in the first place), plan it and seek measures to cover anticipated gaps in the training. You have to be proactive. You cannot expect postgraduate (and to a great extent undergraduate) training to be similar to didactic spoon feeding. This attitude extents to your working life training as a doctor. You need the necessary exposure in terms of case loads. The more you see, assist and do, the faster you will learn and train. This unavoidably means working very hard, working very long hours, working under pressure, having not enough sleep, not having weekends off for leisure activities, etc. One of the blog entries from someone who graduated from the UK deplored the range of “menial chores” to do ie blood taking, setting up of iv lines, getting blood from the lab, tracing blood results, etc stating that nurses can and should do these jobs. Blood taking and setting up iv lines are invaluable and essential skills all doctors should possess. if you are not involved directly in the actual process of ordering and checking and obtaining blood from the blood bank, how would you know the details of the process? Is this important? If you think this is not, you need to take a good hard look at yourself to really reexamine whether you are in the right profession. I have worked in Malaysia, UK and hong kong as a junior and senior doctor and I am not impressed by the work attitude and ethos of young doctors in the UK- too much work, not enough time off. no rest. no weekends off, too busy, rude seniors, bad hospital food, too many patients, etc . The list of complaints go on and on…….. and to top it all- not enough pay!! Housemanship is difficult, tiring, poorly paid, very busy, very demanding, requires a lot of sacrifice. Yes to all and it should be, because it is period of intensive clinical learning and skill acquisition. The more you see and do and get yourself involved in, the faster you will realize the importance of these skills. Having not enough sleep and having to work long hours is something you have to experience , to learn how to cope with. Why are repeated wardrounds important? A houseman must know all his/her patients in and out- and how do you do that? Answer: by doing ward rounds on your own before the seniors arrive! You must take ownership of your patients and actively participate in management decisions. You will undoubtedly be scolded, ridiculed and derided by seniors along the way, but if you look at the big picture- if you say to yourself: I want to learn as much as I can for my patients and for my own training, all these distractions become more bearable.
I disagree with doing wardrounds as a house officer before your senior arrives simply to know your patients in and out. When I was a house officer, I did not do rounds before senior arrive, yet I still know my patients in and out. There are more efficient ways of doing this than spending hours doing needless repeated wardrounds with little time to carry out other jobs. In fact, on days when there were consultant wardrounds, we didn’t even bother to do wardrounds before the consultant arrives. This is the epitome of team working, i.e. senior clinicians make decisions on overall patient managements supported by input and early management by junior doctors.
As far as blood taking, setting up iv lines etc are concerned, house officers should be expected to be proficient in these before they finish med school, not when they are doing the job. I appreciate that this doesn’t happen in Malaysia, but there is no difference between taking 1000 blood samples and 100000 blood samples. Of course, it takes 1000 blood samples to make a doctor good in taking blood. Once a junior doctor is competent in these procedures, there is no need to further make it as part of the daily chores. Otherwise, we will be asking consultants to take bloods.
Exposure to case load is only useful if junior doctors actually learn something from it. There is really no point asking a junior doctor to see 1000 cases of MI when he will diagnose the 1001st patient with STEMI and discharge that patient on tramadol.
While scolding etc is one way of teaching, I do not think that it is the only way to teach. There are more friendly and efficient methods of teaching junior doctors. Just because you have gone through that system doesn’t make it the only system that works. I have also gone through both the Malaysian and UK systems, and I do appreciate that both have their own limitations. I agree that housemanship is an intense period of training and requires some lifestyle sacrifices, but such sacrifices are only worth it if you are actually gaining something from it.
“As far as blood taking, setting up iv lines etc are concerned, house officers should be expected to be proficient in these before they finish med school,”
– Bloods are easy. As a last resort you could hit them with a butterfly and syringe..and it’s pretty impossible to miss, even on the most difficult patients. IV’s on the other hand can be very very very hard. I’ve never cannulated a kid under 5. Not with a 25g. That’s when the senior reg’es and consultants shine. And of course sometimes you just get fat people with veins that dont exist, not even in the CF… ok im exaggerating but what im saying is that it can be bloody hard to pop a drip in sometimes.
I agree that it can be sometimes very difficult to get vascular access, that is when people like me come in with the ultrasound machine. But my point being when a med student finish MBBS, he/she should be expected to have performed a few hundred IV cannulas. By which time, that person should be relatively good at it. HOs should not be starting their jobs trying to put a cannula from elbow aiming towards hand, I have seen such HOs.
Unfortunately, many of the medical grads nowadays do not know how to set branullas. Some unis just need them to practise to insert 1-2 branullas before they graduate!! So, if the students do not take his own initiative, they will land up like what you described.
Anyone has tried out the system in which housemen, medical officers and specialists doing ward round together? If this is the case, i think a specialist will prefer to read the case note, take the history and examine patients by himself since HO & MO have no idea about the patients at all.
In Malaysia, a specialist usually need to review all patients in the ward (up to 40 patients). Would there be enough time to teach?
Whom the Phlebotomist approach for help if they can’t get line or blood? If a houseman doesn’t practice setting brannula and taking blood, would they be able to perform in the future?
This is standard practice in Melbourne. It does work.
The consultant is ultimately responsible for the patient, but interns and hmo’s also share blame if anything goes wrong. Consultants typically come by two-three times a week depending on the ward. Otherwise, a registrar will be with the team.
Many places have policies regarding IV’s…cant get it twice, let someone else do it… until someone eventually does.
HMO’s and interns typically look after roughly 10-20 patients each in the wards. Bloods and IV’s are done by nursing, and you only get called after they have failed two attempts – so yeah, you get all the REALLY HARD ones. I’ve been in a hospital where nurses will write on a board what patients need IV’s (ie. the nurses cant get one in after two tries). I wont lie to you: I failed miserably taking up the challenge… for quite awhile I might add. I suppose interns will eventually learn how to do it properly in such a scenario.
My round always finish at 12 pm, than to finish what been ordered, as well to complete the discharge may take times.. Most often, patient complain why going back late, since we would only able to complete the discharge form at 4 pm. Than without any pity, our MO usu ask us to continue the round at 2 pm , even though much of our job has not yet completed. Patient has to be waited, since their discharge form has not completed
Than we have ridicilous summary discharge to be completed which is just newly introduced in my hosp. We have to summarize everything from A to Z.
The thing i dont understand, why the need to do tds rounds? In my experience, in many rounds i made, only very small number needs attention in my tds round. Not only that, we start our tds at 6.30 pm, and our pm round usu finish at 4 pm. Do u really thing there is acute change with the patient within this short period. I dont mind doing tds round, but lets the round focus only on patient that may need our attention or acute case…like ectopic pregnancy..etc. Why we need to do round on patient, example like stable patient, like rape case, or patient who just comes in with bartholin abscess
TDS rounds = three times better healthcare
hey it does kinda make sense
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Yes, I do not agree with multiple rounds as well. I use to argue with my HOD about this(when I was a senior MO and specialist). TDS should be done on patients who need close monitoring and those where changes need to be made depending on their progress like DKA etc. No point seeing a patient and just keep writing “con’t same”!! Quantity does not equate to quality.
I have had situations where i started rounds latest at 615 am bse my ward consultant starts d rounds at latest 645. but i do d rounds with him. no MO. i enjoyed it bse i was treated and trained to think like an MO.
At the same time i have the TDS morning rounds situation as well. so i used it to my advantage. after mo rounds while waiting for d pakar/consultant to come i did all d paperwork, ie discharge summary. Bse half d time ur mo plan wil b, KIV discharge after r/v by specialist. So why waste time,instead of hoarding at nurse’s cabin chatting away when u can do all dis paperwork in the mean time. There is always short comings in every system, but its up to you and you alone to make a difference.
I remembered one of my old consultant. He used to start his rounds by 630 so dat he could start his OT at 8am sharp. Another guy, was d HOD, he starts his rounds abt 530 am. He does it with the oncall team. d main reason is so dat he can start his clinic at 8am sharp. bse many of d patients come from a far, taking atleast 2 buses for the to get to the clinic. d way he looks at it, why must all d pts suffer by me startin clinic late, when all i need to do is just to get an hour earlier. dis is wat i called as dedication.
hello doctor paga..hope u r doing well…
actually i wud like tu ask a few questions and i apologize if my questions are not realted with this entry…
1.what’s ur opinion about the major influx of HO into medical field…is this news just a hypothesis or it’ll happen for real in da future??can u estimate what year the ratio doctor and patient will be enough??does the influx will cause any negative impact on us(the future HO) like small salary or no enough placement??
2.About the application of postgraduate doctor,what is ur advice on how to get a placement in postgraduate studies as soon as possible…is our undergraduate result will be evaluated as well in the postgraduate application??if not,then some might think they dont have to get really high degree in undergraduate studies as it will not be evaluated in the postgraduate application..
thank you doctor for your explanation pertaining these issues..
Yes, it is true and it has already started. By 2016, there will be surplus of doctors.
I think you should go throu all my post since last year to know more about your questions. All has been answered before.
Dear Doctor Pagalavan,
Thank you for putting up a blog/a channel which we can learn much more information regarding the field of medicine/the real life of doctor, and it is a channel for doctors from the whole country to share their experience/opinion among each other.
I am a purely Malaysia “product”, graduate from Local university, going through Housemanship in one of the district hospital with specialist ( General hospital perhaps), now as a new medical officer in one of the district hospital. So, honestly, i dunno how is the medical system overseas, i guess i did not believe it would be like what i see in TV programme like ER/HOUSE.
In Malaysia, i guess we call them by title because we respect them as our superiors,i used to it, i have no problem with that.I dun really mind about this small title in front of your name, if u are a lousy boss, it doesn’t mean that i call u by MR/Boss mean that i respect you. I had encounter some surgeon in my hospital, which you had to call them by MR, not doctor, they admit that they are a bit arrogant, MR means that they are not ordinary doctor, they have the license to cut, doctor don’t have. Some will prefer you call them by boss.
Maybe the system of consultant/MO/HO doing rounds together works in overseas, but not in aAlaysia. As a HO, u know in and out of a patient, carry task/order, so it is fine for you to do round together with superior. But HO now, if follow this system, they will have no idea about the patient if they did not do rounds, which happen nowadays with the shift system. End up with consultant know in and out of a patient which they always used to be, but the HO totally clueless about the patient.
I take an example which happen recently,now, shift system start at 7am, so HO will come at 7am sharp, which the specialist will come at about 7am as well, doing rounds together with MO and HO, but after the round seems like HO totally clueless about the patient, when specialist come for PM round at 2pm, after finished her busy outpatient clinic and short lunch, she just want to test whether HO learn something about a patient, too bad , none of the HO able to present the case since they do not know the patient at all. Sometimes, they didn’t even carry the order which made in the morning, like taking blood /tracing blood culture,the reason is basically they don’t know the case, forgot some order. Imagine, if you know patient A had dengue fever, surely you will remember what is his latest platelet, haematocrit, it wont be until MO/specialist doing round at 2pm, realizing that morning full blood count was not yet been taken. You will find your HO sitting at counter, chit chat and laugh at the counter after the morning round at 9am, going morning tea at 10am, lunch at 12pm without even bother to clerk patient, knowing some more history from patient. If u cannot remember everything during with consultant round, please take your own time to learn it. As a fresh HO, i was unable to memorize the whole ward 40 patients history in and out, but you will learn it gradually by experience. I guest if no HO round/clerking, then it will turn out to have poor quality MO in future.
Not all medical school allow blood taking as training. Most of the have their first one during housemanship. If they have phlebotomist to do that for them, they wont have the skill learn. They need training to pick up signs and clerk patient to come to a diagnosis. Some of the Houseman, cannot take a history, their history of presenting illness just had 3 lines: fever, cough and diarrhoea. Full stop.Physical examination skill – lacking, cant picked up cyanosis, silent chest, Management wise, dunno what is a face mask oxygen. I just don’t want to mention which medical school they graduate from since it had been mention before in Doctor Pagalavan’s blog before.
So, i guess it is good when housemanship training is more, i used to come at 6am to do round, then 7am with my consultant/MO, but i learn to formulate a diagnosis, try to make a plan, later re-confirm by my superior that my plan works.
Hierarchy is a very common in Hospitals. As a matter of fact, it all started in Med school. It was a shock to me when I first heard this from a friend of mine in one of the ( I would say )reputable public U. As you’ve heard before, new students would have to undergo a programme called ” orientation” when they first step their foot inside the local gov University. During this orientation , these freshman would be terribly ” orientated ” by seniors in med school. For example, in one of the most reputable public U in Malaysia, 1st year freshman would be ” oriented ” by 2nd year, 3rd year, 4th year and 5th years seniors respectively. I would rather call this as bully than ” orientation ” . During this period of 1 month, the freshman would be asked to perform some stupid task like , singing , dancing infront of public, carrying around a egg and make sure that egg does not break if not you’ll be carrying around a coconut. What is the point of doing all these things?
Alex
THis is very common in any university including foreign university. It is a way for the seniors to get to know you. You must understand that they will remain your senior throughout your career. As long as they do not touch or hurt you, it should be OK.
well Alex, it might surprise you as these ‘Ragging’ if it’s not too extreme will help to cultivate a good relationship with the senior.Although there are certain senior that have bad intention, I still stand for what I say.