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I need to change for the betterment of our House Officers, will you?

These are the humble personal opinions of a fellow Medical Officer.

There has been a worrying trend in our daily practice in recent years:

1. Whenever House Officers are unable to take proper medical history, Medical Officers will take over the clerking completely.

2. Whenever House Officers are unable to perform proper physical examination, Medical Officers will take over completely and examine the patients.

3. Whenever House Officers are unable to come up with sensible possible diagnoses, Medical Officers will take over completely and make all the justified diagnoses.

4. Whenever House Officers are unable to plan for the necessary investigations and management, Medical Officers will take over completely and make all the decisions.

5. Whenever House Officers are unable to perform the blood-taking or branula insertion, Medical Officers will take over completely and get the jobs done.

6. Whenever there are basic, life-saving procedures to be performed, House Officers are not there to perform, assist nor even observe because Medical Officers will perform and assist each others in getting the jobs done.

7. Whenever House Officers are clueless in handling daily issues and common emergencies in the wards, Medical Officers will take over completely and get things done.

8. Whenever House Officers are unable to make proper referrals to other teams, Medical Officers will take over the call completely and make those referrals.

9. Whenever House Officers are unable to present their own designated patients during ward round due to various reasons, Medical Officers will take over completely and present all the patients to Consultants and Specialists.

10. Whenever House Officers are unable to prepare formal letters and discharge documents, Medical Officers will take over completely and write all the letters and documents.

11. Whenever House Officers are (allegedly) unable to cope with frequent on-calls, Medical Officers will do more on-calls or night shifts to be the acting House Officers on-call.

12. Whenever House Officers complain, the superiors will always have to entertain them, satisfy them and fulfil their requests. Medical Officers can take over completely and do all the ward work anyway with or without House Officers.

13. Whenever House Officers present attitude issues, the superiors will always have to give in and provide TLC (tender loving care).

Whenever House Officers are unable to perform or carry out certain works, Medical Officers will have to take over and get them done, with or without orders from Specialists, all in the name of ‘service-first’.

Some of these undertrained House Officers and those with limited competency and attitude issues have become the current junior Medical Officers. Most did not improve drastically nor transform completely overnight. The title, the status might have changed but not their capability and attitude.

Another worrying trend

Therefore, there has been another worrying trend in recent months and likely for the years to come:

1. Whenever Medical Officers are unable to take proper medical history, Specialists will have to take over the clerking completely.

2. Whenever Medical Officers are unable to perform proper physical examination, Specialists will have to take over completely and examine the patients.

3. Whenever Medical Officers are unable to come up with sensible possible diagnoses, Specialists will have to take over completely and make all the justified diagnoses.

4. Whenever Medical Officers are unable to plan for the necessary investigations and management, Specialists will have to take over completely and make all the decisions.

5. Whenever there are basic, life-saving procedures to be performed, Medical Officers are unable to perform or even attempt because they haven’t learnt them during Housemanship. Specialists who oversee multiple wards, especially during weekends and on-call, will have to perform those basic procedures without much help from the Medical Officers nor House Officers.

6. Whenever Medical Officers are unable to handle daily issues and common emergencies in the wards, Specialists will have to take over completely and get things done.

7. Whenever Medical Officers are unable to present their own designated patients during ward round due to various reasons, unable to pick up or troubleshoot issues, Specialists will have to flip through the notes themselves, clerk and examine every patient themselves during ward round without much input from Medical Officers nor House Officers.

8. Whenever Medical Officers are (allegedly) unable to cope with night shifts or on-calls, the more senior Medical Officers will have to do more to cover for the juniors.

9. Whenever Medical Officers complain, the superiors will have to entertain them, try to satisfy them and fulfil their requests. The more senior Medical Officers can always take over the juniors’ burden completely whenever necessary.

10. Whenever junior Medical Officers present ‘attitude issues’, the superiors will always have to give in and provide TLC (tender loving care).

With these current circumstances, House Officers are rendered even more irrelevant and insignificant in the team.

Mismatch

When junior doctors are not adequately trained, there will be a mismatch in their responsibility and capability. This mismatch will then incur stress that burden them excessively and cripple them in daily work.

Moreover they might be making more mistakes in carrying out the daily tasks or duty which they should have (but unfortunately did not) mastered well during their Housemanship training. This in turn will deprive them of personal satisfaction in the profession. Worse still, they might be depressed, disheartened, making even more mistakes. Being caught in this vicious cycle and spiralling downward, some ended up committing suicide.

Meanwhile, this upward shift of job scope and shares of burden can potentially disrupt the equilibrium of the whole team at every level. The superiors and senior doctors will have much more works to tend to, thus less time, energy and resources to focus on their utmost priorities in daily works, regardless of how well they prioritize. This invariably results in longer working hours, higher stress level at work, further disrupting the already much-affected work-life balance.

Yet our compensation still remains the same, with increment lagging behind the rate of inflation and the rising living cost. All these factors are driving away the capable senior doctors who subsequently opt to join the private sector for better compensation, better financial survival for their family, possibly happier work and better work-life balance, more quality time for family and so on.

How to change?

How can we change all these for the better ?

Just as recently as a few years ago, junior doctors were working long hours with heavy patient loads as well. We were stressed, exhausted, yet happy and satisfied, motivated to continue our hard work.

Thanks to our superiors and senior doctors, we were given the autonomy to take ownership of our patients even as junior doctors ourselves. We were granted with endless opportunity to help our patients, to get things done for them, to see them improving from shift to shift, recovering from day to day, eventually discharged with big smiles and heartiest “thank you”. The satisfaction was so immense.

During ward round, we would present our patients, in whom we took pride for knowing them well, to the whole team while raising issues and asking questions that warranted help from Specialists and inputs from Consultants. We would also update the whole team on our patients’ progress in ward :

1. “Mr.X has this new-onset fever in the past two days and when I examined his this morning there was a new pansystolic murmur which might suggest new-onset mitral valve regurgitation. There was no other obvious source of fever being identified through history and physical examination.

“Therefore I am thinking of infectious endocarditis. I have repeated FBC, ESR, CRP and renal profile. I have sent three separate sets of blood C&S as per protocol. After discussing with Medical Officer in charge we have arranged an urgent echocardiogram for this patient.”

2. “Mdm Y is currently post-op 48 hours. She complained of feeling feverish and productive cough with greenish sputum since day 3 of admission. The repeated FBC showed increasing total white cell trend, her CRP was elevated and repeated chest X-ray show new right lower zone haziness as compared to her first chest x-ray upon admission. I am thinking of hospital-acquired pneumonia (HAP). Blood culture was repeated and IV Cefepime was started yesterday.

“However she is still stable under room air and no sign to suggest respiratory distress. We will trace the blood C&S and adjust her antibiotic accordingly.”

3. “Mr Z’s serum glucose level was not optimally controlled. His HbA1C earlier this month was >10%. I have counselled him on the importance of good blood sugar control, the need to adhere to dietary adjustment and to start insulin injection. He has agreed to starting insulin. I have referred to pharmacist for counselling on injection techniques, dietician for DM diet in the ward and further dietary counselling.

“We have started regular Dxt monitoring while adjusting the dose of his basal-bolus insulin regime. So far we are able to keep his Dxt in the range of 6-10mmol/L. Bedside ophthalmoscopy examination showed no obvious DM retinopathy changes. However I still referred him to Ophthalmology team for annual screening.

“There was no feature of neuropathy or peripheral vascular disease. However there was a small diabetic foot ulcer with minimal slough for which a bedside desloughing was done yesterday. I have also sent urine investigations and renal profile to look for possible DM nephropathy.”

4. “Mr ABC developed septic shock secondary to pneumonia last night. His hypotension did not resolve with fluid resuscitation and is currently dependent on IVI Noradrenaline started yesterday. The right femoral central venous catheter was inserted yesterday for IVI Norad administration and maintenance IV drip. I have repeated his septic work-up and upgraded his antibiotic to IV Piperacillin-Tazobactam.”

Coming back to my point, what has changed in such a short time? How can we change for the better?

Emphasise on training

Instead of merely taking over the tasks and get things done, I think we should emphasise much more on training our House Officers. Instead of blaming the individuals, we should work to improve the system.

We need to teach, guide, supervise, encourage, motivate and inspire our junior doctors in their day to day work. We need to empower them, allowing them to play significant roles in the team. We need to help them to feel involved and be relevant in daily care and management of our shared patients.

Most of the times, I am guilty myself as well. Whenever House Officers are struggling with their work, I will take over completely but neglect their training. Whenever they are not making sense at the other end of the phone call, I will just shut them down, worse still scold them and eventually ask to speak to their Medical Officers instead.

At the end of the day, negative emotion overflows but these House Officers have not learnt nor benefited through the encounter with me. Worse still, because of me, some of them have lost the opportunity to learn about concise case presentation and making proper referral. For these I apologize to all the House Officers and other colleagues involved.

Therefore, before taking over House Officers’ tasks completely as part of our spinal reflex and potentially depriving them the precious training, I suggest us (Medical Officers) to think twice :

1. Can they still do it themselves with our guidance and supervision?

2. After teaching and demonstrating them the right ways, is it safe to the patients if we ask them to do it again but better this time? Will doing it again with their own hands help them to learn from their mistakes and thus learn the correct ways of doing it?

3. How can we lead by setting a good example for them?

4. How can we best teach, guide, encourage, motivate and inspire them while helping them to improve through the daily works?

5. What can we teach them through this patient or task?

In dealing with junior doctors labelled with ‘attitude issues’:

1. Is there really an issue with their attitude or it was just our misunderstanding / misinterpretation?

2. How can we empathise them with their unique personal challenges and burden?

3. How can we offer a helping hand to make their life easier?

4. How can we offer a brand new, different but helpful perspective and make them seeing it, understanding it?

5. How can we inspire them to aim for new level and achieve greater heights in career and daily work?

6. How can we help to optimise their personal career satisfaction through daily work and interaction with us?

7. How can we create a positive repercussion in their working life thus helping them spiralling up (instead of down) the way to advancement?

Again, we should stop blaming the individuals but make changes to improve the system. By moulding competent House Officers now, we will enjoy the benefit of working with excellent colleagues later on and this will definitely make our working life, everyone’s working life so much easier while not driving away good superiors and capable senior doctors.

More importantly, with more well-trained, capable colleagues to share our loads, our patients benefit as well as through the better quality of care and service.

Dear colleagues, changes start with you and me. Everyone of us can make a difference for the betterment of our beloved profession. It is not easy. In fact it will never be easy. Yet, eventually and definitely, I believe our dedication and determination will pay off.

Are we ready to resurrect the teaching spirit in us to help our House Officers?


DR SCHEE JIE PING is a Medical Officer.

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