THE SHIFT SYSTEM: PRO AND CONS

About a month ago, the head of HO in my hospital asked me to send him opinions from paeds HOs regarding the HO shift system. These were the feedbacks I managed to gather from the team, at time with the assumption that the shift system planned for implementation is a similar one to the one used in A&E posting:

PRO:

1. Enough rest in between work

More energetic housemen and presumably less mistake. Hence, shift system is probably good with departments with expectedly non stop works, and with not much of continuation of care which need brief passing over– for example, in casualty and labour room, but not in wards where continuation of care is essential

2. No oncall allowance for housemen (*definite cons for housemen though)

A huge reduction in the money spent on the health sector by government – good as money can be spent on other healthcare needs, for example hypoallegenic gloves (as part of right and welfare of the employees with sensitive skin) or to get better equipments for treating patients

3. Working time not adhered to regular office hours might be beneficial

Ability to run any errands that need being done during office hours eg going to the bank

CONS:

1. Number of housemen in each department is labile and not fixed (due to possibility of extension)

Not enough numbers to be divided into shift hence difficulties in coordinating the shift duties

2. Limitations which makes hectic morning shift – and might lead to major dissatisfaction if shifts are not properly assigned

Morning shift will be particularly busy – with the specialist ward round, blood takings needed being done during office hours, attending clinics. Surgical based posting with elective surgeries in the morning makes it rather difficult to organise the shift system. Few housemen might be left in ward, leaving jobs passed over to the next shift, but unlikely to be done on the same day if those jobs are limited by office hours only – hence the unnecessary delay

3. Less teaching

Teaching done during office hours, some might miss the teaching

4. The pass-over tradition which in itself is time consuming and might not work well in all departments especially in ward

Those who are less responsible will become more complacent, passing over the jobs to the hardworking/more responsible ones.Either the hardworking ones will continue to suffer or a viscious circle to happen where jobs might be passed over on and on before being noticed, which might compromise the patients’ care. Also, jobs might be missed if passing over sessions are not properly conducted so, effective hand over session is very important, and a clear guideline is required. Having said that, a proper pass over can be very time consuming, hence more time spent for passing over, less work done in time, less care and time for patient

5. No oncall allowance for housemen

This is probably not too bad, providing the working hours is much less than the current oncall system. However, it is of no guarantees, and the working hours might end up with mere minute difference. These extra hours should be entitled to some compensation too

6. No more weekends or public holidays

Difficulties in arrangement of holidays as everyday is a working day, hence ending up with less rest throughout the month even if there will probably be enough rest in between shift. Cumulatively, working shifts might be more tiring

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In conclusion at that time, consensus I think was NO, DO NOT implement it until we are all ready. Or at least that was the consensus among me and my colleagues in the same hospital.

Good grief. I can still picture myself standing up in front of all housemen and DG in my earlier days of working, asking about whether or not the shift system is soon going to be implemented. And why on earth did I ever have the nerve to ask that question?

And now having been in the system for around 10 days, I can see the pitfalls here and there which I will try to conclude in another entry after having a post mortem with other colleagues of the department. Enough to say, I need daily motivation to go to work now....

HILARIOUSLY IRRITATING

I was reading this one article that I accidentally found upon googling for articles on the yet to implement shift system for all housemen in Malaysia. Hilariously irritable. I repeat, irritable.

No offence to the nurses, my near 2 years experience have exposed me those who are unexpectedly of cannot-make-it calibre, as what the blogger named it. Go on, have a read:

DOCTOR, DOCTOR! by Home of the Manx (I think the blogger is a psychiatrist)

The head nurse of my main ward was slightly upset when I told her my opinion that some nurses of certain wards are of cannot-make-it calibre. But it’s true. The ones in my main ward are generally OK despite being relative greenhorns. They have an acceptable average level of intelligence, integrity and diligence, with an outstanding one here and there. On the other hand, some staff in other wards really make me want to bang my head against the wall. I tell myself that there is no point in sacrificing my noggin like that. If I used their heads to smack the wall instead, the building would crumble.

Example.

(Phone rings)

Me: Hello.

Nurse: Hello, Dr. Katie. This is staff from Long-Stay Ward Pee-A-Lot. Do you think you could come and conduct an urgent multidisciplinary ward round with the medical officer, nursing staff and pharmacist? This afternoon?

Me: (thinks: that would be the equivalent of chartering an emergency jet plane to buy groceries for tonight’s dinner) Huh? Why?

Nurse: We want to convert all the patients on Valiant tablets to Valiant syrup.

Me: Huh? Why?

Nurse: Because we had one patient who nearly choked on a Valiant tablet.

Me: Oh? When? No one told me.

Nurse: Last year, before this ward came under you…

Me: (moment of disorientation – this is late July, right?) Okayyyy…

Nurse: … so there was an enquiry, and now we have to think of ways to prevent further near-choking incidents, so I thought we should change his Valiant tablets to syrup form. Then I thought we should also convert everybody on Valiant tablets to syrup. That’s fifteen patients. That’s why we need you to do a multidisciplinary round for everyone to institute the changes.

Me: Whoa, wait wait. This patient who nearly choked – was he only on Valiant tablets?

Nurse: No, he’s also on Fluent tablets, Hallucinate tablets, Chlorophyll tablets, Di…

Me: Uhhh… so you’re telling me that putting him on Valiant syrup plus ten other tablets will prevent him from choking on tablets?

Nurse: Well, it was Valiant that he nearly choked on.

Me: And the other fourteen patients? I suppose they’re on lots of other meds too? For which there is no syrup form?

Nurse: Yeah…

Me: So how does converting them to Valiant syrup make sense?

Nurse: Well, true, it doesn’t… but there was an enquiry. We have to do something!

Me: (sighs) OK, fine. If there HAS to be a change, I have no objection to this one patient being converted to syrup form. Leave the other patients alone. No multidisciplinary round. Just get the medical officer to convert the Valiant to syrup form at the same dose.

Then came the clincher.

Nurse: But Dr. Katie, Valiant syrup is very expensive, you know. Are you sure you want this patient to be on syrup instead of tablets?

Good grief. No amount of bonus is gonna compensate me for the brain cells that died during this conversation.

My very shallow experience so far has enlightened me of how unbelievable nurses could be and of how much the nurses' works has shifted to become part of the junior doctors' jobs, because we (junior doctors) have apparently become the glut.

One example of mine:

One hectic night in a surgical based ward, a patient was having a problem to pass out urine post op (which is not uncommon) and another patient who has low GCS due to intracranial haemorrhage ran amok in ward. Not to mention there were another few cases who I had not yet fully clerked after seeing them shortly with my MO - at least the diagnoses and plans were already there. I was left alone in ward as another HO oncall in the ward had long gone into the OT to assist the surgeries.

Before handling the latter patient, I have requested the nurses who were chatting at the counter (and was probably finishing off their very important report which copied every plans by doctors) to prepare the catheter set for the former patient.

After the amok patient been taken care of, I upsettingly found that the set were not ready yet. To make it quick, I prepared it myself and pushed the trolley to the patient's bed myself, passing through the nurses who were too busy chatting or probably gossiping. Then I had to pull the at least 2 screens to secure the patient to his own privacy - there were no curtains in the ward you see.

And to make it worse, it was a male ward and I was completely aware that I was much in need of a chaperone for those kinds of procedures - but like that ever happened in this hospital anyway. Surprisingly in Malaysia or maybe just in this hospital where the chaperone appears in every single introductory papers to be signed off by new doctors entering a new ward, having a chaperone practically were made compulsory only if you are a male doctor having intimate procedure done on a female patient. Other than that, it is definitely not widely practised here.

So I shouted out that I needed a chaperone, in which later on as expected, nobody came to chaperone - let alone if I asked them to assist me. Again to make it quick, I just proceeded with the procedure but it was not as easy as expected. I needed a smaller sized catheter and hence shouted for another help.

Me (shouting): Akak, tolong bowok cbd size 12 se (nurse, can I have a size 12 catheter please?)

After twice or thrice shout out, a nurse came with the wanted catheter and she placed it on the trolley next to me who were all sterile.

Me: Thanks... (before I could finish off with asking for another favour to open the catheter packing up into the sterile set, off she went to the other two nurses at counter)

SPEECHLESS. That was all I remember. I was completely speechless! Hello, it was a only a common sense for you to open it up, d*** you.

Luckily my MO (who was quite new in this hospital at time) passed by and he nicely helped with the favour I was about to ask and chaperoned me until I finished off my procedure, asking during that while 'what are the nurses doing leaving you alone here?'

Exactly. So what do they do? Obviously we need more doctors to compensate for those jobs that previously not done by doctors. So why complain of the glut?

Anyway, having said that, there are some nurses who I love so much and I think these are the nurses that achieve the same standard as those in the UK. If there are awards I can give to the best nurses, I will definitely pass them to these two nurses I have met in my career so far - 1st one in renal male ward who would call you to clerk a new patient who needed a peritoneal dialysis at 3am in the morning and by the time you reach the ward, everything has already been prepared, and when you were doing the procedure she was closed to you so you do not have to shout to ask for favours (I know nurses have tasks to do too, not that I always wanted her to be on my side even though that is what u get in the UK), and when you finished off the procedure she would take care of the other sets after you thrown away the sharps as she knew your phone just cannot go silence for a while and there were other patients you need to see and take care of.

And another one I met in ortho ward who would call you to clerk a case and by the time you need sedation and analgesic for a close manual reduction, he said it was already prepared as he already anticipated it. Prepared as in already diluted, mind you.

Seriously, thinking about these two particular nurses made me want to cry, thanking God for still making them exist in my current world. How I wish things are different, but who am I to change things?

THE BIG BOSS

Some people missing in action in working time, is not a peculiar subject for me anymore. People coming in late for the ward rounds in the morning, or go back so early and leave the burden of the ward works to the others, also sounds so familiar. I can go on and put in complaints, and the list will be endless. Including things about my own self, like how I feel how slow I can be at times. But complaining alone won't achieve anything. Feedback like those in today's handovers is more likely to cause improvements, complaints won't.

I like my Big Boss, he is so far the most responsible H.O.D. I have met. He has this weird 'flight of ideas' speech when we were presenting cases or during the handover sessions, but he is very thoughtful and he does take good care of the staffs and the department; about things that should be in its right place. No one is allowed to come late. Which is good. I dislike punctuality too, even though I have always been rushing to work - but to my defense, that is only so that I arrive on time. I can list up ten reasons how coming in late for ward rounds will cause your punctual colleague to suffer. Of course, there are exceptions to being a few minutes late, but if it is a habit, it is something that hardly changes.

Back to the Big Boss. He knows what is going on in the department. Absconded staffs, nonfunctioning computer system that delay things, absconded patients, issues with other departments...etc. People who were missing in action and those staffs who weren't helpful were also warned today, so hopefully things will get easier and quicker for me. I love those nurses who were so helpful and not just bossing around, scolding doctors (read: housemen) because they have to do jobs. I love the former I would bake cakes for them. If I have the time and energy =)

Anyway, feedbacks like these, discussed in today's handovers are more likely to cause improvements, complaints won't. When I said feedback, I mean complaints made to and done by people who are able to do the changes for the better, and not just merely complaint to friends, who are at the lowest position like yours.

Attempt to get help from the supervisor was to no avail the last time, and even when we ran out of the lab forms yesterday, nothing very helpful was done about it. If the Big Boss is not in his current position right now, I wonder if adrenaline will always be enough in the emergency department.

Malaysia and good feedback system, is still a long way to go. The last time I put in suggestion in a suggestion box, a few weeks (or months) later, the box was gone. When my medical boss lodged an incident reporting to improve some systems, which I seconded, he got an incident reporting attack as if he was doing that out of arrogance.

Reminds me to how Newcastle University library answers NICELY to all the suggestions sent, oh how good the system is.

Same goes with the politics. But not going into that topic tonight, too tired I need some good sleep right now. And the conclusion is I like my Big Boss. Taraa...

THE GREEN FEVER

I was working at green zone this morning, and most of the cases I have seen today were those with fever. Here goes some conversations:


SCENE 1

Me: Bakpe mari?
Patient: Demam doktor
Me: Bile start demam?
Patient: Bangun tidur tadi
Me: (glancing at the watch which showed 1030am) Ooo...baru 4jam laa lebih kurang?
Patient: Lebih kurang gitu aa
Me: Amik panadol doh ke?
Patient: Dok pon. Buleh ke gitu?
Me: ????


SCENE 2

Me: Mokcik, bakpe mari hari ni?
Patient: Demam doktor
Me: Ooo, berape hari doh?
Patient: Lima hari doh
Me: Lagi ade masalah lain ke?
Patient: Ade...batuk-batuk doktor
Me: Ooo, berape lame doh batuk?
Patient: Lame doh doktor
Me: Ye la, berape lame?
Patient: Lame sangat doh doktor
Me: Mokcik, (again, with all the patience) lame tu, berapa lame? Seminggu, sebulan, setahun?
Patient: (sengih) Lame doh, mokcik dok pindoh rumoh anok mokcik lagi mase tuh
Me: ?????? (and how on earth would she expect me to know when did she move to other house?)


SCENE 3

Me: Bakpe mari hari ni?
Patient: Rase pening aa doktor. Hawe2 nok demam ade gok. Tadi daroh saye tinggi
Me: Ooo...kad takdok lagi ni, doktahu lok tekanan daroh awok berape (assuming it was the BP he was talking about). Saya panggil je dulu sebab takut ramai lok beratur kekgi. Berape tekanan daroh awok td?
Patient: 146 gitu aa
Me: Hok atas ke bowoh?
Patient: Hok mule2
Me: Ooo dokla tinggi sangat
Patient: Tapi memang tinggi tadi doktor!
Me: Dakpe, kekgi sapa kad kite tengok

(after noted his diastolic BP was more than 90 for four times, and him having symptoms of hypertension with a high haematocrite and viral illness symptoms, he was advised for admission)

Me: Awok kene masuk ward ni, tekanan daroh memang tinggi, apstu kite takut denggi jugok
Patient: Hah? Dok payoh la doktor, saya rehat kat rumoh je laa. Doktor wi ubat je ke saya
Me: Doh awok siap kelabu mate lagi, tu tanda2 tekanan daroh tinggi. Dohla mude lagi dapat doh. Kene cek betul2 ni. Lagi daroh awok dok comel sgt, takut denggi. Ade due sebab doh ni saye nok suruh awok masuk ward
Patient: Dok payoh laa doktor. Bagi ubat je laa
Me: ??? (tadi die jugok yg beriye kate tekanan daroh tinggi, pening dok berenti)
Lucky he finally took the advice for admission, if not I myself would go hypertensive.


SCENE 4

Me: Ye dik, bakpe mari ari ni?
Patient: Sakit perut doktor
Me: Sakit kat mane...bla2
Patient: Sakit kat beloh ni...bla2
Me: Ade demam dok?
Patient: Semalam rase macam ye, tapi tadi misi kat depan tu kate saye takdok demam pon
Me: Tuh hok die cek, die dokleh rase awok demam ke dok. Awok sendiri rasa hawe2 demam dok, dik?
Patient: Doktau laa saye. Takdok la kot
Me: (susoh nguh ikut ke misi pulok doh)


How I wish history taking can be much easier...

SHIFT VS ONCALL SYSTEM

For those who would like to know our working time as houseman, this posting will enlighten you in general of how it works. It might be different with different hospitals or postings.

I am working pm shift today. We have three shifts per day at casualty. Morning or AM shift starts at 0800 and finishes at 1530. Afternoon/evening or PM shift from 1530 to 2230 and night or ON shift from 2230 until 0800 next morning. But every weekdays' morning starts at 0730 with the handovers, and usually the morning people will start the shift at 0730 then.

In general , everyday we are entitled to work for at least one shift. There are days where we will be working double shift, which means we work in the AM and ON shift. And the next day, those who worked the night shift at the red or yellow zones MAY be entitled for a night off - meaning they don't have to go to work the next day, but those in green zone, still has to come for a PM shift the next day. This is how it works here.

Even if we have a night off, we will still be coming for CME (continuous medical education) presentations for our learning purposes on the night off day, and every weekdays, regardless of us in the PM shift, still has to come sharp at 0730 just for the handovers. I don't mind that seriously, as it forces me not to prolonged my sleep too much, like today (because it's a weekend, and hence no handovers). Plus, sometimes there are so much to learn at the handovers. The HOD (head of department) really likes to ask questions, and I think that is how I learn much. Even though most of the time, I was not even close to answering the questions.

I think I'd prefer the oncall system better, but maybe it won't work well in casualty because the patients are non-stop, and you will most likely be exhausted after the formal working hours. At least with double shifts, you get to go back for a while before continue with the night shift. But still, so tiring.

For those who had no idea how oncalls work in other departments, this is how it works - your working hours starts as usual from 8am to 5pm, but you come as early as 7am or earlier for your morning rounds. If you are not oncall, you go back after 5pm only if you finish your job that are not supposed to be burdened on the oncall people. Say you have too many jobs in the ward, you might only goback after 10pm. If you are oncall, then your oncall time starts at 5pm until 8am the next day. Then you continue working, until 5pm the next day, or later if too many tasks need to be done, as mentioned before.

Let me give you the example of one of my tiring schedules with the oncall system. It was when I was in medical posting, at times where the total medical housemen was 17 and we have four main wards to cover, not to mention the clinic and other periphery wards, also the H1N1 breakout at time. I had a few EOD (every other day) calls that month. I came to work at 645am, carried on with the sleepless night with the oncall, then I only went back at 1030pm the next day after the all sorts of procedure done. Then next day I came back at 645am for the morning rounds, and was oncall again, only to be back around 10pm the next day.

Dear my beloved Damia me niece who always keep mentioning that all I do at home is sleeping, if only you could understand this, you won't blame me for coming home and sleep for sleeping is the best rest, after the long working hours with those sleepless nights. In medical. But please note that, not all days were like this anyway, especially in different posting.

Anyway, back to casualty. Only the 4th and above poster housemen are allowed to enter the department, so we won't get any new freshies here. The total of housemen in the department is reducing. Therefore, holidays are out of questions these days. Both my brothers' family are coming home for the upcoming eid (raya haji), and no holidays are allowed during the days they are back here. Now, these are the days I resent becoming a doctor.

I just pray that I will manage to apply a straight four days off I need in December, as I have already paid such a big amount for something I have long wish done. I give you a clue:

But I wonder if I had enough stamina for the much awaited event.

BAD WEEK

These few days I have been feeling very upset with the lab, with the nurses, even with the patients, but especially with myself. The peak was on Saturday, when I actually lost my temper on a patient that I think every patient in my ward could almost hear me scolding him. And I feel very terrible, it is still haunting me, even in my sleep. All those advice to be a good doctor received when I first graduated keep haunting me. But words are those things you cannot possibly take back. You can only wish you can turn back time and do it differently, but the fact is there is no time machine available and there will never be and you just have to accept that.

I blamed myself the most for not being able to cope with it. Being post call, the tiredness and the hunger, also the upsetting blood takings which sometimes provided me with no results at all, and the nurses who were not as helpful as what I expected them to be, and the patients with difficult veins and high demands not when the m.o.s are around, but only when they have long gone and I am left on my own to manage, plus, loosing 3 patients in a day - these all just add up to the weakness in me - I thought I have been very patient so far, but I lost it. I lost it already. I gave up.

It is never the patients' fault if they refused to do things we told them too - it is so up to them to decide, as the outcome will eventually be on them. (but again, how patient can you be with a non compliant patient who turned up to the ward very frequently even on day 2 post discharge?). We doctors just help managing them, in other way 'fix' them if possible and allowed to. I know I should never have scolded patients for moaning because who are us to determine how much pain they were in? I might not endure the same pain as my patients are enduring now.

The Prophet (saw) said, "The real patience is at the first stroke of a calamity."
Sahih Bukhari Volume 2, Book 23, Number 389

It hit me straight to the heart when I read this post at facebook from a good friend of mine. Indeed the real patience is far from me.

Today is the first time in medical posting in which I doubted my decision of coming back to work here. It makes me feel terrible. I actually very much enjoyed being in nephro ward, that I even asked for Kak Salmi to place me in the same ward for another 9 days before I move on to the next posting - surgical. But I just can't help it anymore.

How I wish there are tubing system here like in the UK where I can make sure blood goes right to the lab and not being wasted after all the hard work of difficult venesections. It hurts the patients too ok - and it took time to plead them for femoral blood as peripheral veins are either too thrombosed, or they are invisible and impalpable.

It is upsetting when I called the lab for important blood results at night time, when I had to wake up all night to review patients, and even waked them up from sleep just to see if haematocrite was rising - but nobody at lab even bothered to answer the phone because they were BUSY sleeping. Or when I needed ABG sent stat at night time, the PPK is nowhere when there are no diet to serve, nothing to do at night time but sleep and chat - yes, and it was all my duty so I had to leave the patient with a GCS of 6, went down to lab in hurry but then had to ring the bells for 4 times (harshly) to wake the lab staff up. If this is the case, PPK might as well work up to 10pm only, because doctors have to send blood to lab anyway.

And why is there no ABG machine in medical ward at all? (supposedly no budget, of course, how I forget Terengganu is one of the poorest country in Malaysia despite the money we should get from the petroleum). I have sent this suggestion to have the machine at least at neuro ICU, and the last time I went to the lab it was still there in the suggestion box, which funnily provides no pen nearby, as if no suggestion is encouraged at all.

This week has been terrible. I accepted the fact I am weak, but being unsatisfied with the system and all, I am changing my opinion to why doctors in the end leave government, or why medical students from developed country refuse to come back to Malaysia - it is because of how the system works here. I have to agree to the first few parts of this article, honestly because I have on my own been in this situation.

WHY WE LEFT AND WHY WE WILL CONTINUE TO LEAVE...

"Why be a slave in your own country, when you are a king in another?" He replied.

Indeed, if anybody would want to find a reason why all of us left, either after housemanship, after being a specialist, or even after sub specializing, and now, even prior to doing housemanship, they need not look at our payslip, or the wealth that we have gained overseas, but only to the Medical System that has been rotting in the ignorance and politic-based stupidity that Malaysia has been well-known for (in the medical field).

I have served the system for nearly 2 decades of my career, waiting for it to improve for so long, and only finding myself in despair, quitting with a 24-hour notice and serving abroad. The system is, in my opinion, keeping doctors, since the beginning of their career as House Officers to the end of it, in the lowermost priority. When I was working there, doctors are so ill-treated, while the nurses and the medical assistants are overpowering us.

I still remember the days when I was doing seeing patients and rounds as an MO, while the staff nurses would mind their own business, having breakfast in the pantry, or having gossip chats at their own leisure. My House Officers would then have to do merely all the labour-work, up to the extent of setting intravenous drips, and serving medications. If I am to expect the nurses, my patients would have been dead, or the work would have been too slowly or incompletely done.

When I was a House Officer, I had to run down 4-5 floors just to review a blood investigation of a dying dengue patient. The ward staff would either be nowhere around, or will say that he is busy (busier than the doctor?) or the answer I got at that time:

"Doktor nak cepat, doktor turun sendirilah, gaji doktor lagi banyak dari saya"

Read the rest of article here.

I am loosing my innocence (konon) day after day, and I hope I won't loose my patience inappropriately anymore as I do not want to be who I am afraid I will turn out to be.