Interestingly, I have received several messages the past few weeks from final year medical students who were already thinking about their housemanship. Should I do my housemanship (or internship) in Malaysia or continue abroad?

Most of these messages came from students who were already abroad and were hesitant in starting their housemanship in Malaysia due to many factors, but mostly concerning the work culture. I suppose the healthcare scene in Malaysia is notoriously known for the workplace culture, i.e bosses bullying house officers, asking them to get their GRAB food and not say thank you (whatever), bosses who aren’t thoughtful, considerate or helpful. Well, it is true there are some bosses who are notoriously known for their attitude, particularly prevalent in a certain department than others, there are however exceptions to superiors who are helpful, nice and very approachable.

Workplace culture differs from teams to teams, departments to departments and hospitals to hospitals. I suppose researching the hospital departments should aid in your decision-making process before applying for housemanship. Never apply to a hospital for logistic reasons. Housemanship is a difficult time period, choosing the right hospital is important and necessary to safeguard your wellbeing for the next 2 years.

While a lot of talk is about the workplace culture, housemanship in Malaysia generally gives you a lot of practical experience compared to overseas. I mean, how can you not do more? You literally mend the whole cubicle with 10-12 patients every day, and sometimes you are put alone in the ward with 28 patients, so how can you not learn to work strategically? But bear in mind, learning in these conditions are not always optimum and your learning may not always be right, seeing as how you need to manage all 28 patients quick and fast, otherwise, you’ll never be able to finish working and be able to leave on time. So even though you’d learn how to work fast, it may not always be using the right methods. Your hands may not always be as sterile as it should be.

And of course, on top of that heavy workload, your superiors may expect you to know all the cases, be able to manage everything a house officer is expected to do. Malaysia still has a lot of these unreasonable settings due to a lack of manpower, inefficient/ineffective hospital admins and lack of helpful/thoughtful colleagues. Nice people can be hard to come by.

Culture, skills and workload, when you add all of these up, it’s left with time management. You will almost always never leave on time. How can you? When you have to manage the whole cubicle/ward, on top of all the IV cannulas that aren’t working, and all the additional morning bloods you have to take, the requests and referrals you have to make, the AM, PM reviews you have to write, the lunch you have to pick up from the main entrance that your superior never got for you (sorry, sarcasm), how could you ever finish your work? And there isn’t a culture of passing over such to the oncall house officers either, so all you could do is finish up your morning plans before you go back, otherwise it’d be deemed “passing over shit”.

Malaysian housemanship is a lot to handle. It’s less enjoyable, but you see a whole different side of a dysfunctional healthcare system made up of bones that are trying to hold it together. Sometimes, it cracks a little, but it will stay and it won’t fall. The amount of learning depends on the individual. Some people learn a lot, some just don’t. Personally, it’s hard to learn when your every day is stressful. So learning, depends.

Given the recent announcement of more permanent positions and the eligibility of contract doctors to pursue masters, specialising isn’t really a huge problem in Malaysia. There is still a strong bottleneck for only those elite + those with connections can enter a master’s program. Given my time in Australia, training over there seems to be better, more tolerable, more research-oriented, more independent, more goal-oriented, but harder to level up. Hence, it might take years and years before you could become a consultant. But training in Australia is generally better (and the pay is great).

Should I do my housemanship in Malaysia or abroad?

There’s a few things to consider. Remember, Malaysia’s housemanship is brutal. 2 years of service makes you a competent MO. Internship training abroad unfortunately doesn’t give you that level of experience as it is here. Hence, most internships aren’t recognised in Malaysia. So if you were to do your internship abroad, coming back might mean you will have to restart your housemanship.

The other option is completing your housemanship here, then going overseas. There’s always this glimmer of hope that perhaps being a doctor in Malaysia is not that bad, if that’s the case, try starting your career with being a house officer in Malaysia then decide from there onwards. At least you’d be able to get your license at the end of it.

But of course midway through your housemanship, if you feel strongly about the need to quit because of bad mental health, bad work ethics, bad work culture, bad superiors, then tender your resignation. Your own personal morale should take precedence. Proceed with your plan abroad.

Can I return after my internship abroad?

You can return anytime but be prepared to restart your housemanship. There’s this saying whereby if you were ever to return, always return as a specialist. It’s just easier that way than to come back just to restart the process of being a doctor.

My main concern is my family, what should I do?

An honest discussion with your family should allow you to decide on what’s next. If you can’t go abroad, then your best option is to pick a hospital that’s good for you. Alternatively, an MBBS degree doesn’t always mean being a doctor. Lots of people end up in other successful careers, they earn better too.

I hope this helps.

Regards,
Darien

This is for all the fresh graduates who just entered the workforce. Welcome to 2 years of hell. Seniors used to tell me it will get better, but did it really? In some ways it did, but for the most parts, it’s just the same shit, different things every day. But anyway, I guess one of the key lessons that nobody teaches you in medical school is reviewing patients. Sure, taking history and examining a patient is one key aspect, but when it comes to reviewing patients, asking relevant questions on a day to day basis, is a whole other continuum that nobody teaches you. It is as much common sense as it is practical experience that is to be gained throughout your internship. Before I lay out a format, here are some pointers.

Writing reviews are easy, it just takes a couple of practices, with familiarity and repetition, you’d do it like a robot (legit, same shit every day). But writing reviews aren’t as important as seeing your patient, assessing them and making sure they are making progress every day.

In Malaysia, as you know, we go to work on average 5AM everyday. In some departments you start taking blood before writing reviews. That may mean you’d actually have to come much earlier just so that you are able to finish taking all the bloods and completing all your reviews before your MO comes. My trick is (if I already know the patient) is to assess the patient as and when I’m taking their blood. A simple “how are you doing today?” is a good way to start. If you know this is a patient that came in for some cardiac issue, important questions to ask would be “any shortness of breath or chest pain?”. These questions become important when you document in your review later. The same applies to other organ systems.

A quick and simple assessment of your patient is CCTVR:

• skin colour (C),
• capillary refill time (normal <2 seconds) (C),
• cold/ warm extremities (T),
• pulse volume (V) and
• rate (R).

Whenever you start writing your review, it goes in this order:

• patient details/demographics
• underlying conditions
• issues
  • and relevant information
• progress/current state
• examination
• impression (if a new issue pops up)
• plan

Here is an example:

Ali 69 years old gentleman Underlying 1. T2DM 2. Hypertension 3. Dyslipidemia Issue: 1. NSTEMI – Trop I (on admission) 4590 -> 3000 -> 2500 – Started DAPT (Tab cardiprin I/I OD and Tab clopidogrel 75mg OD) – on S/C Clexane 60mg OD Day 3 – Planned for angiogram 2. Uncontrolled Diabetes – HbA1C (2/2/2022) – 9.5% – on S/C Insulatard 20units ON and SC Actrapid 14 units TDS Currently, Comfortable under room air Tolerating orally well No chest pain/SOB BOx1 yesterday On Examination, Alert, conscious, CRT<2s, warm peripheries, good pulse volume, pulse is regular JVP not raised. Lungs: Clear CVS: DRNM PA: soft, non tender, not distended. No hepatomegaly Plan: 1. Continue insulin regimen. 2. DXT QID, inform if DXT>12. 3. For cardio to review. 4. Inform if chest pain/SOB. 5. Continue DAPT. 6. Continue S/C Clexane.

My example is of course an oversimplified version. A good and detailed version should entail home medications (prior to admission), years of illness, location of follow up under the underlying conditions. Your issues could probably be elaborated further, e.g initial presentation, progress in ward etc. And of course, your examination should be more comprehensive.

If this is your first time reviewing a patient, it is good to include the initial HOPI prior to your issues. This makes it easier to present your case later. It sets as a good reminder (assuming you’d be able to flip open your case notes for some pointers, which may not always be the case).

In an ideal world where admission clerking is perfectly done, your daily AM reviews need not be as detailed, but rather include information that constitutes the patient’s progress. This allows you to write a comprehensive discharge summary later on. I’ll probably write about this at some point later. I hope this helps all you juniors!

Cheers,
Darien

“One HO come to OT now.”

“HO, one patient admitting today, please do the necessities.”

“HO, please postpone all elective list patients.”

The reality of healthcare, for us all at the bottom of the hierarchy is this: we don’t have names. The last I checked, our mothers gave us all names, yet we’re subjected to two letters H-O, not even the entirety of it – house officers, as if our ranks have just been degraded to a mere two letters. Let me be clear, they know who we are and they know who is working for the day. I am sure because I introduced myself to everyone. So why not call us by our name?

“Darien, would you mind postponing all the patients coming in next Tuesday?”

Now, wouldn’t this be a better more polite approach?

Even if they don’t know who’s working today, then…

“Hey, who’s working today? I just need someone to help me with something.”

How’s that?

There is a strong patriarchy culture amongst Malaysian doctors, nobody else matters but you. So far, out of two postings, I have only met two doctors who are so down to earth that they would be willing to do all the discharges while you do all the bloods and all the other pending ward works. This doctor once said “Darien, let’s focus on doing all the discharges.” That day, I was so swamped, I was the only house officer taking care of the whole ward with 14 to 16 patients, 5 discharges and 5 admissions. At some point, I think I teared a little before he eventually came to the rescue. It was a blessed day to have received help. Also, thank you to all my colleagues for lending a helping hand when I needed it.

Once, there was a registrar whom I’ve worked with the past 4 weeks, who would say “What matters is not you or me, what matters is the patient. Your sorry won’t help anyone. So don’t apologise.” It was also a bad day, everybody was stressed. One thing went wrong and all hell broke loose.

What are the odds of working with superiors who don’t consider the type of work, so long as the patient is well and gets discharged, then it really does not matter who does the work. It is awfully rare to be working with people like that. If you are reading this, you know who you are, thank you. I had the opportunity to work with true doctors who didn’t consider the work of a house officer any different than that as a registrar, all work, equally important.

But truthfully, I have only been in two departments.

As I recall, there were days where it was busy and as a house officer, we have to be prepared to handle multiple discharges and admissions coming in, not forgetting active plans, referring and requests. With 15 patients, all with active plans, there comes a minute where you just don’t know where to start or how to even begin. If you work with doctors who would be willing to help you, then you would know, no matter how busy the day gets, you will survive. But a bad day is when you receive no help and you are left to fend for yourself. That happens, and it sucks.

By the way, there is absolutely nothing wrong in asking for help.

But why are MOs and Regs the way that they are?

Depending on the department and the hospital, I suppose, most MOs working for the team for that day, will be juggling both ward and the ED referrals. So it’s not surprising for them to be constantly busy, on their phone, on their feet, moving back and forth. Registrars are mostly only seen during rounds, in our eyes, if not, they are likely either in clinic, OT, ED, teaching or some meetings. So literally, we live up to our titles “house officers”, we take care of the house, i.e the ward.

Sometimes, for the benefit of the doubt, it’s not that our superiors don’t want to help us, it’s just that they are way too busy handling their own work.

But I have also met numerous other bosses who would simply not give a damn about the work. They merely expect you to do what you have been hired to do (slavery).

Just to illustrate a point, on many occasions back in orthopaedics, I had to request for “urgent” MRIs and CTs. The very first time I requested, I was obviously unfit to make any requests (I was day 1 of life). Nobody had helped me. In fact, my MO said “did you say this? you gotta say this -“, then he said “try again”. He hung up the phone and I was left to fend for myself against the very angry, annoyed and intelligent radiologist who would, of course, know better of the indications. I, on the other hand, who just started, would of course, know nothing about making request, or how to even begin. Interestingly that day, I was taught of the word “goreng“.

“Darien, you need to learn how to goreng.”

“Darien, you must goreng goreng so that you can get the request accepted.”

I supposed the most intriguing bit of this entire conversation was that, there was a need to ram up the issue, make it so severe that it must have warranted an MRI. That day, I was not taught of the indications, instead I was taught that I needed to do better, to “goreng” better. Truth is, it does not matter how sick your patient is, so long as your boss wants it, you got to get it. Most people don’t think, but if you try too hard, you might just land yourself in trouble. To the radiologist if you are reading this, this is the sad unfortunate truth that happens everyday. Your time and energy is wasted because these people exist to take up your time and energy for non-emergent cases, that are already occupying bed spaces, of which patients who really need them, aren’t getting it. Sorry for the time you have wasted. And to the world, the reality is we are understaffed, under-resourced and we simply don’t have the capacity to treat the population coming to us, we are simply overloaded with patients.

Day 1 of life, the most important lesson, apparently I needed to know was “how to goreng 101″. It wasn’t about writing reviews or managing chest pains or SOBs, but instead it was how to have your request granted urgently.

That’s the culture of it all. Truth is, sometimes, bosses don’t care. As long as you get the job done, then they are happy with you. That is, also unfortunately the sad truth. Because this also translates to nobody really cares about your learning and whether you are on track, what matters is you get the job done.

The jist of it all is when you have very busy superiors, they tend to treat you less. When you have superiors who are more free and able to help, they would if they wanted to.

But of course, I have heard worst in other hospitals. Literally, one house officer to 20 patients? Lack of MOs and registrars in other hospitals.

Then the questions remains – can we blame our superior for being mean, annoyed and angry all the time? Are they simply just tired and fed up of the system that they can’t be bother dealing with us? I think there’s always two sides of a coin and therefore two sides of a story.

Our system is overloaded with patient, coupled with inefficiency in the way the healthcare system is managed. Lack of resources and lack of manpower does not help at all, unfortunately, if at all, it exponentially makes everything worse. Say if I had 20 patients to juggle today, and suddenly my colleague decided to take a leave, I would be alone managing everyone. Imagine the time I have to be there before my registrar is, imagine the amount of patients I have to review in that morning, and the active plans I have to carry out throughout the day, all alone. As a house officer, we can only pray that the world doesn’t hit us hard, on a daily basis, and that it comes at a pace, at a rate that we can handle. To our superiors, we hope that they treat us well and we in turn can learn and do our work better.

So, the Malaysian doctors’ culture is this

1. Depending on your hospital and your department, there will inevitably be some superiors who are arrogant, selfish, difficult to work with, vulgar, intentionally make your life difficult, lazy, unreliable and undependable.
2. Lazy is a common aspect where superiors may simply rely on your finding and come up with a management plan. ALWAYS get them to double check unless you are confident.
3. The “apa-apa sahaja”, “sesuka hati kau”, “do whatever you want” culture certainly exist. Remember if this was your father or your mother, you wouldn’t do whatever you want. But believe me, cultures like this exist. As house officers, all the more reason to be stern and professional and do the needful for your patient’s sake.
4. Mean doctors are everywhere but never let them get the better of you. Somebody once told me that even mean doctors have something to teach us. They teach us to be better than them. But just because we have experienced such culture, doesn’t mean we can go boomer about it to our juniors in the future. “Last time ah.. we used to…” (You know what I mean.”
5. Harassment. Big big issue, hardly ever address. But it exist. Sexual harassment exist. And I would say report them, you won’t lose your job, so no worries. Why would you lose your job after getting molested by your superior? It simply does not make any sense. But if at all, remember our generation have the willpower as strong as social media. That’s our strength, utilise it, go all out. Nobody will judge you, only the perpetrators will be judged. Doctors are notoriously known to protect their reputation, so what better than tarnish them altogether? My point is harassment is a big deal, and if doctors cannot understand that, they don’t deserve to have a spot at service.

The culture exists in many form. Some good, some bad. It takes one bad apple to rot the entire department’s reputation, e.g O&G. But for the most parts, I am optimistic that most doctors remain good, and true to their work and passion.

Even though in the last decade, the image the doctors have portrayed hasn’t been all good, most doctors I have worked with are still kind at heart. Keep an open mind, dear juniors.

P.S I hope not to offend anyone with this article. Merely stating my experience and offering a perspective most might not have heard. To the doctors who may be reading this, I hope this provides an insight you wouldn’t have imagined/known.

Cheers,
Darien Liew

It has been a terrible week.

Sorry, I could not think of how else to define/describe the past 7 days I put myself through, or rather what I have gone through.

First off, 15 house officers left the surgical department to the next, with only 2 entering the department. Only about 10 house officers working each day since the start of this week. There are seven working teams: Hepatobiliary, Colorectal, Vascular, Upper GI (or MIS), Urology, Neurology, and Endocrine & Breast, with the former three being a major team. This week, I have been allocated into the Urology team and likely to remain for the coming week or so. It has been one hell of a week. I alone covered the entire urology ward with an average of 13-14 patients per day, an average of 4 discharges per day and 4 admissions per day. Not to mention patients who come in specifically for trial of void (TOV) where they too are considered admissions. Speak of more work! So yes, it has been a very tiring week.

Literally my schedule every day now looks like this:

In spite of the terrible working hours, the specialists and the MOs were very nice and supportive. I supposed that makes the working environment all the less hectic, considering they too played a working role in the ward. For example, there was a day where I had concurrent admissions and discharges to do, I did all my admissions but only managed to start doing the discharges at 6PM, my MO literally sat down and told me “look Darien, no worries, we are going to focus on doing all the discharges now”. I looked at him with a sign of relief and I felt my shoulders relaxed a little.

I supposed one must wonder why this had to be pointed out. Typically, MOs in the urology department take on the lead to see peri patients and ED patients, so they too are held up with a lot of work. Other surgical departments may play a similar role, but not as busy. So in spite of my MOs being super busy, they were able to spend some time in the ward to help finish up pending tasks, and that everyone, deserves an applaud. Because you cannot imagine one house officer juggling 14 patients, with multiple requests, referrals, blood taking, admissions and discharges all going on at the same time. It’s just an impossible workload made possible, nevertheless.

Suffice to say, the department has been very hectic but it has been very enabling at the same time. And that is what makes it possible to work in. Thankful for the team.

Steep learning curve, but it has made me learnt to work efficiently and effectively.

I think it’s hard. I think it’s been incredibly hard to work as a house officer. This is the harsh truth.

Just today, I made a mistake and it hit me that what really bugs me the most is the constant anxiety that something can go wrong, anything, everything, any time, any day, whenever. It happened today and I felt absolutely helpless, regretful and can only hope that all will be well. It is time like this you would wish that someone will tell you “it’s alright, we all made mistakes”. But the reality is this, you are not allowed to make mistakes, they bring dire consequences, and you know it. I supposed this is the job we all signed up for as doctors.

11 weeks and counting. That is how far I have survived through housemanship. In all honesty, I think the work is doable. I think it can all be managed as long as you are resilient enough to push through the day, with your mental health in the right state of mind, and your mindset and attitude in the right places. I think for the most parts, housemanship is survivable. But who am I to say that when I’ve only completed half of my first posting?

I’ve known friends in other hospitals, unfortunately in a less ideal workplace environment (and culture). The work is undoubtedly demanding. Bosses are demanding. Superiors are demanding. Some days, there is so much work that you you just cannot help but feel like the whole damn world demands from you. That makes it all so difficult. But for the most part, it’s still doable, I think.

I spent the first 4 weeks, in fact even now, still familiarising with the system. It was frustrating at first, when you are expected to function like every other individual, yet when you are so unfamiliar with how everything works. It was hard, really hard at first. By the fifth week, you’d think you’d get a hang of it. But every day continues to be a challenge. One day you would be ask to get a neuroconduction study, and you would be like “How do I do that? Do I need to refer neuromed?”. Other days, you’d be asked to request an ECHO, and the same thing goes “How do I do that? Who do I call? Where do I go? Do I need to refer cardio?”. But this isn’t the best part. When you finally get a date, say for an ECHO, your bosses will tell you to get an earlier date. Say that these bosses round at 4PM in the afternoon. You’d now be stuck in a daze and be like “What do I do? Who do I go to? Where do I go?”.

It’s challenging when it’s demanding.

It’s challenging when there’s so many plans.

It’s most challenging when you know so little of the system and you are just not equipped to handle the workload.

I think when you are a first poster, naturally everything would be difficult. You would literally wake up every day and think that the job is hard, and you would just rather give up. Truthfully, the challenges every day and the things people put you through, the way the environment and culture pushes you through, every day it gets an inch closer to the threshold where you can no longer tolerate. After all, why put yourself through such lengths?

Naturally, every job has its own difficulties. No doubt. As healthcare professionals, your job is to prevent death for as long as you can. Some deaths are inevitable, i.e natural death, patients with really poor prognosis etc. But little do you know, every little plan you carry out every day has its risks of causing death. One tiny mistake can ripple out in so many ways. Say, terrible handwriting, you may have mistaken a 100 for a 10 for medications. Too much or too little, patients can die from it. Sometimes you get so tired you may miss things out. Some things that cannot be missed out, inevitably gets missed out. Some days are just terrible days, and it happens.

But I supposed when we get into this career, we all know what we signed up for. Or do we not?

Once a student, I think I do know some of it. But I never knew the reality of working through it. It is so much harder.

Now, actually working through it, I understand the complexity and the true nature of the job. The nature of the job? It demands so much from you, and yet so little comes back to you.

Once with hopes and dreams, great ambitions and desire to achieve so much, now you are just so tired everyday that you would want to do the bare minimum and survive through it. That is all you can think and do. That is simply because the work is demanding, and you are just exhausted every day.

Let me now venture into passion. Undoubtedly 80% of the individuals, today, entering medical school would probably say ‘born out of passion’. Yeah I would agree, passion gets us started. Passion puts us through 5 long years of education. Passion drives us to do better, pass our exams, shine in front of our peers, and in fact gratify our innate need to succeed. Passion gives us that.

Passion is the ultimate driving force for one to study medicine, and to graduate with a Bachelor of Medicine, Bachelor of Surgery, or the equivalent of it.

Passion puts us through all that.

But passion does not equip us enough for the demanding workload that you never realise existed. Passion now no longer exist. Passion now dies because everyday is about securing your mental health, getting yourself through and pulling yourself together, for the next day.

Remember, passion gets you through 5 years. But the 5 years after? You are ultimately on your own to fend for yourself. You are now an independent worker, you now have a need to earn for a living, a need to survive through a harsh (sometimes) toxic environment and a need to support your family and yourself. Passion for learning is not the same any more now that you are working.

Learning back then, working right now, is far different in terms of gratification, satisfaction and expectation. Simply, less gratified, less satisfied and unfair expectations.

Putting all together. You would now probably notice the contradictions within my article. I started of by saying it’s hard. Then I say it’s doable. Then I say it’s challenging and demanding. So, what is it? Which is it?

Here’s the truth, there are days where it’s incredibly difficult, and days where it felt okay. Some days are chill days. Some days are busy days. Some days you get bullied, some days you don’t. Some days your bosses are nice, some days they are not. Every day is a different day. In spite of all the challenges, we still wake up every day going to work. Because how can you not? Remember, you now need to earn for a living, you now need to live your own life. It is a constant juggle between maintaining your mental health and the need to sustain a living. The best you could do is just pray for a no nonsense day, and that every day is a good day.

For those who struggle in housemanship, especially if you are starting out, I feel you, and I know how challenging it is. I cannot help but wonder, would it be the same 10 weeks later, 20 weeks later, when you are a bit more familiar with the system and experienced with the work? After all, in practice, medicine is rather repetitive. Could it be extra challenging for us now, just because we just started? I mean look at the 4th and 5th posters. They seem to be doing fine? I think.

11 weeks and counting. I personally have an innate desire to complete my housemanship, it is the lingering thought that I will not be able to, that bothers me everyday. We still try to be positive every day, anyway. After all, what else can we do?