Picture: yourhealth.asiaone.com
The past few weeks have been interesting for doctors in Malaysia. One single issue has brought our profession together and everyone was so eager to voice out his or her opinion. The hot debated issue is none other than the “Houseman”.
I have read almost all the blogs and articles, as well as the subsequent comment and discussion among doctors. From my observation, there are two main issues concerning house officers (HO) that were discussed i.e. the long working hours and the non-productive working environment.
To start with, I presume that the majority of doctors would agree that all the complaints are degrading to the profession. Issues that are being raised not only happen in this profession but because of what has been written and published, it portrays a bad image on the profession of doctors as a whole. It is also unfair to the thousands of other HOs out there who perform admirably as doctors without any slightest intention to grumble and whine.
However, lets just be practical and try to see the complaints from a more objective standpoint. Rather than just snubbing what we read by saying those whiners are “babies”, let us examine those issues in a more serious note.
ON-CALL SYSTEM ‘VS’ FLEXI SYSTEM
I did my two-year housemanship training from June 2009 – June 2011. The current Flexi System was first introduced by Ministry of Health (MOH) in September 2011 to replace the On-call System with the initial purpose of reducing the working hours to an average 60 hours with two days off per week.
However, based on feedbacks and series of meetings, final framework of a Modified Flexi System was introduced by MOH Medical Development Division on 23rd October 2013, that stated among others:
- – Duration of working: 65 – 75 hours per week
- – Shall not work continuously for more than 16 hours per session
- – All days are considered as working days INCLUSIVE of Public Holidays and weekend
- – 1 full day off per week, which can fall on any day
- – Post night duty off (afternoon off), which counted as 1 day off even if less than 24 hours
- – Each discipline/hospital is given flexibility to modify the flexi system accordingly to suit its own local environment as long as it conforms with generic framework above
LONG WORKING HOURS
Let me bring you back to the time when we did our housemanship.
Work officially began at 8am and ended at 5pm on weekdays while on weekends, work lasted for half day up until 12 noon. That gives a total of official 53 working hours per week, including lunch hour which was a privilege if we get any.
We came to the hospital every morning since our day off was only after 12 noon on the weekends, provided that we were not on-call. We did an average of two on-calsl per week, and that gives a total of 74 working hours if both on-call falls on weekdays. If we were to on-call on weekend, the total working hours for that week goes up to 88 hours.
We too did the 10-14 days tagging period in which the working hours were extended officially up to 11pm with no day off, resulting in total of 105 hours per week!
All these “official” working hours do not include the unofficial hours that we clocked since majority of days were started well before 8am and finished beyond 5pm. Let just say we work unofficially from 6am – 6pm (12 hours of work every day as some current HO eloquently put it), then our “unofficial” working hour could go as high as 102 hours per week, and worse, up to 119 hours during tagging period!
Now, let us examine the current Flexi System.
House officers in my department are doing flexi-hours with three shifts i.e. AM (6am-6pm), PM (6am-10pm) and ON (9.30pm-12noon the next day). For the record, we let the HO themselves sort out their duty roster and they are the one who comes up with the said working hours.
On average, every HO will do three AM shift, one PM shift followed with an ON shift, and one full day off per week. That gives a total of 66½ working hours. Depending on the roster, one person may get two PM shift per week which is equivalent to 70½ working hours. Even if a person do concurrent AM shift for the whole week, the total duration of work for that week is 72 hours.
The only time it can pass the 75-hour mark is during tagging period, in which it reaches up to 96 hours per week. But even then, every HO is still entitled for a full day off per week.
These figures corroborate that we have complied with the MOH guidelines. So, if the working hours are not that different and definitely better in comparison with the old days, then what is with all the grouses about houseman doing long working hours?
Currently in my department, there will be about 6 – 10 HO for each daily morning round in a single ward and every HO will review about 1 – 4 patients each. On a good day, some of them do not even have to review any patient at all. So, are they currently overworked?
For that reason, I firmly believe that the complaint of HOs being overworked and doing long working hours is mere personal grouses from small group of HO. I do not deny the fact that there may be HOs in certain hospitals who are currently working more than 75 hours per week. Even then, I seriously doubt that it is purposely done just to cause inconvenience to the HO, but rather due to requirement of service e.g. inadequacy of HO; or one’s own personal incapability to perform up to the standard which requires extended tagging period.
We are all human. Any personal story usually highlights only the negative part. How many times do we see a statement in social media telling the entire world how busy someone days have been? But have we ever seen any doctor sharing in social media about their non-busy working day? That on a certain day, they are just sitting around in the ward chit-chatting, walking around in the hospital aimlessly looking for something to do, and occasionally being allowed to leave hospital earlier than the scheduled working hour.
It is human nature to feel important and being noticed by others. With some embellishment, we always tend to make our personal predicament sound like a universal problem. Therefore, I think all the gripe of long working hours should be addressed in that particular department or hospital alone. Writing to the papers will not do anyone, especially you, any favour. So please, I beg you to stop. We should not generalize the issue because it simply does not reflect the entire housemanship training system in this country.
WORKING ENVIRONMENT
Much has been said and discussed regarding mistreatment or alleged bullying of HO by certain MO or specialist. All the complaints published in papers or social media influenced the public to equate this profession to a hostile working environment for the training of young doctors. Senior doctors are reported as people who tend to shout and carry out public humiliation.
Well, every profession has its own Gordon Ramsay and Simon Cowell. All the scolding, shouting, and sneering that make you feel depressed and demoralized was done with the intention of shaping you to be the finest cook and entertainer. Or the best doctor for this matter. Every person has a unique personality and so do those in the medical profession. That is what makes life so colourful. Otherwise, our daily routine will be very dull. One day, you will definitely look back at your encounter with these ‘lovely’ people and share a nice laugh with others by just talking about it.
I believe that apart from few “tyrants”, majority of senior doctors are hardworking and dedicated teachers and trainers, who tirelessly will continue to train juniour doctors on top of carrying their daily routine works.
Some doctors, for reasons of their own, possess very poor work ethics and/or bad personal attitude. Again, this should not reflect the entire medical profession. All problems should be addressed on an individual level rather than to generalize the whole training system as hostile and abusive.
Bad influence can be a great teacher provided that you see things in a positive way. They can mould you to be a complete individual and there can be no other great teacher other than your own life experience. After all, what better way to de-stress from your hectic daily work other than badmouthing all the bad influences over a lunch or dinner with your colleague.
ROOM FOR IMPROVEMENT
I believe that time has changed and we should embrace it. We should look forward to the future and find ways to improve the current training system. To do this, we should start with the understanding of the actual issues. And it is definitely not long working hours or non-productive working environment!
The real issues for me are the capability of current young doctors to be trained and the willingness of the senior doctors to adapt to the changes.
As much as we like to compare current times with our past, the senior doctors should come to realisation that life is not as what it used to be. We ought to stop using the comparison to show how worse our condition was compared to the present moment. We should look forward and see how to improve on that, rather than belittle our juniours that they are not as strong as we were. Why should they suffer as we did before? This country will never progress if all of us have that backward mentality. It will be worse when the current juniour doctors are repeating the same cycle in future.
In discussing the issue, we should also stop being egotistical and self-centred. All comments made in social media were mostly irrelevant apart from to promote oneself as the best. It does not solve any problem nor does it offer any reliable solution. What it only does is to lengthen the never ending discussion since everyone in this profession has their own story to tell.
But ultimately, all of this would never come into discussion if the HO themselves understood the expectation of becoming a doctor and the aim of the training system. It is our intention to make sure that every doctor in Malaysia is competent and safe to the public and community at large. The current training system of house officers is designed to do just that. It all boils down to coping abilities and adapting to your new life as doctors.
The frustration among senior doctors is not with the privilege that the juniour doctors are enjoying now as HO compared to the old days, but rather whether these young doctors are well-equipped to be independent, safe, and competent doctors in future. With the current quality of fresh medical graduates, training of junior doctors is not as easy as it used to be.
Put yourself in the shoes of your MO and specialist. If previously they can review 10 patients every day and remember every single one of them, how do you think they feel when you only do review on 2 patients but still flipping case notes on a simple question like latest haemoglobin level or total days of antibiotics?
At the end of the day, it needs a mutual and collaborative effort from both the trainers and trainees alike. Both parties have to remember that the ultimate priority is towards the patients. Juniour doctors must learn and train hard because one day, they will become MO and make life and death decision. On the other hand, senior doctors must also impart knowledge and experience because we all hope for better colleagues in future.
BEING A DOCTOR IS A PRIVILEGE
Few days ago, I was having a meal at a hawker stall and I found out that my bill has been settled. While I was wondering who would do that, then came a stranger who shook my hand and said, “Doctor, you may not remember me but you did a surgery on me before. And for that, I am truly grateful.”
That, my dear juniour doctors, beats all the hardship and adversity of your life as doctors.
Look past beyond how many hours you work every week and you will see the privilege of carrying a ‘DR’ in front of your name. We touch people’s heart and that is what we do best.
Your housemanship will eventually end, but your training will last forever. Have good attitude and aptitude to continue this journey forward. We all pray that you completed your training as HO and join our family as a fully trained and qualified doctor.
Dr. Aimir Bin Ma’rof is a medical officer working in Sarawak.
This is the personal opinion of the writer and does not necessarily represent the views of The Malaysian Medical Gazette.
[This article belongs to The Malaysian Medical Gazette. Any republication (online or offline) without written permission from The Malaysian Medical Gazette is prohibited.]
Thank you Editor for publishing this article. I sincerely do not expect it to be published as I submitted it quite a while ago. Therefore, I hereby declare that the same article is also published in Berita MMA, January 2015 edition.
Thank you Dr Aimir. We had to make way for the flood related and back to school articles first. We have also updated the editing.
Dear doctor, i am a houseman. And i do believe some comments/complaints made by these colleagues of mine are way exaggerated. But let me tell you this, it do happen in certain hospital, where working hours are dragged to long it exhausted our spirit.
Maybe you can check the medical department in the biggest hospital in Klang Valley. At the moment they are having extra if not extreme shortage of HOs, that they have to do EOD on call. Straight. For more than a month already. And the oncall system though they said postcall can go back at 12pm before continuinig oncall again the next day, you know well yourself they will only go back around 2-5PM, depending on how fast the morning rounds and the pending works. I am not kidding when I say they are currently working at 125++ hours per week without proper off day. Only postcall off as you said previously in your post. And because of too tired and exhausted some of them started MIA and quit, leaving those persevering much more works, and of course extra working hours.
I guess it’s a matter of HO distribution in hospitals around malaysia and also across departments in a single hospital.
But of course usually we only want to believe what we want and what we see in front of our eyes. And as you said in your hospital life of HOs seems good,then good enough for them. But please have a look/listen at other hospital HOs as well. They might be experiencing things differently
Dear HO, thank you for the comment and hence the statement, “I do not deny the fact that there may be HOs in certain hospitals who are currently working more than 75 hours per week.” I am from Klang Valley by the way, and as much as I pray to work there as HO for the sake of convenient, I ended up being ‘thrown’ here to Sibu. So yes, I know how Klang Valley hospitals are and to you personally, yes, I do “have a look/listen at other hospital HOs as well”.
This is the edited paragraph published in Berita MMA:
Currently in my department, there will be about 6-10 HOs for each daily morning round in a single ward and every HO will review about 1-4 patients each. On a good day, some of them do not even have to review any patient at all. I am referring to the same hospital where five years ago, every HO is accustomed to review 6-12 patients on a regular daily basis. So, is it true that current young doctors are overworked?
I added another sentence to my original article because I know some people like you would say that my hospital is not busy and HOs here are having a wonderful life. Remember when I said we tend to embellish our story? Everyone wants to say they are working in the biggest busiest meanest environment hospital, and somehow it usually comes from doctors in Klang Valley. Dear HO, all of that is very subjective and unless you make an objective comparison with ALL hospitals in Malaysia, please do not announce yours as the biggest/busiest.
It is true that there is maldistribution of HO and my department was the last in Sibu to implement the shift system because simply we don’t have enough numbers of HO previously. And they too did EOD call as well. We received one or two complaints from some HO and parents when they were doing on-call system. But eventually, the numbers of HO increase and we honour their right for the shift system.
What they experienced and what some of you is experiencing now is part and parcel of becoming a doctor. All of your seniors went through it before. Do we hear their complaints in newspaper? Not because we accepted it as it was but because we understand the situation required it and our patients need us. Trust me, we all craved for less working hours but what about our patients. We endured, we persevered, we suffered..all because of our patients. Occasionally, no matter how busy you are, there will be good times when you can just sit around doing nothing and look back on what you have experienced with pride even though how stressful it was.
There were moments in Sibu where only 6 HOs available in medical department. Can you imagine how they worked? You talked about doing EOD call, I did back-to-back call as HO before!! So don’t compare with how many EOD calls I did before. All of us has our own fair share of struggle but it depends on your attitude how you perceive every struggle.
Coming back to your comment about that medical department in that biggest hospital of yours, that is what I’m trying to convey in this article. I understand how some of you feel. No one should be allowed to suffer like that. I admit that you are having that problem. But you having problem is not equal to all HOs in Malaysia having the same problem. Be an adult and deal with it professionally. If the feeling is mutual among all your colleagues, approach your HOD/Hospital Director/JKN Director and settle the problem as adults. If that 6 HOs in medical department at my hospital went through the 4 months without whining/complaining or single complaint letter in newspaper, why can’t you do the same?
Lots of people are having a “look/listen at other hospital HOs as well”. Otherwise, there will not be any Flexi System as it is. Medical profession will continue with on-call system forever. But maybe, HOs nowadays should start “looking/listening at their ownself as well” because maybe, that is where the problem lies.
If you are posting about HOs but are not subject to the current system, having undergone a different system, of course you will say yours was harder.
I mean, what else could you say that is going to validate your position?
I mean tyrant doctor alert! Dismiss anyone who doesn’t agree with you? The HOs are working to correct the difficult outdated medical training with something more effective and better for the medical profession. The least you could do is help them.
And in the next few years when a new system is introduced, current HOs will be able to say that theirs were the hardest. And the stories never end…
Ever since I became MO, one of my aims is to make life easier for HO because I do not want them to go through as I had before. The only little things that I ask of my HOs are the professionalism as a medical doctor and a correct attitude to be trained and guided in order to be a safe, competent and humble MO/Specialist in future. But then again, some people will always misconstrue our intention and nothing you can do about it. Ask any of my HOs and I will always count on them to “validate my position”.
This is from a doctor who is CURRENTLY still a HO, and we understood each other and the struggles that we faced together as doctors in HOSPITAL SIBU:
“It could be your reader has not been through 4 months of EOD calls without off day (and without office hours), therefore it’s an issue for he/she to have 1 month continuous EOD calls. Perception and comparison varies greatly from individual to individual. Let us refrain ourselves from finger-pointing culture, but to work together and show some collaboration among seniors-juniors, strive for a better future and not continue to tarnish our image as medical professionals in the public. Glad to be 1 of the Sibu Hospital’s HO”.
Hurm, sometimes it is really hard to make people understand the real issue. There is nothing wrong with the system. The problem is with the people in the system, be it the seniors or the HOs themselves. Do not feel that only “the HOs are working to correct the difficult outdated medical training” because we are all in this together. Even if not all of us, some of us will. So, let us work together as PROFESSIONALS! The least I could do is help and guide my HOs and the least you could do is to write your real name!
The long working hours of HO are horrible. I\’m an engineer, to me the way HO are forced to work such long hours is illogical. Even machines need resting and maintenance, I do not understand how a human body can withstand such torture, it\’s against the law of nature! Doctors are supposed to be experts and benchmarks of health, but yet you live a supernatural life and work in every way against a healthy life. Doctors are burning candles, sacrificing yourselves to serve mankind. I pray that all good doctors will have good health and happy lives. Thank you doctors.
Hi, aimir. I have to admit that I agreed with you. Life is never easy. My houseman ship was 8 years ago. Medical posting was the busiest, the most tiring, tensing and whatsoever thing can described. EOD calls? Nah.. That just a small part of it. Straight calls for 5 days in medical posting during long public holidays with one person covering 30 patients? Yes. I did it before. With 4 intubated patients and 4 hourly ABG and 4 patients on PD and 4 hourly BUSE. Anyway, the thing is I am not trying to compare the training during my time with the current time. Now patients are more educated. They read and googled before seeking treatment. They asked lots of questions because they are concerned and internet is easily available. Not only young doctors have difficulties, the seniors too. So these are the challenges that we must faced. Wake up and get up!! These are the rainbows. Sometimes there will be clouds or even storm. Cry if you must but never quit. This is what you are \’designed\’ for. A bit of fine tuning, a bit of pain, a bit of lack of sleep and there you are. At the end of the day, look back and say proudly \”I survived\”. And your patients will survive too. There\’s nothing sweeter than seeing the old granny without a single teeth smiling at you thanking for saving her life. Houseman ship is definitely the toughest as some say\” the beginning is always the hardest\”. The circle of life will begin again once entering master program. There is no full stop if you are dedicated to learn.vbxdn
Its nice to hear the younger doctors voicing their opinions. Maybe we dont have enough avenues for them to express themselves. Another thing lets not loose our sense of humour at laughing at ourselves!