I have not been on call in years, so some of you may wonder- am I qualified to be writing a guide to housemanship. Uncle B had the misfortune to be admitted recently for severe abdominal pain- most likely from overeating or food poisoning from orcal-fecal contamination. You know how these disgusting orcs just poop everywhere. And what with our fondness for food and beer, good or otherwise – especially during Oktoberfest. Anyway, from where I was sitting at the emergency department where Uncle B was waiting for attention, I can observe many of the young doctors on the ground bustling around doing their changes, and what a heart-warming sight it is!
After hours of waiting in the P2 area in the emergency department, kept fasted because no one can exclude an acute abdomen, xrays done were unable to see free air or bowel gas because there was too much adipose tissue … anyway- we finally got a bed in the subsidized ward where we waited for a CT scan. Nowadays, a CT scan is ordered to diagnose anything from acute appendicitis to chronic ingrown toenail.
He had a precarious blue plug on his left hand- after many failed attempts… of course, our hairy feet precluded any chance of plug setting there. The drip was finishing- the trace of blood back-flowing up was mildly disturbing to him as a layperson.
A fresh-faced young lass came up to him and started clerking. Interestingly, she has already filled in much of the clerking sheet. The questioning went something like this,” So, Mr B? You know what you have? Pain right? Ok. Don’t eat until my senior comes and sees you. Thanks, bye.” Apparently, she has already obtained the history and physical examination from what was already available from online. The rest of the night was uneventful, except for my Uncle B making a fuss about to eat, and me secretly sneaking in a vending machine sandwich for him. He was discharged well the next day.
Being the good nephew that I am, I kept him company the whole night, and it was an interesting experience being the patient’s family, rather than being the managing doctor! From what I can see, housemanship has changed a lot since my time. For one thing, there’s a lot more of them! It used to be one houseman looking after 30-40 patients, now it seems like there are more doctors on a ward round then patients sometimes! Of course- in my time, policemen wore shorts, the television network was called SBC and most importantly, Britney Spears was still a virgin on the Mickey Mouse Club (OK I exaggerate on the last point. I actually meant Madonna).
Housemen nowadays are a mixed group, maybe one-third are “out-of-phase” doctors from foreign universities; some are post-grad doctors- most of them are “residents”, already pre-selected into a specialty training program, and some display this in a few ways:
1. Bochap-ness when it’s a condition outside of their chosen specialty
2. Confidence, bordering on arrogance when it comes to a topic that comes under their specialty (never mind that they are 2 weeks fresh out of medical school; all full of book knowledge but no clinical experience.)
3. Talking back to their registrars or consultants (it used to be, when my boss said jump, I asked how high? And just do it. Even if I can’t really jump, what with my bad knees. Now, residents will argue that there is no need to jump, if you want, go ahead and jump yourself.). Some even call their registrars and consultants by name (which in my time, along with buying McDonalds for supper, was a crime punishable by death or exile into the Phantom Zone).
However, this doesn’t mean it is all bad. We are still getting the best and brightest into medical school, so they must be the best and brightest young doctors. In fact, now that they have structured, protected training, they are even better than the current registrars and consultants. I bet, if the current Regs and Cons have to do the ABSITE, the scores will be dismal. So maybe they are entitled to their hubris. After all, residents’ and students’ complaints and feedback are taken so seriously that Registrars and Consultants get penalized; while it is near to impossible to fail a HO/MO, no matter what a lousy doctor he/she is.
Skills and job requisites for housemen have changed a lot as well. I think the key skills needed now are:
1. Proficiency with computers- with the rollout of electronic platforms for EVERYTHING, a good doctor must be one with the computer. Tracking patient’s location, ordering investigations, getting consent, tracing notes from other institutions, looking at imaging, changing settings, reviewing medications, etc. Naming these programs Sunrise and Aurora may be misnomers. More appropriate names are “Hangman”, “Crashes” and “Error loading”.
2. Fluent in Acronyms- SOOB, BIBA, TOC, ERx, CPSS, C-DOC, OTRS, OOTS, CPACS, AIC, CMIS, ROSC. OMG, LOL.
3. Diploma in printer repair- a good doctor must know how to unjam paper, replace toner, replace ink; change printer settings from single to double page; must know how to print things from a remote location because the printer in your ward just won’t work, especially when there’s an emergency OT chit to be printed out before the porter & nurse can bring patient down to the OT.
4. Certificate of competency in Whatsapp-ing (SMS is so ‘90s)- the convenience of chat groups for a generation raised in this media age is a welcome escape from actually having to talk to a colleague to hand over cases. If clinic reviews may be done via Facebook or Snapchat, it’ll be embraced. An example:
Postcall HO: “Hey Team 3 HO, pls note ytd adm 1 perf PDU, for EOT, chit n consent up. Tq. ☺”
Team 3 HO: “g8t, thx!”
Despite the years between us, some things never change. The good houseman must still be like an octopus- multitasking and getting things done, because they are the invaluable ground team and mini-miracle workers who get things done. Many have used the minions from Despicable Me as their FB photo. I can still relate to that!
The good houseman/resident must still be able to:
1. Create a patient list (no matter what computer program is used)
2. Engage in bovine-worship (In ancient Biblical times, there was the golden calf, now there is bowing at least 4 hours a day before the ubiquitous COWs – computer on wheels)
3. Lie through the teeth to get an urgent review or scan done
4. Convince a social over-stayer to go home/ convince MSW to hasten application to nursing home
5. Trace changes, order meds (done in the comfort of the aircon lounge because it’s all online!)
6. Look after patients when their seniors have disappeared to clinics/OTs/snake temple
7. Take a good history (with more foreign patients nowadays, good thing we have more foreign nurses and doctors to help with translation. Unless it just so happens that the combination is not ideal- eg. PRC patient, clerked by a Singaporean overseas grad who speaks only Queen’s English, with a Fillipino staff nurse, and a Tamil speaking assistant nurse.)
In fact, while housemen nowadays seem to my old, jaded eyes to be less well-trained; is it the fault of the system which has made them so? I won’t be able to function as a houseman nowadays; I type with both index fingers. I can take bloods, set plugs, do hypocounts, insert NGTs, do ECGs, put up drip; but I can’t type fast. The modern houseman has more help from nurses and allied healthcare to help with the physical changes; to the point that some perhaps, have not quite learnt how to do them. More importantly, there is this surreal expectation from policy makers practicing zero-risk medical administration that once you pass housemanship, you can miraculously take on new and additional responsibilities like sign a death cert and take consent for simple procedures.
Moving forward, how can we improve the training system for doctors, and specialists so that we won’t face a shortage of generalists in 10 years’ time? That is a topic for another day; The Hobbit II “The Isolation of Smug”. I need to go have lunch with my Uncle B