The Desolation of Smug – Hobbit’s Guide to Being a Good Resident

When I first heard this term, I thought, “As in, Permanent Resident versus Citizen?” or as in the game and movie “Resident Evil”? I also thought itmeant that the resident RESIDES in house 24-7, otherwise why the term? That first one year of rolling out Residency Program, there was chaos. It used to be that call rosters are straightforward, and hierarchy is clear.

The houseman clerks the patient (ie. talks to the patient, fills in something calling a “clerking sheet”, sets a plug, draws blood, does an ECG, orders a CXR). The good houseman gets all these done, steps ahead of the rest of his team. The bad houseman asks his MO to help, because having 2 admissions at one time is too hard to manage.

The medical officer then reviews the patient (by checking that the clerking was done properly, orders more stuff to try to impress the registrar; maybe tell patient things like “kiv CT”, “kiv “PFO”). The good MO functions as a top-notch HO as well as effective registrar. The bad MO hides in the call room and claims all the credit for the HO’s work.

There are different grades of HO/MO. The best ones are hardworking and smart of course; of the rest, they may be classified into:

Grade 1: lazy but smart- “Slacker”
Grade 2: hardworking but stupid- “Blur cock”
Grade 3: lazy and stupid- “Space cadet”
Grade 4: lazy and stupid but think they are God’s gift to Medicine- “Consultoid”

Consultoids actually aspire to greatness when they do not have any of the required ingredients; similar to current Mediacorp serial: “The Journey: a Voyage”. For those of you who have not watched this (which I reckon is about 99% of the profession), the serial is about 3 ASTs kena jammed by the residency system and now have to complete their specialty training overseas in strange foreign lands.

Grade 1: no need to do anything, they will drift into their chosen subspeciality or locum-land
Grade 2: keep teaching and hope that eventually something sinks in
Grade 3: leave alone- hope that they drift off out of medicine and never be in a position to do harm
Grade 4: no cure- they grow up to be bad registrars and bad consultants

The registrar does the final review on call, and makes the tough decisions (eg. What shall I get the team for dinner? Bak Kut Teh or Zi-char or pizza? BTW, YLLSOM graduates do NOT eat pizzas when on-call. These are reserved for those with posh-nosh foreign degrees)

Seriously though, in most disciplines, the most senior person who stays in-house is a registrar. He must make the right balance; manage sick patients independently without compromising patient safety. If everything call consultant, will be seen as useless; if everything don’t call consultant, may be seen as reckless. The good registrar knows his work, escalates to the consultant appropriately (rather than a phone call to say, “eh, sorry boss, should have called you earlier before patient went into asystole…” and looks after the junior team well. The bad registrar is the consultant’s worse nightmare. The smart con soon learns to be friends with the roster planner to avoid having a bad registrar on call for him.

The consultant on call is the final bastion. His word is law, his will be done. Except when there is a VVIP patient in which the consultant (especially a young one) will be reduced to standing around in the corridor until the Head of Department, Division Chairman, CMB, CEO, GCEO appear to make a collective decision on anything from performing major surgery to whether the VVIP gets fish or chicken porridge for breakfast. Otherwise, the good consultant is a master of his craft, a teacher, a good administrator, a good researcher and a healer. The bad consultant doesn’t really know his work, does not know how his hospital systems work, has forgotten (or maybe never knew) basic medicine and surgery. He was probably a consultoid in his younger days. The good consultant is well loved and well respected by his juniors and peers. The bad consultant is hated, being the cause of a lot of unnecessary work. (Refer endocrine for hypocount 14, refer GS for Hb 12->9 after hip replacement, refer CVM to start medicine for hypertension or fitness for OGD when it is obvious the bleeding peptic ulcer patient is going to die if an OGD is not done…)

Nurses used to know clearly whom to call to do certain things- actually, everything call housemen first. Housemen are the magical elves who make things happen. But over the years, as more and more duties get taken away from housemen- eg, phlebotomists take blood; nurses do ECGs, check blood before transfusion, etc; consents are taken by at least an MO and above… housemanship seems to become more and more about clerical work.

Now, back to RESIDENTS. Different programs take in residents at different years post-grad. Residents are a varied bunch- some have just graduated medical school, some are medical officers of varying seniority, a few are foreign grads who might not have working experience in Singapore, and some are trainees in the old system who got played out and had no choice but to change to the new. You can recognize them because they walk around with a look on the face that screams “Screw me harder – I can take it!!”. [machiam Leonidas from “300”]

So, a team of 3 HOs and 3 MOs may have 1 HO-resident, and 2 MO-residents- and the roster reflects them as “residents” instead of the traditional HO/MO. What this means on the ground is that, nurses were not sure who call to do changes sometimes! It didn’t help that some departments appointed HO-residents to tag on MO calls, without actually doing MO work because of the P-number, but also not doing HO work. While this may seem superficially to be beneficial for the HO-resident, it actually is detrimental! This HO may not learn enough skills as a HO to be effective at a MO level; and when he turns into an actual MO, can he perform his tasks? Anyway, the key message is that the clarity we had in the HO/MO days is now a royal mess.
A good resident is expected to be a super high achiever. The student who applied would firstly, have to have good grades; secondly, the compassion of Mother Theresa; thirdly, a national sports champion and finally, Friend to all. Continuing this self-fulfilling pattern, he then goes on having to live up to expectations of being in the 100th percentile for ABSITE, win President’s Charity Award, complete training in 4-6 years, get good feedback in the “360 feedback”, publish 10 papers a year and be the next DeBakey.

This Hobbit has noticed that more and more “junior” people are looking down on him. Not just because Hobbit is short. Residents seem to be uncertain how to behave- confidence comes across as cockiness; humility is a forgotten virtue. Yet, how many of them feel pressured to act confident because they fear showing any signs of weakness? Confiding in your peers may be the last mistake you make because you don’t know who will betray you to the PD (program director). No way is any resident going to confide in a senior. So how? Just hide behind a facade and try to juggle everything.

Please let this Hobbit reassure you, dear resident. Have faith (not just confidence, but faith)- you were chosen because you are good. Do not let anything distract you from being the best doctor you can be, and that comes back to the heart of what makes you a good doctor- your initial passion and empathy to want to help the sick.
You must have been a “hardworking and smart” HO/MO to get to where you are. Resist slipping and becoming lazy- being smart can only take you so far. Keep reading and studying and operating to stay “smart”- and not just book knowledge, but be an all-rounder- build up teaching, research and leadership skills. Don’t neglect interpersonal relationships- truly be friends with your peers, seniors, allied health; don’t be friends just to get them to do things for you. Be friends because you do want a good working environment and a second family. Remember to still invest time in your first family, whether it’s your spouse, your parents, your sibs, etc.

Find good role models, and aspire to be like them, or even better than them. Be a master in our craft- how did this consultant KNOW that patient had aortic dissection just by LOOKING? How did this consultant manage to “NEVER” have a perioperative morbidity? How did this consultant become so well loved by everyone? How can this consultant have >200 publications? Admittedly, role model consultants are getting rarer with each passing year as the old legends retire and the younger ones leave for private practice to escape the system that you are in now.

But then, what do I know? I just live in a hole in the ground.

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