Life of a Houseman

I could not even begin to describe how my life has changed tremendously for the last one month. My current and previous work is nothing like one another. I used to work 40 hours a week, from 9 to 5 in Geneva. Even if I go to the gym in the WHO building, it still counts as working hours. Even my 30 minutes nap after lunch in the 'Quiet Room'! Little could I imagine back then that I would now be working more than 85 hours a week, waking up at 4.30 AM everyday, drive 20 kilometres to work, arrive around 5.30 to 6 AM, and work non-stop till 8 PM. That's more than 12 hours a day.

Life back when I was a medical student was even much easier. We go to lectures and teachings. No class? Go to sleep. It is true that working as a doctor and studying medicine is a whole different thing. Medical school is all about medicine. Full stop. Working as a doctor, half of the time involves non-medical stuff like dealing with patient's family, implant company agents, police officers, wardens in the nearby Sungai Buloh prison, lawyers, private investigators, SOCSO agents, and once I have to even deal with SYABAS, a water supplier for one of their employees who they believe is faking or exaggerating his illness. It's a crazy world, this doctoring world.

I was overwhelmed in the beginning, thinking 'what the heck, is this really what I want to do all my life?'. During the start of my work, when I was tagging, the job seems so daunting that I wake up with anxiety and nausea everyday. As taggers, we have to know all 28 cases in the ward, expected to present them at any time during ward rounds, without looking or refering to any notes. The task was gargantuan, and we have to stay until 10 PM everyday, which is the earliest (usually we won't be able to go back until 11 or 12 PM because of more work), and come to work at 6 the next day. That left like 3 to 4 hours of sleep everyday. I did that for 19 days, until I finally got off-tag. It was really a tough time for me.

But I always believe that we can get used to anything if we expose our brain long enough to the new challenges. Our brain rebels when there is too much new information coming in all at the same time. It needs time to digest things. It has been a month and my brain has started to accept this new working environment. I no longer wake up feeling anxious and nauseous. I begin to take more responsibilities, managing clinics, scrubbing in to operating theatres, attaching to the emergency department. Work is still stressful especially in the morning before ward rounds, but the stress goes downtrend as the day goes to an end. At the end of the day, nothing beats the feeling of driving back home feeling good you had a patient's sugar or blood level controlled just by putting a sign on the drug prescription, you sutured close a gaping wound nicely and stopped the bleeding, you nicely trimmed some fingers that went into a cutting machine, and inserted a steel rod into the legs to temporarily help with fractures. It is a truly satisfying feeling.

I no longer have doubts if this is what I will be doing all my life. It can be fun, but we can't see it while we are in the middle of the hectic working hours. It is time like this current moment, where I have a half-day off and working night shift tomorrow, that I can take a step back, think about what I did for the past one month, remember all the things I went through, that I feel it is worth being a doctor. For me, if a work is too much it becomes stressful. But if a work is too little it becomes depressing. I remember times where I had a whole day to write just a single report, but it becomes so depressing because I kinda have a mental block when there is too much time and I don't know what to write. I start writing 2 hours before the deadline in the end and feel depressed again feeling that I could have done a better job. Working in the hospital, you never have free time to be depressed about work. It's stressful, but it's a positive stress. All the work is done in the ward, when you go back you pass over your patients to the night shift doctor, and you go home not needing to worry to much because you believe your patient is in the safe hands of your colleague.

So in the end...yeah, being a houseman doctor isn't so bad. The only thing I still resent is the inability to confirm and convince to your non-medical friends when you will be free. I have always been asked for appointments and meet-ups for either HBB or just catching up. It is so hard to confirm a date where you'll be free because we work on weekends and our day-off can fall on any day and changes every week. It sucks, but otherwise, life's OK ;)

Mountains Beyond Mountains

My favourite paragraph from Tracy Kidder’s Mountains Beyond Mountains. To be honest, I never expect to be working at the ‘HIV Central’ of Malaysia. I always thought that I will be posted to Kuala Lumpur General Hospital. But God has better plans for me. I could not even believe I am saying this, but after 10 month being away from clinical work, I am longing to start again. I enjoyed working at the WHO HQ in Geneva, global public health is still my passion and it will always be, but the field is so vast, and I feel that I need to carve out my own niche, and infectious diseases, the biggest threat to public health, is one of the things I am most interested in. If I look at the public health figures I look up to most, they are physicians first, leaders in public health later: Mahathir Mohammad, John Snow, Paul Farmer, Rudolf Virchow, to name a few. I truly believe that by diagnosing diseases of a person, it will shape your mind and way of thinking to diagnose diseases of society in unfathomable ways. In Rudolf Virchow's words, "Politics is nothing but medicine on a larger scale". So come tomorrow, "ID says treat. Love, ID".

2013: Take It and Go

The past couple of weeks have been so refreshing. I wanted to use the word awesome but I think the words has been too overused last year so I am going to save it for an appropriate event, like, seeing auroras or volcano blasts or things like that this year. My department was on holiday for almost 2 weeks since it is an international organization, everybody gets back to their home countries for Christmas. Since it is easy and quite cheap to get anywhere around Europe on the train, I decided to do a bit of the tour.

The first place I went to, my friend and I met this young couple living in a small ski town in the Alps. We had the chance to see their house and hitch a ride with them to the train station. To be honest, we couldn’t really converse very well since their English is not that good, but from the little bits of conversation, I gather that they are very content with their lives, and that fascinates me. It is such a beautiful place to live, really, surrounded by mountains, lakes and lush landscapes, and they leveraged on that by living simply and being in touch with nature. For one thing, the house was built by their father, on his own, brick by brick. They have good internet but prefer to stay off social media and they fill their time taking long walks on weekends instead, hiking, cycling, skiing, and the likes of that. Many times during our conversation, they would tell how proud they are to live in the small village, away from the hustle bustle of the city. I have wanted to tell them yes, that makes their attitude totally different from the people in the nearest city we were in. I don’t think anybody in the city would be kind enough to let us hitch a ride to the train station and let some strangers see their house. There is just too much paranoia in the city.

 It makes me miss the times when I live such simpler lives too. So I gave it a try, one morning in Zurich I went off all social media, deactivating Facebook and Twitter, and just let my feet take me anywhere I see attractive. Being so used to uploading photos every time I see anything interesting and updating every thought in writing, I seem to struggle at first not to reach for my phone. But then, later a sense of freedom starts to overwhelm me. Walking through the old cobble-stone alleys of Zurich, I no longer see the beautiful scenes mostly through a camera lens, but instead with the perfect view of my eyes. Camera lens never do justice towards the beauty of nature anyway. The city, the old buildings, the lake, with the background of the majestic snow-capped mountains, I sat at a high point in the city and be still in the moment, observing life below me pass by, thinking these are the moments in my life that I feel most alive. It is true. These are the moments when I have full gratitude to the Creator for letting me live another day.

The renewed sense of freedom was so good that I felt I could stay this way for awhile, at least until the end of my holidays, since many of my work, especially with my NGO depends heavily on social media. So I still stayed off until I decide to write this entry, early new year, 2014, where my work starts again tomorrow. I have seen a lot of things in 2013, travelling across continents back to back. Doing things I never thought I would. But one thing I learn about doing things out of your normal circumstances, is that the ‘out of ordinary’ thing, now becomes the ordinary. I am not sure if that is a good thing or not, but it actually puts me at peace. It is not like losing interest and excitement in life, as if coming down with depression, no. It more like looking back, still couldn’t believe you did all that, smile and not talk about it unless being asked to. I think that is one way for a wise person to be humble. Do extra ordinary things when you are young, so you don’t grow arrogant with inflated sense of self-importance when you are older. Because you have done all of it when you are young, and it doesn’t mean too much to you anymore, that you don’t have to talk about it 24/7. Yeah, I like that idea. I am going to be content, say 2013 was a great year, and leave it there. In the words of Russell Peters when imitating the Indian culture: “Take it, and go”.

“We Actually Get Stupider When We Work Too Much”: The Case of House Officers

I have a habit of eating vegetables on the plate after I have finished eating everything else. It is surprising that many times when I eat with my friends, while I am wholly enjoying the ‘ayam masak merah’ with steamy rice, leaving the vegetables at the side to be consumed later, they would jokingly point out “Ha, you don’t eat vegetables? I thought doctors always ask people to eat healthy food?” This is a simple case of a common people assuming the doctors are not walking their talk. We have all heard the story of the heart surgeon who smokes a lot, the physician who is too obese, the psychiatrist who is always depressed and all those sorts of irony. As doctors, we always advice people to maintain a healthy lifestyle: Go for workouts, do not eat fast food, eat home-cooked meals, spend time with family and friends. But surprisingly, as we tell people all these things, deep in our minds, we say to ourselves “yeah good luck with that, even I have no time for those”.

Recently there has been a lot of commotion about the incompetence of Malaysian House Officers. We had the same furor half a decade ago, and the solution thought by the Malaysian Medical Council and Ministry of Health is that the House Officers need more exposure. Hence, from the one-year housemanship time period, it was increased to two years. Then a few years down the road comes again the same complaint. The assumption? Still need more exposure. We cannot increase the number of years (been there, done that). Hence, the suggestion was to increase the hours.

Doctors are not manual labors. Every decision we make may mean life and death to somebody. Tasha Eurich, a Ph.D. holder in psychology and author of a new book ‘Bankable Leadership’ go as far to say that “We actually get stupider when we work too much”. No matter how competent a doctor is, no patient wants a half-asleep doctor taking their bloods. The decision-making of a person is severely impaired simply because of sleep deprivation. I am a coffee lover and am familiar to the adage: “Drink coffee and keep working, you can sleep when you are dead!”, but research shows that even stimulants do not help. The researchers at Harvard Medical School recently found out that people who were sleep deprived might as well make a random decision. They performed less well as compared to those who had enough sleep even when given stimulants. Then when they were given a long period of recovery sleep, baseline decision making skills are back to normal.

As for the house officers themselves, studies show that over time, working long hours can increase their risk of depression, heart attack, and heart disease. It also increases the risk of road traffic accidents. This might not be proven yet in Malaysia, but with all the same stories I receive from house officers, I think a research should be done on how many housemen fell asleep at the traffic light back from a long day at work. It is downright dangerous. House officers, they have gym memberships but never had the time to go, they learn to cook healthy foods when we were students but now we are going to have to forget all of them, they have good friends and families, but never have time to see them. They go out of the house before the family wakes up, and come back at night after they have slept.  For those with spouses, an article on Harvard Business Review reveals that 50% of workers who work more than 40 hours a week are so depleted and drained when they get home at night that they’re speechless, incapable of conversation. Can you imagine how this will take a toll on relationships? How are we supposed to take care of other people when we do not have the time to keep ourselves healthy?

Realizing the bad effects of working long hours of health, we should forget the idea that to increase competency we should increase the number of working hours. It is not the hours that are at fault but the years before they graduated from the medical schools. We have too many students graduating from unrecognized Universities, too many private medical schools sprouting out without the capacity of enough lecturers to teach, too many students in a teaching hospital wards, and such. In recent years, the health indicators of Malaysians have seen good progress. Working here at the World Health Organization, Malaysia is always held in high regards when it comes to health care. It makes me proud being a Malaysian. House officers are too used to being told by specialists: “during the old days, I am the only doctor in the ward, worked on call 2 days straight”. Well then, look at the Life Expectancy, Malaysian Maternal Mortality Rate, Deaths of Children Under-5 and Prevalence of Infectious Diseases in the old days. If you want everything to be ‘like the old days’, would you also like our health indicators and life expectancy to regress back to the ‘old days?’. Doctors are also human beings included in all statistics on health indicators.

Going back to the conversation that I had with my friends as I was eating ‘ayam masak merah’, I wish someday I can fork the vegetables into my mouth, eat it all and say “Yes, I eat vegetables, I exercise at the gym 3 times a week, I usually cook my own food, and I usually go jogging on weekends when I am not working”. “Gosh, you are a doctor, you have time for that?”

“Yes, a doctor  is an advocator for health, no?”

Sources:

1. The impact of sleep deprivation on decision making: A review. Harrison, Yvonne; Horne, James A. Journal of Experimental Psychology: Applied, Vol 6(3), Sep 2000

2. 

 
1. Burke RJ, 
 
2. Cooper CL
 

. The Long Work Hours Culture: Causes, Consequences and Choices. Bingley, United Kingdom: Emerald Group Publishing Ltd; 2008.

3. 

 
1. Nakanishi N, 
 
2. Yoshida H, 
 
3. Nagano K, 
 
4. et al
 

. Long working hours and risk for hypertension in Japan. J Epidemiol Community Health 2001

Reviving the Politics of Responsibility

3rd week working at the World Health Organization (WHO) in Geneva, reading old reports, this particular paragraph made me proud to be Malaysian:

"on November 21, 1997, there was an official request to fund for an emergency rescue loan. Indonesia and Thailand signed up. Yet Malaysia did not. Amid mass demonstrations, the Malaysian prime minister Dr. Mahathir bin Mohamad, refused IMF assistance...It instead implemented a fiscal stimulus of 7 billion ringgit, including a boost to social safety net measures to mitigate the impact of the crisis...Malaysia took a dramatically different approach..Those choices helped prevent Malaysians from suffering the fate of Thailand, Indonesia and South Korea whose politicians chose to swallow the bitter pill of austerity. Indonesia and Thailand experienced significant increases in poverty and prevalence of malnutrition. Malaysia, by contrast expanded its food program to impoverished citizens and experienced a much smaller rise."

I like the old political landscape in Malaysia, where politicians decide on what they feel is right instead of what is popular. Sometimes radical decisions must be made, even if the decision seems to be less popular. Believe in what we feel is right, not fumble upon every demonstrations that threatens the number of votes. Leadership is not a popularity contest, especially when it involves the health of the whole nation. I am still waiting for a Malaysia that thrives on the politics of responsibility rather than popularity