House Officers: A Rose By Any Other Name....

We can call these medical graduates housemen, interns or by the acronym H.O. One lady surgeon even calls them slaves. The fact is, house officers are indispensable in Malaysian healthcare.

The day house officers in government hospitals go on strike is the day Malaysian healthcare collapses and comes to a total halt.

There is...a dire need for a system that places an emphasis on accountability and meritocracy. The lying house officer must be brought to book, the incompetent house officer sent back to his books, and the outstanding house officer written in the good books.


House Officers: The Backbone of Malaysian Health

Hypocalcemia in Pregnancy

It was 3am in the morning. A lady at 32-weeks of pregnancy came to the hospital complaining of numbness and very mild weakness over her right hand that was limited to a few fingers. The first house officer who attended to her, Dr. Gua, had no definite diagnosis in mind. She took the routine blood investigations anyhow which included a calcium level. Her calcium level came back as 1.9 which was low. Alarmed and concerned, Dr Gua referred the patient to her obstetric medical officer who was similarly troubled. She too had no inkling of the underlying cause and in turn referred the patient to a fellow medical officer from the department of internal medicine. The trainee physician arrived dutifully in a short while, attended to the patient, asked a few questions and ordered a truckload of blood investigations. The barrage of blood tests included a thyroid function test, liver function test, serum phosphate, serum magnesium, renal function test, serum and urine cortisol amongst others. She was worried over the unexplained severely low calcium level and decided to admit the patient for intravenous calcium gluconate.

Once in the ward, a second house officer reviewed the patient. Dr. Ahmad read through the notes and asked some basic questions. He too, was increasingly worried, but for different reasons.

Here’s why.

The initial blood was taken with a tourniquet that was applied for a pretty long time. Such a method of blood sampling may result in an artificially low calcium level due to physiological changes around the area where the tourniquet was applied. In other words, the pregnant mother did not have low calcium to begin with. Intravenous calcium gluconate is dangerous and could have killed her instantly.

The story does not end here though.

Dr. Ahmad repeated the blood sampling without a tourniquet. The result of the second calcium level was 2.2, which was acceptable in pregnancy due to physiological changes in the blood constituents. His medical officer however, did not think so and again referred to the medical team for further advice. It was decided that the plan to give intravenous calcium gluconate should go on. The mother was started on calcium tablets thereafter. Dr. Ahmad remained unconvinced and suspicious of his superiors’ management throughout. He complied nevertheless.

In retrospect, the pregnant mother presented with symptoms very typical of carpal tunnel syndrome. It was the right timing at 3am, the exact symptoms and in the ideal patient. There was no need for any blood investigations or any possibilities of an impending stroke whatsoever.

House officers and the Quality of Malaysian Healthcare

The public healthcare of Malaysia will rise and fall with the services of the house officers. I do not know about the rest of the world but this is fact for Malaysia.

The first personnel to attend to a newly admitted patient in the ward is usually the house officer. The ill patient who suddenly takes a turn for the worse is usually referred to the house officer on-call. Blood investigations, applications for radiological procedures, referral letters and discharges, and basic clinical procedures are all carried out by the house officers.

Without house officers, much work will not be carried out or would have to fall upon the shoulders of the medical officers.

We can call these medical graduates housemen, interns or by the acronym H.O. One lady surgeon even calls them slaves. The fact is, house officers are indispensable in Malaysian healthcare.

The day house officers in government hospitals go on strike is the day Malaysian healthcare collapses and comes to a total halt.

The Malaysian Medical Association (MMA), when they are not boozing away in the MMA house, has been fighting for the rights and welfare of house officers for decades now. I say aye to more rights and welfare and renumeration for house officers, yet I also know pretty well that we have a very variable and colorful population of house officers in the civil service. Not all of them deserve their basic salary of RM 2137.70 much less their much acclaimed right to greater benefits, higher allowances, more oncall claims and automatic promotion to a U44 grade officer.

I only have the experience to compare Malaysian graduates from local universities to Malaysians who graduated from foreign institutions.

Truth be told, despite all that they say about the low standards of our medical schools, the majority of our local medical graduates fit in fairly well into the local healthcare system. Fitting in is not synonymous with competency and excellence but most of our local graduates nonetheless are able to function in a system they are familiar with.

Granted a chance to work with foreign graduates in a foreign land, I just might be singing a very different tune. However, I am not even for a moment under the delusion that other nations naturally produce more ethical and more knowledgeable medical graduates.

I do know however that in most developed nations, there is a prevailing sense of responsibility and a emphasis on a culture of accountability.

That is something that is sorely lacking in our healthcare services.

The ‘Don’t Know’ House Officer

All doctors do not know something to certain extent. In fact, all doctors will not know anything about something if you prod them hard enough. Personally, I studied pharmacology rigorously like a mad man in medical school and naturally, I take pride in knowing something about drugs and toxins. If someone asked me something about the histological variants of ovarian tumors however, I will reply with nothing less than a stupid blank stare and declare with no shame that gynaecology is not my forte.

There are many house officers who however, seem to know nothing about all things. It’s really anyone’s guess whether this has always been the trend even in the good old days of Tanah Melayu or whether such a dunno tak tau culture is the result of half a century of race-based intake into local medical schools. The NEP policies have given rise to a complacent lifestyle among both Malay and non-Malays students. Why study hard when one has been having things served on a silver platter one’s whole life? Why study hard when one can pass an exam because the marking standards have been lowered to cater to the ‘special children’ with special rights?

House officers from foreign universities are not naturally better though.

The most reasonable and objective statement is to evaluate each house officer as an individual and not from the university one graduates from. We have a great number of lousy, undeserving students entering local universities both public and private institutions and they are not restricted to any particular race. We also have an abundance of mentally-challenged personalities graduating from India, Ukraine, Ireland, Indonesia and China. No doctor should be identified or stigmatized by the university one graduated from. The final competency of any medical student is really all about the person’s own initiative.

Unlike graduates from computer science and social arts and food technology, medical graduates upon completion of their studies are never ready to get up and work. A ‘don’t know anything’ house officer is terrible, but not beyond help. A conducive training environment made up of willing teachers, understanding superiors, supportive nurses and adequate facilities will make a world of a difference.

The ‘Don’t Know, Don’t Care’ House Officer

A forty-something man was admitted for hemorrhagic stroke. After a few days in the ward, he developed pneumonia and required mechanical ventilation. The house officer on-call whom I’ll just name Dr. Chong was entrusted with the task of sampling the patient’s arterial blood gases. He did so, but did not know how to interpret the results. Even so, he did not seek help. At 8 a.m six hours later, the patient died. Postmortem, the notes were reviewed and the results of the blood gases taken before the patient’s death were nothing less than shocking. It showed severe combined respiratory and metabolic acidosis.

Dr Chong is the kind of house officer I categorize as the ‘don’t know, don’t care’ type. These are characters that never fail to baffle me. I wonder what these clowns are doing in the profession of medicine in the first place.

They don’t know, not because they have cerebral palsy or severe mental retardation.

They don’t care, not because it’s not their business, but because they are callous, indifferent or simply uninterested. They appear to hold firm to the belief that ignorance is bliss. No matter what is happening, what instructions were given and how these house officers are reprimanded, their response is always along the policies of ‘don’t know, don’t care’.

“Doctor, patient is in pain…” – Don’t know, don’t care.

“Doctor, patient’s potassium is only 2.6…” – Don’t know, don’t care.

“Doctor, how is my surgery going to be like tomorrow?” – Don’t know, don’t care.

“Doctor, I am having a cough and a fever…” – Don’t know, don’t care.

These house officers are beyond help. As the person battling at the frontline, they do not seem to realize that the things they do and do not do at a certain time can make a big difference to a patient’s outcome. Perhaps they are not truly beyond salvation. Perhaps when one of their own family members die or fall ill, they might turn over a new leave and change for the better.

The ‘Don’t Know, Don’t Care, Bullshit Non-stop’ House Officer

These are the most dangerous and perhaps the most difficult to see through. Some people are born to talk, and then there are those that are born to bullshit. They are not necessarily smart. In fact, those who knew them well and long enough might even suspect them of having mild dyslexia. They are not caring, far from it in fact.

They are however very capable of putting up a face as though they are sweet, empathic and all that’s noble in a doctor’s holy heart.

They slither out of troubles and crises, and I use the word ‘slither’ because these doctors are serpents. Deceitful and cunning, eloquent and loud, these doctors will do anything to save themselves from trouble.

Outright lies, dubious documentation and clinical sandiwara are their practice of the day.

I’m reminded of someone I’ll call Dr. Marvin each time I come across such deceitful doctors.

Dr. Marvin was a graduate from a local private university in Melaka. He’d disappear for hours to have his cigarette session. When confronted about his disappearance from the ward, he would feigned that wide-eyed innocent look, stare you back in the eye like Shrek’s Puss in Boots and exclaimed regretfully that he came across some frail old osteoporotic lady on his way back from the busy clinic who required his assistance climbing the stairs to the second floor. When he failed to turn up for work or oncalls, he would swear on his mother’s grave that his father had a heart attack at home at 6 am in the morning. His father must be a very blessed person, because the senior Marlin has had twelve supposed heart attacks in the preceding two weeks and is still mysteriously alive with no symptoms of heart failure.

Unsurprisingly, these are the house officers most liked and favored by their superiors.

Unlike the don’t know, don’t care house officer, the ‘don’t know, don’t care, bullshit non-stop’ house officer are truly beyond redemption.

The ‘Know Something, Can’t Do Anything’ House Officer

House officers have for far too long been erroneously labeled as being a homogenous group. They might be the lowest in the hierarchy of the administration but they are never all equal and same. Similarly, just because one is a medical officer, specialist or consultant does not mean that the person possesses greater knowledge and more astute clinical acumen.

A young lady at 18 weeks of pregnancy was admitted to the High Dependency Unit for “UTI sepsis”. She was experiencing high fever with shortness of breath. Urine tests showed an ongoing urinary tract infection (UTI). She was treated with antibiotics and hydrated vigorously. Upon completion of the antibiotics, she was swollen all over the body. Her feet were both so puffed up that she couldn’t even wear her own sandals. Fluids were accumulating in her lungs, her abdominal cavity and even around her genitalia.

The consultant obstetrician came and ordered for a full workout to exclude tuberculosis and HIV.

The specialist in turn thought the source of the infection was from her genitalia. The so-called specialist refused to listen to the house officer’s objection and ordered an emergency surgery to incise and drain the ‘labia majora abscess’.

The medical officer complied.

The patient complied too and went under the knife.

There was no abscess.

In the midst of all this stupidity and narrow-mindedness was a house officer name Dr. Mel. Unknown to and unlike the consultant and his team of esteemed specialists and honorable residents, Dr. Mel had sat down and taken a full medical history and performed a complete and thorough physical examination. Dr. Mel had done something none of the obstetricians did. He listened to the young mother’s heart and detected a murmur. Dr. Mel put it all together and opined that the patient’s fever was because of infective endocarditis that had set upon a heart that was defective to begin with. The ongoing generalised edema was the result of heart failure.

He was sure that the obstetricians were wrong. He was sure that the patient had no supposed ‘labia majora abscess’. He was sure that sending the patient for surgery was a dumb and lousy idea. His hands were tight though. In a feudalistic system however, who will listen to a lowly house officer?

His conscience got the better of him in the end. Dr. Mel secretly arranged an echocardiogram for the patient. It showed a mitral valve prolapse with calcified valve leaflets. He restricted the patient’s fluid intake to 500 cc per day. Within a week, the patient was fit to go home. The last I heard, both mother and child were safe.

Summary

No doctors can fully rid themselves of the humbling title of house officer.

At best, every doctor is an ex-house officer whether one is now a consultant, a specialist or a private practitioner. Not all competent house officer ends up as a specialist and similarly, not all specialist was once a competent house office.

The specialist of one discipline may very well be as competent and knowledgeable as a house officer in another discipline. The obstetrician will fumble around when faced with an orthopaedic patient.

Thus, there is no need for arrogance and unnecessary show-off.

There is however, a dire need for a system that places an emphasis on accountability and meritocracy. The lying house officer must be brought to book, the incompetent house officer sent back to his books, and the outstanding house officer written in the good books.

This article was about house officers – their quality and qualities, their ethics regardless of ethnicity.

The contents of this article can easily be extrapolated to medical officers and specialists and consultants in fact.

After all, the consultants of today were the house officers of yesteryears.

For example, the ‘don’t know, don’t care, bullshit non-stop’ HO of 1980 is a neurosurgeon today.

Sigh…..