Friday, May 23, 2008

The Director's Chair / When is a doctor not a doctor?

“I wonder why I work in this dead end job. My hospital is shortstaffed and my hospital director doesn’t seem to be doing anything. He’s like a puppet who leaves everything to God, classical ‘insya allah’ response to everything. The work I do does not commiserate with the pay. Job satisfaction is at an all time low…”

The Director’s Chair
I watch House on a regular basis. I don’t really enjoy the medicine in House. The strength of the movie lies very much in its wicked combination of soap opera and sarcastic humor, especially those coming from the title character himself. I download House episodes in torrent files so I have been able to watch up to the finale of season four.

There was one episode where the doctors were to undergo their annual assessment. House, the archetypical anti-establishment personality that he is, gave identical feedbacks for all his subordinates. In addition, Dr. Gregory House gave Cuddy the hospital director a very blunt and direct assessment of herself.

Among other direct-to-the-point messages, House told Cuddy that “You think you’re a doctor, but you’re an administrator.”

Entertainment will always be far from reality and science fiction will always be fake science. There is much truth and food for thought in House’s comments about his superior cum hospital director though.

All over the world, then and now and definitely for eternity, medical doctors give up on clinical practice for reasons as variable as one can imagine. All medical graduates started off with clinical work though, slogging as house officers/interns, sauntering about carrying out their superiors’ orders before becoming medical officers/residents barking orders themselves.

The Worth of a Medical DegreeBy the end of medical school, most people should have an idea whether their character is suited for clinical work and patient interaction. The few wise ones with much insight will readily concede their dislike of a doctor’s life and will not pursue a medical career any further upon their graduation from medical school. Some folks lament that the five years of medical education were wasted and a huge sum of taxpayers’ money were squandered.

I beg to differ.

A medical degree is just that – a science degree. It doesn’t make anyone smarter or more valuable. By any chance, the average medical graduate starts off as useful as a solar-powered torchlight in a massive power blackout. There is no way anyone will know for sure whether they will like the life of a clinician until the person has gone through the five years of medical school. It is perfectly fine and well that a medical graduate decides not to pursue clinical medicine upon completion of medical school. There is no joy in forced coercion. The person may not make a safe and caring physician anyway.

Then there are those who conquered medical school on a high note. They were all geared up to seize the hour and have even made up their minds to be a knowledgeable physician or a skilful surgeon or a non-bullshitting neurosurgeon. They hit ground zero after a few months upon realization that a doctor’s job isn’t as glamorous and as rewarding as they initially thought. Despite their vast knowledge or admirable surgical skills, many patients simply have conditions that will not respond to the most aggressive medical intervention. Disheartened and disillusioned over the apparent futility of their work, these well-meaning doctors end up with an empty fuel tank and bow out of clinical practice. They don’t end up as bitter losers in life though. Most of them will eventually discover their true calling in life and find it more fulfilling than strutting around in a super hot lab coat and a stethoscope around their necks.

Essentially, finding meaning in our daily work grants all of us a passion to live this life, regardless of our profession. Some doctors derive great satisfaction in mutilating gullible Sabahans in a bi-weekly bloodbath and dub it neurosurgery in action. Some desire greatness but don’t make the grade for clinical practice. These end up as administrators in the form of hospital directors more fondly known as the pengarah in local Malaysian dialect.

This article is based on a series of phone messages sent to me by a medical officer working in a district hospital in Peninsular Malaysia. Dr. Hashim is a close friend of mine and a former coursemate back in the University Malaya medical school. He was a natural smart ass who put me to shame in studies, remembering and mastering most of what he read at the first exposure. I have highlighted his messages in italic form.

Out of Touch

“I sometimes fell so angry, I want to grab my hospital director by the shoulders and shout at him to open his eyes and see that we are facing a big problem.”

I found myself nodding in agreement with Hashim’s statement as I was reading the message. Doctors who cease doing clinical work inevitable lose touch with whatever is happening at ground level in the wards, in the emergency department and operation theatre. Anyone seated comfortably in an air-conditioned office the whole day attending long winded meetings about lofty policies and rigid protocols will surely forget the endless orgy of blood, gore and grime taking place in the general wards every hour.

That is precisely why the perception and worldview between a practicing clinician and an administrator is as different as schmaltz and nasi lemak.

The clinician does his ward rounds and shakes his head in despair at the sight of patients sprawled all over the crammy ward in every nook and corner, cross-infecting one another with cough, cold and diarrhea. He feels helpless because his sincerity and concern for patients’ welfare is inhibited by the somewhat dumb and irrelevant policies set in place by the administration.

The administrator does his ward rounds too but sees a totally different picture. He sees the barren walls of the wards and chides the ward sister for not decorating it with colorful posters and cute little cartoon characters.

Both clinician and administrator busy themselves with figures and numbers. The clinician is concerned about the patient’s high blood pressure and low hemoglobin while the administrator is all worked up over statistics and records for his precious ‘key performance index’.

At the end of each working day, the clinician gives out a dispirited sigh because another of his patient had breathed his last under suboptimal care. The administrator too retires to bed but not before much griping and whining because his own administrative superiors are breathing down his spine.

Out of Sync

“He’s been forced to do clinical work the past few days. Otherwise he will do nothing. Once in a while, he’ll come to see a few cases in the emergency department or help the outpatient a bit.”

Most people will agree that the biggest problem with public healthcare services is the protracted waiting time. From the casualty department to the outpatient clinics to the pharmacy the size of the waiting crowd is nothing less than daunting to both doctors and patients. The number one administrator of the country, our esteemed and most wise Health Minister has vowed to reduce the waiting time at outpatient clinics. He thinks of many ingenious and extravagant ways to minimize the long and dreary waiting time. He has hitherto suggested computerized prescription, 24-hour pharmacies, drive-thru dispensaries and extended general clinics. In the process, he has proven himself to be the number one administrator most out of sync with events at the frontline. Like a broken judebox humming an outdated tune of the past, his ideas just doesn’t gel with the actual needs of the people.

Healthcare is not fast food business and pharmacies cannot be operated like a McDonald’s Drive Thru shack.

The determining factor of a patient’s waiting time at the hospital is really not so much about how the medical staff operates or whether there are sound policies in existence to ensure a smooth delivery of services. The ultimate factor in determining the length of time a patient needs to wait before receiving treatment is simply the absolute number of ill people.

Even a McDonald’s drive thru are not spared long queues if there are many hungry customers making large orders.

Therefore, the only way anyone can reduce the waiting time of patients at government hospitals is to reduce the number of people seeking medical care or to provide more clinicians and treatment centers. It doesn’t matter whether one has lofty slogans and grand ideas, for as long as there is a mismatch between the number of clinicians to patients, the agonizing wait at our public medical centers will continue to be the norm.

Regardless, administrators who only administrate and shy away from clinical work are not helping to resolve issues but contribute to them.

Out of Reach

“This guy just doesn’t get it. We’ve approached him many times before over the last two weeks, even pleading with him and yet it’s the same thing. He’s real thick, like a bloody slab of granite. How he ever became hospital director is really beyond me.”

Most Asians were brought up to practice diplomacy and good manners in their daily affairs especially in times of disagreement and conflict. In our feudalistic upbringing, we are taught to not to confront, not to question and to believe that the higher authorities know what is best for us.

Some characters are simply out of reach though, no matter what we do to make them see the blatant mismanagement that is unfolding in before our eyes. The hospital may be in such a bad state yet the administrator thinks that it has never been better. The administrator has selective blindness to the broken-down elevators, the squeaky hospital beds, the overcrowded medical wards, the snail-paced pathology investigations, the defective ambulance services, the over-profiting hospital canteen and the overpriced essential goods sold by the koperasi.

The director sees what he wants to see and ignores what he doesn’t like to hear.

He dwells on the trivial, insignificant and irrelevant, like ensuring each department and subdepartment has a personal corporate mission and vision that is penned oh so wonderfully and magnificently.

When complaints arrive at his desk and ears, the director behaves like a typical bureaucrat. He delegates all that is unpleasant and ugly to his subordinates who proceed to sweep most things under the carpet so that the issue concerned is eventually forgotten with time.

My friend Dr. Hashim is spot on. The big guy in the administrative office just doesn’t get it no matter how we try.

Out of Work

“He’s got this ‘what to do?’ attitude that needs to be slapped the shit out of him.”

It is pretty ironic that most administrators appear so preoccupied with the petty issues yet appear so helpless when the really significant issues loom and demand a definite solution. I’m quite sure Dr. Hashim’s big boss meant that he doesn’t know what to do for that particular problem brought up by Dr. Hashim.

The other possibility is of course that his superior was asking Dr. Hashim if there were anything for him to do because he has no work left undone. I believe that there is no end to administration work. I also believe that a lot of administration work is unnecessary and irrelevant.

In this respect, I can think of no better example apart from the issue of doctors’ white coats.

The classical white coat may appear elegant to the lay person and has for ages been the trademark for the medical profession. In reality and especially more so in the tropical hot and humid weather like Malaysia’s, the lab coat is cumbersome and serves little purpose except for the lady doctors to keep their wallet and stuff. It is also a source of infection, a formite to transport resistant, hospital-grown bacteria from the wards to town and back again. Lastly, white coats are usually not white. There is always some part of a patient left behind upon it – a drop of blood, some diarrheal stains or a suspicious pee-like stain. It is not surprising therefore that authorities in the US and UK have abandoned the ageless white coat in favor of hospital scrubs, throwing the coat out along with neck ties and other bodily accessories like watches and bracelets.

However, our administrative doctors here have a different opinion altogether.

Instead of promoting patient safety and reducing cross infections, they make it compulsory for doctors to wear white coats. The hospital I’m working in has appointed a nurse in each ward to jot down names of doctors found lingering without their white coats and submit these names to the director’s office at the end of each month for disciplinary action. It’s like having a prefects’ board within the hospital, the head honco of whom is the high and mighty pengarah himself.

Whenever my name gets written down by the ward prefect, which is like every single day, I would tell the prefectorial staff nurse that there are better and more constructive things to be done, pointing towards Gapong Balinting lying over bed 35 in his whirlpool of torrential mucoid stools or Lambinah Gagau in bed 12 wailing in great discomfort over her worsening bed sores.

It is because of such nonsense that I sometimes believe that doctors in administrative positions seriously have nothing better to do.

Out of Drive

“I wonder why I work in this dead end job. My hospital is shortstaffed and my hospital director doesn’t seem to be doing anything. He’s like a puppet who leaves everything to God, classical ‘insya allah’ response to everything. The work I do does not commiserate with the pay. Job satisfaction is at an all time low…”

I have earlier written about the different doctors who give up clinical work and why. For as long as I have known Dr. Hashim, he has been nothing less than enthusiastic to learn new skills, gain greater knowledge and meet a variable pool of patients. I have sufficient reason to believe that his passion for medicine especially the field of obstetrics has not changed since medical school.

If he does give up on clinical practice because of job dissatisfaction brought upon by an indifferent hospital pengarah, he’ll make up the last group of ex-clinicians – those who are through with clinical practice because of non-clinicians who do not understand the circumstances a clinician goes through.

It will indeed be a sad day for Malaysian healthcare if more clinicians like him leave the service because of superior-subordinate disharmony.


I am not anti establishment. I believe that we will all benefit when we have a system with sensible rules and sane regulations. The opposite is also true I assume – we will all crash under the leadership that is out of touch, out of sync, out of reach and out of work.


ShARI said...

ah, my fave line: 'Never underestimate the power of denial' -- fr American Beauty. I enjoy your writing tremendously and would like to feature you/your non-med work in my paper's Blogspot and views -- done a few among them Palmdoc, 5xMom and MomsGather (who remained anonymous in respect of her privacy). Can? Especially on migrant abuse.

ShARI said...

Nobody is big enough, nor should be given that 'privlege' of making you feel bad - especially when you do a whole lot of good, such as with this blog. Serious, after reading today's patronising pieces on 'Maids doing more harm than good' and the stats of those pregnant, I reflected on your earlier pieces of the jerks visiting your clinic. (I even have a helper in my neighbourhood whom I think is a victim)... I can always recommend an abridged version of your earlier piece, and professional fees are due... who knows, you might just be lured into becoming a full time writer! Can you email me? cheers

Kong said...

"Dr. Hashim.......He was a natural smart ass who put me to shame in studies, remembering and mastering most of what he read at the first exposure."

This brings back what I have always believed in. There are very smart and hardworking Malays but the flawed NEP make everyone of them professional a suspect in their ability. So sad.

Kong said...

"Some folks lament that the five years of medical education were wasted and a huge sum of taxpayers’ money were squandered. I beg to differ. A medical degree is just that – a science degree."

While it is definitely not a waste, it's just less cost effective should they not practice medicine.

StarGhazzer said...

"Essentially, finding meaning in our daily work grants all of us a passion to live this life, regardless of our profession. "

I find this quote from you really inspiring.

I'm a med student who's in clinical years now and I find it less and less meaningful going to the hospital and clerking patients. Granted, it's part of our learning process but it's really frustrating as students because we're not technically part of the treating team. All we do is get in the way of doctors/nurses/allied health professionals who are more directly involved in the patients' care.I probably need more inspirations to keep myself motivated, yet I confess that after all these years of mugging the enthusiasm has somewhat faded slightly.

Having said that, the thing that gives me the most satisfaction is when a patient tells me that I listen to his/her problems more than anyone else in the entire ward.

I've been reading your blog for some time now and I'm enlightened about the dire situations of our medical system. Keep up the good work, and hopefully things will change for the better in the future.


Jason Leong said...

Spot on about the labcoat! The admin ppl these days are all about image, visi dan misi and all these bullshit, but they have no clue whats going on ON THE GROUND!