Q&A

Yes, it's been a while since my last entry, but that's what happens when I'm swamped with work and experience a string a phenomenally bad night shifts ( which is when I usually blog, once things quieten down ).

I'm posting this primarily in response to a recent email from a reader, who is considering medicine as a career and had the following queries:

"But there's somehow always some self-doubt lingering in my mind. I have heard some doctors lament the state/hours they work in, others opting to work instead in admin/policy settings, and still others totally giving up practice.

I ask myself: Is this what I really want to do? Is this for me? Can I do it? Can I sustain the gruelling hours, and God knows what else to come? So I write this email, hoping to hear some thoughts, comments, and advice from you regarding the pursuit of medicine in general, how it feels to work as a doctor in Singapore, and the issues I should consider."


Well, I'm going to pen my own thoughts, but invite anyone with advice ( whether you're a doctor yourself or know someone who is ) to leave comments.

This May marks my 10th year in the workforce, and the change in perspective is indeed significant.
While I'm sure there're those who never lose that optimistic streak and walk around with perpetual, beatific smiles on their faces, I'm not built that way, and make no apologies for being cynical and high-strung.

Here're a few lessons I've learnt in the past decade ( I'm rather exhausted, so please forgive the rambling ):


1) It isn't necessarily medicine per se that irritates me, but "external factors".
This is a very broad category, and can encompass anything from annoying patients and relatives, to bad working conditions.

A few may argue that the practice of medicine involves all these peripheral aspects, being a holistic discipline and all. But I've always had a vision of the way medicine can and should be, and am constantly disappointed that reality comes nowhere close to that.

Personally speaking, the suffering I went through as a house and medical officer didn't bother me. It's only after I turned registrar that a lot of things began to get on my nerves. Why? I guess youth had a lot to do with it -- happily working my butt off in pursuit of a specialist position, rotating through different departments and picking up new skills.
Once you become fixed in a certain department, the initial euphoria of a pay rise can dissipate pretty quickly, especially when you fight the same battles day in and day out, with no light at the end of the tunnel.

Again, long-time readers and close friends will know that for all my grumbling, I don't actually regret choosing emergency medicine, and am merely voicing frustrations about a wide range of issues, many of which are chronic.

I ask myself the same questions: Is this what I really want to do? Can I sustain the gruelling hours and God knows what else to come?
Funnily enough, yes, and yes.

Despite my repeated cursing and swearing, I'd probably curse and swear a lot more doing something else. I've gone through at least 10 departments ( excluding the ER ), and couldn't wait to leave each time. The operating theatre is a living hell for me ( even though one surgeon thinks I'm a whiz at manoeuvring the laparoscope - thanks to my many childhood hours playing video arcade games haha ), clinics are such a bore ( as opposed to ENT sessions, which are painful beyond imagination ), and I'd rather have a root canal than go through a dreaded ward round ( and I'm already terrified of dental work in general ).

The ER, on the other hand, is oddly comforting in a strange way. It resembles the operating theatre to some extent ( resus and minor OT ), the clinic in others ( consultation rooms ), and we even do mini ward rounds with our observation protocol cases. But I can handle it in small doses, and variety is key. Even the psychos and foul-mouthed drunks offer respite from the octogenarians and other run-of-the-mill conditions.

The things that irk me -- from inefficient MOs to rude relatives and an overcrowded ER -- while not insignificant, are still not compelling enough to make me quit emergency medicine altogether. At the risk of sounding cheesy, yes I want to help people and relieve suffering blah blah blah. No-one's more surprised than I am by the fact that all those ideals I harboured as a child and young adult still hold true today. This becomes most apparent when I treat the frail or elderly, especially the neglected and destitute, who come alone without any demanding relatives, and still know how to say thank you. Now those are the patients who make me smile and feel as if I'm really making a difference.


2) The practice of medicine in Singapore has become quite perilous.

Again, this is a reflection based on personal observations made over a period of 10 years. An extension of point (1), it expands on my many complaints about unpleasant people and less than ideal work environments.

While Singaporeans are still nowhere as litigious as Americans and Australians, they're quite nasty in other ways, and can severely test the limits of your tolerance, especially when your reserves of goodwill are already running low.

Asking for updates and further information is always warranted, but I notice that locals tend to border on outright rudeness and arrogance even when making the simplest request. This is especially the case with young adults and middle-aged men, who like to raise their voices, point fingers and make baseless accusations.

A busy ER is no place for such drama, but we bear the brunt of the abuse, thanks to ever-increasing patient attendances and a constant manpower shortage ( aggravated by a handful of clueless and/or lazy MOs rotating through every 6 months ).

Singaporeans also like to consider themselves knowledgeable where medical issues are concerned, armed with information they picked up from media sources or a relative / friend, using this to wrestle additional tests / hospital admission from the doctor. The so-called facts they regurgitate are often erroneous to the point of ridiculous, and we try our best to persuade them otherwise, with varying degrees of success. The greatest loss, however, is the immense amount of time consumed by the entire process, when it could've been spent seeing 2-3 other patients.

One other sad realization is how totally ignorant Singaporeans are about their own health problems. I have seen foreigners who carry their medical reports and prescriptions around in folders, or are able to recite complicated medical terms without batting an eyelid, and here we have well-educated, English-speaking locals who can only tell you they have "a heart problem, dunno what exactly" when you ask them about their past medical history. They lose their inpatient discharge summaries the minute they leave the hospital, have no idea what meds they're taking, and think it's hilarious to default treatment and follow-up ( I regularly see patients who giggle when asked why they didn't come for their appointments ).

Sure, everything's computerized now, but no system is perfect. The other day, we lost access to all this information during a major downtime period, and barely survived the backlash from patients and relatives who didn't seem to buy our explanations.

And let's not forget one of the commonest threats doctors now face: I will write to the Forum and COMPLAIN! Most of them don't go through with it, of course, but it never fails to annoy the hell out of me. If the newspaper is propagating such behaviour, I think the editor should do something to rectify the situation.


3) Be prepared for an unsympathetic administration.

At the risk of getting a phone call from my head of department, I have to say that my opinion of admin personnel is unfavourable.

I am not talking about my own ER colleauges. I'm talking about the Powers That Be. People upstairs who have the power to make positive changes, but refuse to do so either because they're set in their own ways of thinking and lack the courage to innovate, or worse, hold a personal grudge against us for whatever reason, and want to torture us for their own enjoyment.

This hostility obviously varies depending on which department you're from. Surgeons and cardiologists are unlikely to experience such difficulty, which illustrates yet another point: the more money you make for the hospital, the better you're treated.

Emergency physicians and certain non-surgical specialties enjoy few of the perks other profitable disciplines are accorded, and in the worst case scenario ( something I'm going through right now ), you won't be granted funds for a piece of equipment that badly needs replacing for clinical and teaching purposes, and you'll find your application for an overseas fellowship in the Rejected pile.

I am particularly offended by the latter, hence part 3 of this section: administrative people can't be trusted. How else to explain the complete disregard for a promise previously made, in return for not approving a project proposal?

Thankfully, a recent change in hospital leadership has resulted in a number of much-needed improvements and renewed interest in the way emergency physicians practise. I can only hope that this same leader will approve the funding we so desperately need before the abovementioned equipment decides to disintegrate.


It's taken me 2 hours to write just a few paragraphs, but will stop here for the time being and let you digest, as I'm sure you have more questions coming.

I will say this though: the majority of doctors in the public sector does go private, with only a very small group staying on till retirement. Money has a lot to do with it, but I don't believe that greed is the only motivating factor, and sometimes feel that I'm able to endure my current situation mainly because I don't have that many mouths to feed and have no social life.

For you, I recommend the Duke Graduate Medical School route, as your Ivy League background will serve you well.

While I honestly believe that every person who pursues medicine does start out with the best of intentions, it would be foolish to put every single doctor on a pedestal, because I know many who're absolute monsters, and consider the university's screening process completely useless. People change, and that's just unavoidable.

What I've written wasn't drafted beforehand, and is by no means sufficient in relating my complicated feelings about my profession. But I will make the following suggestion: if you have the interest and ability, consider yourself pretty tough yet have a kind heart, and are willing to work harder than you've ever worked before, I think those are good enough reasons to apply for medical school. There's no way to predict what'll happen 5-10 years down the road, but if my account hasn't thrown you off, then there's still hope. :)

Besides, if you get sick of it someday, you do have other degrees to fall back on, whereas I'll have to opt for strictly extra-curricular pursuits like churning out a novel or screenplay ( likely to be opposed by my employer ).


Bad Habits

Continuing with the griping session, a few disturbing traits we've noticed in the current batch of MOs.

One has taken 5 days of MC in less than 4 months.

A few take MC a day or two before going on leave.

One switches his/her phone off and sneaks out of the department during shift.

Another is slow and indecisive despite rotating through another emergency department just before coming here. This MO is banned from night calls -- yes, it's that bad -- but hey, s/he spends so much time talking to each patient, s/he recently received a compliment via feedback form!
Maybe I should slow down and get myself a star too.

Sigh...


Some Good Stuff

The professor from New York City arrived last week, and has already won rave reviews for a lecture he gave on Friday. One consultant told me he was so inspired he went home and dug up a book to read more about the topic.
Best of all, the professor is, despite his renown, extremely warm and friendly, with no airs or expectations. I can't wait to see what happens at the annual scientific meeting later this week. :)

Just another 7 days to go before my cortisol levels start tapering off. The past few weeks have been exhausting, and I can't wait for life to return to normal.

First on the R&R agenda: the sold-out Jason Mraz concert! Have got something special lined up ( L knows what it is ), but will post details after the show.

The Bridge Project's The Winter's Tale will also arrive soon. There was an article about the play's opening in NYC last week, featuring a photo of Sam Mendes and Kevin Spacey. The latter looked really good, and I don't even know why. Maybe it's the gorgeous suit he was wearing. :)

As for TV, check out Machines Of Malice, which airs every Thursday at 11pm on Discovery channel. Last week's episode had medieval Greek and Roman torture devices, among them something called The Brazen Bull -- essentially a gigantic bull-shaped oven designed to cook a human being at 800+ degree temperatures. Well, you learn something new everyday.

Time to do an exit round then head home for the Oscars ceremony telecast. Haven't seen most of the nominated films so have no idea who to root for, except Heath Ledger, who was phenomenal in The Dark Knight and is a clear frontrunner. And of course Wall-E will win Best Animated Film. :)

Till next time...

Frustration

It's 2 hours before the night shift ends, and what a horror it's been.

A continuous influx of drunk and assaulted patients arriving via ambulance and on foot, accompanied by equally intoxicated friends demanding instant service.

One young lady who arrived alone -- brought by paramedics thanks to some kind soul who called 995 -- screamed expletives at us non-stop for a half hour before I ordered IM Haloperidol to shut her up. Where's the Mediacorp TV crew when you need them?

All this wasn't helped by the stupid computer system maintenance, which took place from 12am - 4am, causing our emergency room and inpatient software to be completely inaccessible during this crucial period.

I'm not the sort to use the F-word out loud, but my MOs were more than making up for that. :)

We don't usually get this much action, even on weekends. Even now, there's a list of young adults in for various forms of assault ( slapped, punched, hit with a beer bottle / metal rod, etc ). And all totally plastered with alcohol.

One possible reason: the bright, shining full moon I spotted from the rooftop of our ER as I exited the tea room not too long ago.

A retrospective analysis for journal publication perhaps? Haha...


Another encounter a few days ago really disgusted me. And I consider my threshold pretty high.

A patient's son -- male, middle-aged -- walked up to me at the nurse's counter during a busy shift, asking, "How many doctors are there at the moment?"
Perplexed, I asked why he wanted to know this.
"My mother's been waiting for quite a while and no-one has seen her yet."
It wasn't what he said that irked me, but how he said it. His next remark confirmed my assessment.
Waving his hand around the area, he stated, "How can this be called an emergency department? All these people don't look sick what."

I glanced at the handful of frail geriatric patients behind him, one of whom was groaning in distress, another with a nasogastric tube and diapers. A psychiatric case was sobbing nearby, and our MOs and nurses scurried around doing changes, reviewing results and making urgent calls.

I attempted to explain that we were trying our best to clear the queue, but of course, he couldn't care less. In fact, he began to smirk, flashing me an incredulous look.

Knowing that I wasn't getting anywhere, I politely asked him to wait outside. Relatives aren't allowed to loiter in the P2 area, and our security guards had gone MIA.
As expected, he refused to leave.
So I picked up the phone and called security to intervene. That did the trick.

This is the sort of crap we face on an almost daily basis. And you know what, it's never the old patients who give us problems, but the younger ones. And most of the time, the accompanying relatives and/or friends consume much more of our time and energy compared to the actual patient.
This is my 10th year post-graduation, and it keeps getting worse.


Tick, Tick... Boom!

No, I'm not suicidal. That's the title of the latest Broadway soundtrack I'm hooked on.

Staged in 2001, it's an autobiographical piece written by Jonathan Larson ( creator of the hit musical Rent ).

I bought this from Amazon for only one reason: Raul Esparza, who plays Larson.

While the songs aren't the best I've heard, those sung by Esparza stand out, buoyed by his exceptional vocals and emotional deliveries. Favourites include See Her Smile, Why and Louder Than Words -- slightly-above-average ballads that dazzle with the Esparza treatment.

I'm always thrilled by the discovery of new musical talent. Thanks for the intro, L!


TV Highlights

The Ghost Hunters are back! The new season aired on Wednesday on StarWorld, and somehow, I'm never bored by their little expeditions.
The latest outing was to a Revolutionary era dungeon, complete with solitary confinement cells and creepy tunnels.
There were hair-raising moments aplenty, like the disembodied voice of a female crying, "Mommy!", multiple glimpses of a ghostly face and even a positive thermal image of a human figure in Casement 11 -- absolutely terrifying.

There's also a movie you may be able to catch on HBO: titled Haunted, it stars Kate Beckinsale, Aidan Quinn and Anthony Andrews, featuring an eerie old house in the English countryside. I watched it with my mom late one night -- an extremely unnerving experience.

But it doesn't come close to the TV adaptation of Henry James' Turn Of The Screw. *shudder*

Also, Monk has returned, better than ever. Tune in every Friday to catch the genius detective solving bizarre crimes in the most innovative ways. CSI really sucks in comparison.

Last but not least, the cable TV premiere of Becoming Jane tonight on Star Movies. Not sure why this film has taken such a long time to reach the small screen, but it's a gem! One of James McAvoy's best work to date.


Well then, it's back to the grind. Morning rounds beckon. Sigh.

Strange But True

Watched The Incredible Hulk and liked it. Quite a lot. Much better than Lee Ang's Hulk, which bored me to death.

Attribute this to the fine cast -- Edward Norton and Liv Tyler have great chemistry, Tim Roth is terrifying, and William Hurt unrecognizable ( though effectively stern ). Norton's fittingly vulnerable here, proving once again his impressive versatility ( just see Fight Club and American History X to experience that range firsthand ).

Also caught The Mummy III: Tomb of the Dragon Emperor. Was a little apprehensive about the grown-up-son problem ( critics didn't think Brendan Fraser looked old enough to be dad to a 20-year-old guy ), but I disagree. While Fraser is admittedly boyish, the wrinkles do show, and Rick O'Connell is appropriately fatigued in this outing, leaving more of the action to his boy and the CGI team.
At least I didn't fall asleep, ridiculous as the plot may be. Still can't believe I dozed off during Hellboy II. That was weird!

Met my JC class and our ex-tutor at his home yesterday. 12 of us showed up ( 50% of the cohort ), with 3 spouses and 6 kids in tow. There were a few chaotic moments, as the children ran around and our tutor trailed behind wielding ang pows. Quite a sight!
Great catching up with everyone, who still look the same as 15 years ago. No-one seems to have gained significant weight, which I find amazing.

Last but not least, an annoying ( and rather moronic ) question from an MO-on-call the other night. Can't print it here or I'll give away the department for sure, but it's one of the dumbest queries to cross my path in a long time, and I can't decide whether to laugh or pull my hair out.
But I kept my temper in check, and got a second call from same MO, who later sheepishly reported positive findings.

By the way, Kumar's performing at the Esplanade. Bought my tickets! :)