Young docs walk a tightrope

After completing a gruelling course, young doctors have another challenge to face – a demanding two-year housemanship where they rely on lots of coffee, cope with very little sleep and put up with public chastisements.

SHE had always wanted to be a doctor but six months into her housemanship, she snapped and just couldn’t take the stress anymore.

*Kavitha found the workload and endless hours on call a real burden, sapping her energy and spirit. Today, says her concerned father *Gurdave, she is close to having a nervous breakdown and is seeing a psychiatrist for counselling.

“The work load was too heavy and the hours too long. When she was on call, she sometimes had to work for up to 36 hours straight. She wants to be transferred to another hospital but every hospital is just as bad.

“But I don’t want her to walk away from the profession. I have spent close to RM400,000 on her education. I don’t want anything back but just for her to get through this,” says Gurdave.

Unfortunately, housemanship is taking its toll on many young doctors like Kavitha. Statistically, she is one of at least five housemen a month who is found to be suffering from mental illness.

Health Ministry director-general Tan Sri Dr Ismail Merican revealed last week that many of the medical graduates are unable to cope with their housemanship.

“The mental cases range from psychotic to neurotic. Psychotic cases include delusions and hallucinations, and neurotic behaviour includes anxiety, fear and anger due to the competitive environment.’’

On-call system

The term houseman refers to an advanced student or graduate in medicine gaining supervised practical experience. In Malaysia, it is compulsory for doctors to undergo housemanship for two years after completing their medical degree. During housemanship, they are rotated among six departments – emergency department, medical, paediatric, general surgery, orthopaedic, and obstetrics and gynaecology – where they are attached to for four months each.

Over the years, those undergoing housemanship have been voicing their unhappiness but these complaints have generally fallen on deaf ears. The biggest grouse housemen have seems to be the on-call system, where they are sometimes subjected to work 36 hours at a stretch.

*Pedro, who is into his sixth month of housemanship, says he has on occasion worked 38 hours straight with only one hour rest in-between.

“In some hospitals, the patient load is non-stop as they have to accept referrals from other hospitals,” says Pedro, adding that this is more apparent at hospitals in Johor Baru and Klang which are the busiest in the country.

Housemen are provided facilities such as beds and they can sleep if they have no cases to attend to. However, this is rarely the case and the most sleep they get is about two to three hours. And that is only when the housemen take turns to sleep, says *Lalitha whose housemanship stint ended recently.

“We force ourselves to carry on. What keeps us going is coffee and tea. It is only after we are no longer on call that we can go back and crash until the next day,” she says. Depending on the department and the hospital they are serving in, housemen could be on-call for up to 15 days a month. Lalitha says that during her first posting, she would work from 6am to midnight every day.

“We go home, have a bath and sleep for five hours before the cycle is repeated. They are preparing us for the on-call,” she says.

Shortage of doctors

Dr Kuljit Singh, president of the Malaysian Society of Otorhinolaryngology and Head Neck Surgeons (MSO- HNS), believes that one factor that can cause high pressure for trainee doctors is the shortage of doctors at some hospitals.

“Some hospitals have a lower doctor to patient ratio, so the housemen, being the lowest category in the medical fraternity, have to take on a lot of the work and responsibility, especially the lousy tasks, in the name of training,” he says.

Universiti Kebangsaan Malaysia Medical Centre (PPUKM) dean and director Prof Datuk Dr Lokman Saim agrees, saying that pressure from their heavy workload can push some doctors to the brink of breaking down.

“It is normal for a doctor to be on duty for more than 36 hours with on-call duties. In Europe, this has been recognised as a problem and they have passed a law to state that doctors cannot work more than 12 hours straight. Maybe we need laws like that if we want to improve our doctors’ welfare,” he opines.

Under the European Working Time Directive in 2004, junior doctors can work no more than 56 hours a week. They can work up to 13 hours a day but then have to have an 11-hour break.

Acknowledging that the number of doctors in Malaysia may still be too low for such a ruling, Dr Lokman nevertheless thinks it is a possible solution for the future.

Dr Lokman thinks that the problem of housemen suffering from mental problems can be prevented at the entry point of the profession.

“Currently, for public universities, students are selected by the Higher Education Ministry based on their exam results and co-curriculum activities. No interviews are conducted, so there is no way for the individual medical schools to assess their attitude and character. If we get the right candidates for the programme, we can be sure of the doctors we produce,” he argues.

However, he admits that it is not a foolproof method but he believes that it will help weed out the obviously unsuitable candidates.

“Many students are forced by their parents to take up medicine and these students end up very stressed because the course is difficult and they are not motivated. It will help us ascertain if a candidate has the right attitude and disposition to be a doctor,” he adds.

He highlights that a majority of students who fail and drop out of medicine are those who are forced by their parents into the field.

Bullying

But for those who successfully completed their degree, the challenge is dealing with the hospital environment.

They may have to contend with a handful of senior medical officers with the “Napoleon” complex who make the lives of the housemen difficult, says Dr Kuljit Singh who had served in government hospitals before branching out into private service.

“There is sometimes an element of bullying and high-handedness in the way some senior medical officers and consultants treat their junior house officers. They become Little Napoleons and are dictatorial. They say they went through the same regiment and that made them good doctors, so the newbies need to go through the same process,” says Dr Kuljit.

A senior doctor in the Johor Baru hospital, *Zul is also not happy with the treatment dished out to housemen.

“I have seen the degrading treatment given to medical officers, even after they have finished their housemanship,” he says. Zul himself was a houseman in the same hospital a few years ago and he says nothing has changed.

“If they talk about your work then it’s all right, but then they go into character assassination,” he says.

The housemen are usually screamed at by their specialists in the wards and in the clinics, he adds.

“The words used in front of patients are sometimes so degrading that in my opinion, it is these specialists who are the ones suffering from ‘mental woes’,” says Zul.

Those who fought back would be referred to the head of department who would either try to rectify the situation or extend the posting of the houseman, adds Zul.

A few of the housemen say there have been times when they were threatened with extensions in the department by medical officers.

Zul says that three of his friends quit the medical profession during their housemanship, with one of them ending up as a housewife.

“One of them would get anxiety attacks whenever she came to the ward. The thing is she was an excellent student,” says Zul.

*Maniam was barely a week into his housemanship when a specialist yelled at him in front of a patient.

“He asked me if I paid to pass my exams and also said I was the worst doctor he had ever come across. How can he say such a thing when I was there for only a week? They tend to look down on us as if we don’t know anything,” says Maniam.

However, Dr Kuljit, who taught at Universiti Malaya, shares that many students today are more pampered and have led a sheltered life, and thus cannot stand the pressure. Many come from a protected family environment, so when they are reprimanded, they get stressed and depressed. He believes that medical schools need to instil more soft skills, particularly interpersonal skills, in their students.

“We have many top scorers taking up medicine but many of them lack people skills. These students can manage with their studies but when they start working, they don’t know how to deal with their superiors, especially when they get scolded by them,” he says.

Pedro, on the other hand, does not have problems with any of the senior doctors he has to work with and says they are gems.

“I have no complaints because they teach us a lot. They offer us the opportunity to learn complicated procedures. They are willing to teach you even if there are possible complications. Even the specialists take time to teach you,” he adds.

President of the Malaysian Medical Association Datuk Khoo Kar Lin is unsure about the cause of mental problems faced by the doctors although he says the finding by the Health Ministry is a concern. He says a survey should be done on housemen to find out the causes.

“We have not received any complaints (about housemanship). I went through the system myself and from my impression it is not different from say 30 years ago. They are not being more overworked than yesterday,” says Khoo, adding that he enjoyed his housemanship.

“Every profession will have its challenges. We have to be cautious because people will always think that they are victimised and work longer hours compared to others,” adds Khoo.

President of the Malaysian Mental Health Association Datin Dr Ang Kim Teng says that housemanship could be a contributing factor to mental problems.

“It is not the job that causes it but the underlying susceptibility. Some people are more prone to this and the job stress could be a triggering factor. Factory workers, policemen and teachers can also face the same problem.

“It all depends on the individual’s ability to cope with stress. A lot of housemen go through their stints without any problems,” says Dr Ang.

Lalitha enjoyed her housemanship despite the many challenges in the different departments.

“We know this awaits us in the field. When I first started, I asked myself what I was doing here. The doctors pick on your mistakes and are not bothered if you have enough rest,” says Lalitha who got used to housemanship by her third posting.

She believes adaptation is the hardest and those who studied in foreign universities may have it tougher as they may not understand some of the terms used.

For *Tan, her social life took the backstage and she had to cut down on spending time with her family and friends.

“Those were the times when I thought of quitting but the feeling passed very quickly,” she says.

Tan didn’t really encounter any problems with the staff but has friends who have had books thrown at them and senior staff nurses giving them a hard time.

“At the end of the day, I am satisfied that I have somehow made a difference in a patient’s life. I don’t have any regrets getting into this line,” she says.

For Pedro, the only time he feels discouraged is when he has to get up at 5.30am for work.

“Once you get there it’s over in a snap,” he shares, adding that he feels really good when patients come out of life-threatening situations.

Pedro also says with all the running around they have to do, housemanship is the best weight loss programme.

“I can now fit into pants which I wore in Form Five!” he quips.

Prevention at entry

Dr Lokman Saim thinks that the problem can be prevented at the entry point of the profession, which is the medical course.

“Currently, for the public university, students are selected by the Higher Education Ministry based on their exam results and co-curriculum activities.

“No interviews are conducted, so there is no way for the individual medical schools to asses their attitude and character. If we get the right candidates for the programme, we can be sure of the doctors we produce,” Dr Lokman argues.

He admits that it is not a foolproof method but he believes that it will help.

“Many students are forced by their parents to take up medicine and these students end up very stressed because the course is difficult and they are not motivated. It will help us ascertain if a candidate has the right attitude and disposition to be a doctor,” he adds.

He highlights that the majority of students who fail and drop out of medicine are those who are forced by their parents into the field.