Afiza’s Principles of Good Health Care Management

I promised in my previous post that ALL my criticism would be constructive. Here is the post that will deliver that promise.

I name this post as Afiza’s Principles of Good Health Care Management

1)Principle Number 1:The concept of Favor.

You do someone a favour when your action benefits her.

And whether or not something is beneficial is not defined by YOU; it is defined by HER.

In the first place, we housemen don’t care whatever it is you want to call the system that we are working in; be it the shift system or the flexi hours or WHATEVER.

In the first place, all we want is not to have to do on-calls because it means working for 36 hours straight without rest!!

It doesn’t mean we want to work in shifts! It only means that we don’t want to work for 36 hours straight because it is inhumane; it doesn’t benefit the houseman and it doesn’t benefit the patient.

And I have always believed that the best plan is the simplest plan. If I have the authority to put a decree on this, I would simply say, “Berkuatkuasa pada hari ini, semua jenis ON-CALL adalah haram sama sekali. Kamu bekerja seperti biasa sewaktu office hours. Manakala  sesiapa yang diperlukan untuk berada di hospital pada waktu malam, tidak perlu bekerja pada waktu office hours. Mereka hanya perlu datang dari pukul 5.00 hingga 6.30 pagi keesokannya dan dibenarkan pulang setelah orang pagi tiba bekerja seperti biasa. This goes to the MO as well.”

Simple kan! Apa yang susah sangat?? I know I don’t like on-calls…but the shift/flexi-hours that we are implementing is not so great either even though I am willing to give it a try.

I admit, the system that I suggest above would still reduce the number of housemen working during office hours (whereas the on-call system means you have more housemen; who cares if 6 of them are sleepy and exhausted, right?). However, MY system would have a lot more housemen around during office hours compared to if we are implementing the shift system.

If with the on-call system, you get 40 housemen working during office hours; then with MY system, there’ll be 34 housemen working during office hrs (minus the 6 that will come post-office hours). Whereas with the shift system, a lot more of them will be working out of office hours…which is NOT WHAT WE WANT!!  We want more housemen during office hours because that’s when all the referrals, and all the requests for radiological investigations need to be done.

MY system is a balance between two extremes! So, get it done!

Remember the concept! If you want to do housemen a favour; you give them what they want. Essentially, all they want is to NOT have to work 36 hours straight while at the same time maintaining the harmony of enough housemen during office hours.. Not wanting to work 36 hours straight  is not equivalent to wanting the shift system. Because even though the shift system means there’s no more on-calls, it is also disruptive to the normal office hours where the majority of the work need to be done.

Is someone up there listening??? Please.

2)Principle Number 2: The Concept of doing it ‘All or Nothing at all’ / ‘Not doing things in halves.’

“O those who believe, enter Islam COMPLETELY,… -“

Once upon a time, I was given a perfect lecture by my ustaz. My ustaz told me about the wisdom of a particular mufti.

“The mufti was asked by the media, what is Islam’s solution to AIDS. The mufti then answered, had you implemented the Islamic system from the very beginning, AIDS won’t even exist in the first place and you won’t be asking this question from Islam.”

If there had been no rampant sexual promiscuity, no homosexuality, no IV drug abuse, no alcoholism (and hence, no all the previous evils mentioned) AIDS won’t spread. You subscribe to a hedonistic system of life, but when something bad happens, you sought solution from another system altogether. How is that not plain stupid, you tell me!

If something is wrong with your iPhone, do you ask SAMSUNG what is THEIR solution to the problem your facing with your iPhone? Of course not!

Apple won’t claim that there won’t be any problems with their product. No companies can make that claim. But any self-respecting companies would claim that they will have the solution to whatever problems that may arise in the system that they create! It’s only fair to expect THAT of any system!

See the western system of economy. They legalize riba (usury), and now their economic system is collapsing around their ears with a loud crash. And now they are spending more money to find out why they had lost money in the first place. The system does not have the answer…will not have it…EVER. They engage in riba, they engage in currency speculation….and they have gotten away with making money out of nothing for years and now the terrible consequences of such endeavors are catching up with them fast and furious. I dare them to ask what is the Islamic solution to this!

Now, I hope I have made it clear that you cannot mix and match different parts of different systems and not expect things to become plain insane.

Now you have to choose. What kind of system do you really want us to work in? Do you want us to work in shifts or do you want us to work as we used to?

You have to understand that if you want us to work in shift, you have to design a proper system for it. Not simply mix and match.

For example, in HSB medical department, the system works like this: The morning shift is from 7.00 am to 5.00 pm;  afternoon shift is from 11am to 11 pm; and the night shift is from 10 pm to 10 am.

The amount of housemen who work during office hours are reducing…so we are covering more patients than we are used to. But our superiors still expect us to know all the cases well; the bloods are still expected to be ready especially if the night people were unable to complete them, we still have to do the housemen round first, before the MO/specialist round.

We end up starting our morning shifts at 5.00 am!  To make matters worse, in certain wards, we rotate like the hurricane. On Sunday I was covering ICU, on Monday I was covering CCU/CRW (because the person who covered this ward on Sunday was rostered to do night shift on Monday) and then on Tuesday I was rostered to cover 1st class ward (because the previous houseman who covered the 1st class ward on Sunday and Monday is now rostered to do night shift on Tuesday). I don’t know any of my patients because I am changing wards everyday! How can you REASONABLY expect me to know all the cases well when YOU can’t do it too if you were in my shoes unless you come at 4.00 am to study all the cases you have never seen before in your entire life until that day itself? You tell me!

You see, you can’t implement system in halves. You said the objective of implementing the shift system is so  that we will have less working hours and a better lifestyle. So, you said that the morning shift starts at 7.00….but then you also expect me to be able to do all the things that I am expected to do during the old system. (you want one thing from one system, but you also want another thing from another system….so you end up not reaching the objective you set out to achieve in the first place which you CLAIMED as for us to work less)

You want us to cover more patients per shift. But you still expect us to be the phlebotomist, the attendants, the ones who do the procedures, the ones who arrange patient’s future appointments, the ones to fill up all the STROKE Registry forms and Cardio Registry forms, the ones who refer inter-departmental cases. We used to do all these while caring for 6 patients only and we still went home later than 5.00 everyday.

See? I am not averse to the shift system. But I am averse to the discrepancy in how it is implemented and your expectation of us when the system is implemented.

3)Primciple Number 3: The concept of technology as a means of solving/easing daily problems.

By rights, when we use technology, it is with the aim of making our lives a lot easier.

So we have to recognize…what is our problem….and solve it with technology.

But in HSB, with the e-HIS system, it is the other way around. We end up using the technology because it’s there; regardless of whether or not it is helping our work.

Hospital Sultanah Bahiyah is number ONE when it comes to creating daily nuisance in the disguise of the e-HIS system and all sorts of computerized technology. Take the OBS CENTRAL in the ObsNGyn Dept for example…using continuous CTG monitoring in healthy pregnant women is one perfect example of how we have no idea how to use technology PROPERLY.

I will list the problem in order!

1)      The nursing reports are done in the computers… for the online ‘ghost’ to read, perhaps?

2)      In certain wards like ICU, CCU and 3C, it is so-called paperless….meaning even our daily reviews are made in the computer.

3)      We need to order blood investigations and radiological investigations through the computer first before it can be made available online. (I will tell you why it’s bad, later).

When I was a student in Australia, I actually enjoyed reading the nursing reports that were handwritten in the patients’ files. I thought it was important to read the small paragraph of what the nurses had written…I really did think it was vital for me to know if the patient was sleeping well, was the patient taking orally well, and had the patient pass motion etc etc. I actually read their reports because it was there, written in the same place that I was going to write MY reviews on.

In HSB, all the nursing reports are done in the computers! While my reviews are done in the patient’s files! As the consequence, none of us housemen actually read the nursing reports. We end up asking the patient the very same thing that the nursing reports would have told us in a glance.

It’s not efficient!

We should be using the E-HIS system in things that are absolutely vital for us to be able to trace it back a few years down the track when the patient  represent himself in the future. For example, the discharge summary SHOULD be done in the system…because when the patient gets admitted in the future, we would want to know the patient’s previous history and admissions. Also the blood and radiological Ix SHOULD be made permanent by having them online; we need to be able to trace them back for the patients’ future admissions.

But what is the use of the nursing reports being made ‘permanent’ online? Is it going to matter a few years down the track, that during the patient’s last admission he has passed motion well for one day, and then vomit the next day and then got constipated the day after that…and then got diarrhea the next day.

No, right?

A few years down the track, those things are online rubbish. What’s not rubbish is knowing (from the discharge summary) that during last admission, the patient had suffered from irritable bowel syndrome or gastroenteritis or rectal carcinoma etc etc (not the details of what happened everyday).

Do you get me or not when I say we don’t use technology properly…but we use it just because it happens to be there, so we better make the nurses use it to their heart content! Heh!

And you know what the funny thing is?! The funny thing is, even the nurses hate it! It complicates their works. Their roles as nurses are not to spend time doing reports online. Their role is to look at their patients. Not to glue their eyes on the computer screen and let the student nurses do all the observations/ sponging/ suctioning/ procedural-assisting.

It is for the same reason that I am VERY MAD when it comes to doing my reviews in ICU/CCU/ and 3C. Because I do not get WHY, oh WHY, do I have to do it online? Doing reviews online takes time because you have to open a few windows (to check the Ix results as well as the reviews in other previous entries). Doing my reviews online takes a lot of time because I have to compete the use of the computer with the nurses! Now, I am not lacking in competitive spirit…but not for something that will become an online rubbish. Like I said, a few years down the track, my DAILY reviews online is not important anymore. The patient will only have a few diagnoses that I have to recognize in the discharge summary for the benefit of the patient’s next admission. So only the discharge summary should be online.

You know, in Australia they know when to use the computer; and when not to use it.  Daily reviews are done in the patient’s files. Only the discharge summary is done in the system.

Furthermore they are also smart in the sense that they get all the blood results to appear online. But they can order the investigation through paper, which takes less time than having to order it in the computer.

The size of the paper that they use to order the blood IX is about 1/3 of the A4 size paper. All they have to do is get the patient’s sticker (which is already pre-printed in bulk with the patients names, age, MRN; in other words, they don’t need to go online to get the stickers printed) and stick it on the form; then write down FBC/RP/LFT….and then put the patient’s blood sample together with the forms in the specimen bag.

Like I said, they know how to make technology works for them. They know they need the result online, but ordering it online will take time (especially, if you have to compete the use of the computer with the nurses who are busy passing reports to one another). So they design a system that enables them to order investigations in the easiest way possible while also making it appear online.

Look at us! It’s true in one sense; our work is easier because we can get to see the investigation results in the computer stat when it’s ready. But we make the ordering of it to be so hard and time consuming. What a fool we are.

Do you see what I meant in my previous post when I said that we are HORRIBLY inefficient in using our resources; human resource as well as our technologies.

I spent time writing very long post on this because I think it’s important that we recognize our mistakes in our healthcare. It’s not that we don’t have enough doctors….we just use them for doing non-doctor things….and thus they will always be busy NOT BEING DOCTORS. We have the nurses doing reports online for Allah only knows which ghost to read! As a result, the nurses are not doing nursing stuff….so we then come up with the inspired idea that we don’t have enough staff.

We have good technologies….even at par with other developed countries. But it’s time we recognize that non-proper use of ANYTHING will not get us ANYWHERE. It’s like what the Malay means when they say bagaikan kera mendapat bunga!

4)Principle Number 4: The Concept of Useless PaperWorks (useless to the ones who actually do the patient nursing care in the wards)

We set up stroke team, infectious disease team ….and the jobs of the team consists of sending us FORMS for us in the ward to fill up. The jobs of those teams are not to fill up their own forms…but to distribute the forms to other wards with the related cases.  It’s US who have to fill it all up, like we don’t have enough to do.

Oh yes….if the patient happens to have all AIDS, Hep B/Hep C ….then the forms should have two copies, too…because they will go to separate divisions.

So what the heck is the job of those teams??  If we have to fill up one form to notify that the patient has all AIDS, Hep B and Hep C….shouldn’t it be THEIR job to double up the forms since it has to go to separate divisions…THEIR divisions! We do our nursing/doctoring jobs in the ward…..and then we also have to do your team’s administrative job. You guys memang pandai unburden yourselves…..and put the paperworks on us who do the actual care that actually benefits the patient.

You and your paper work can do nothing to a simple thing like a patient’s spiking temperature.

I know it’s important to notify these things. But since we have already done our part in caring for patients in the ward, which is something that YOU didn’t do….why can’t YOU do your paper-works job, for a change, and leave us alone!!

Thank you!

**That ends the online-lecture of Afiza’s Principles of Good Health Care Management.**

9 thoughts on “Afiza’s Principles of Good Health Care Management

  1. Heheh…well said there. I look back to my houseman years 2008-2010 and realized aside from completing my 2 year stint as a houseman, I’m also now a well-certified expensive clerk! The ho-ship benefited me for my rural MO posting now, the clerk-thing just went down the drain (I honestly went a bit cultured shock when from paperless the system in rural became paper-ful, and honestly I liked the old system better.) But like you’ve said, we’d benefit more with the bloods, radiological investigations to be available in computers aside from the discharge summaries. Hell know I’d be interested if a patient could BO 5 years ago!😛

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    1. Oh yeah….Hospital Selayang is another so-called paperless system.
      When you mentioned that you like the old system better, does that mean you prefer the paperless system when you were a HO, rather than the current system in your MO-ship now where it’s paperful?
      Or did you mean you like the ‘old’ system as in, traditional system, as in less-technological system where it’s not paperless?

      I can’t wait to be an MO myself. And I want to be one in KK! Yes, HO-ship has ruined whatever interest/ambition that I have in medicine.

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  2. Dame regen

    There’ll always be all kinds of systems out there but most importantly is how you react or adapt to the system. A lot of things are beyond our control. I was a houseman year 2004-2006 in the 2 busiest hospitals in the country – HKL and HTAR, Klang and I enjoyed my experience because I became a doctor prepared to work like a dog as I know that’s the fastest way to gain knowledge and experience. After all, u only have 4 months in each department/ rotation so knowledge gained is parallel to hours served. Not everyone knows what specialty they want to be in fresh out of med school so this helps one decide. And no experience is wasted even if you plan to go to KK.
    I was lucky that I had colleagues who shared the same outlook as I did and we worked well together as a team. Everyone knew about everyone’s patient and everyone stayed back to help the on call person if the office hour errands were not complete or we see an influx of new patients coming in at 5pm. We always let the on call person go back and freshen up first before he/she starts her call. And being nice to nurses definitely helped as they would give u a hand with tracing results, taking blood and even setting lines while u’re asleep because they didn’t want to wake u.
    After serving in wards of 60-80 patients with only 2-3 functioning houseman at a time and needing to take most of the bloods every morning AND needing to know every dengue patients’ platelet count AND their morning BP lying and standing AND the appointment for the next ultrasound AND setting central line single-handedly, I feel a sense of accomplishment and appreciation for life now. After all, it’s only for 2 years. After all that, district posting was a breeze.
    So don’t fret, it gets better. Even if it doesn’t, think positive because it is not what has happened to u but what u thought of that day that makes it a good or lousy day.
    All the best!

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  3. esah

    great job afiza.. I was there 6 years ago, but piece of advice, there will be time when patient will start thanking you (come on.. of course you are not hoping the system to compliment u la kan.. ) and you will become a ‘doctor’ again.. hang in there!

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  4. amin13

    not easy become a doctor… HO is just a beginning, used to work much more worse than this… whining not resolves the care of your patient…tq

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    1. I am sure you are used to working much worse than this? Did you like it?

      Whining won’t resolve the care of your patient. Just like commenting on my post here will not change the care of your patients.
      We talk because there are things that we could do to improve. If you are the sort of person who does not like progress, that’s your problem.

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