Shall I Compare Thee To A Summer’s Day

**I had especially written this article for Blogger Ubat Muda earlier this month. I am re-publishing it in my blog for the benefits (and critical perusal) of my blog readers. Enjoy and criticize, if you wish. It’s my policy that I publish ALL comments that DO NOT contain any swearing or rude words, regardless of whether I agree with the comments or not.**

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No one likes to be compared.

No one, but NO ONE likes to be compared unless the comparison is made with them being the more superior. Of course.

Perhaps, it’s a middle child syndrome. Perhaps it’s just me. Growing up, I absolutely loathed being compared to my more brainy elder sister. My parents, I was certain, did not love me enough. Or loved me less, I thought.

But later, MUCH later, I came to realize that comparison can be viewed in a positive light if one could actually sit and reflect on the basis of the comparison being made.

Just forget the hurt. Forget the emotional defense we erect against the (imagined) feeling that we are not appreciated. Do not even speculate of the feeling that the comparator may have about you when he/she makes that comparison.

Do not torture yourself in that manner, I beg you.

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“Look this is terrible. When I was in Australia….” I could not stop myself had my life depended on it. I gave myself a mental shake to just quit the tirade before I start.

But I COULD NOT.

I told myself, people will get tired of hearing you comparing Malaysia to Australia. Or they will hear what you say thinking you are a snob; someone who after 5 years of being abroad, has totally gone berserk making this and that comments about Malaysian Health Care system. Or they will think that you are trying to broadcast the fact that you are overseas grad. Macam bagus, chet!

But look, I wouldn’t compare if I didn’t care.

I couldn’t help it. I care. Too much. I am not an outsider, working overseas, looking at us critically. I am an insider, working in Malaysia, looking at us critically.

My parents can criticize me and compare me to my sisters all they like. With them, the intention is clear; they want me to be better. Not the best, but better. But would I tolerate the same treatment from strangers? Of course not (well, not meekly and not without serving them one or two of my branded sarcasm). Because the intention is questionable. Why would you criticize me when you don’t have any stakes in my success nor my failures? Unless you, as a total stranger can SOMEHOW convince me that you love me like my parents do and want all that is good for me, you must be either a busybody with nothing better to do, or you are a chronic impulsive backbiter, or you are just the sort of person who likes to criticize just for the sake of criticizing; criticize in order to hurt or brag.

But I have stakes in the success or failures of the health care system in Malaysia. I chose to work here.

Whatever I say that may hurt the feelings of anyone in the system, hurts me just as much. Let’s not our disagreement in what is only my opinion, spring forth from my limited knowledge as a mere mortal, cause friction against us who works in the system. Let’s disagree, COURTEOUSLY. Ladies act like ladies; and gentlemen behave like gentlemen. Have we so quickly forgotten the restrained elegance of our ancestors when they deign to have a conversation?

“Tuan hamba yang bijaksana, hamba khuatir kelancangan kata-kata tuan hamba akan menyebabkan kita terjerumus ke dalam daerah binasa. Hamba fikir tuan hamba terlepas pandang akan beberapa perkara penting sewaktu melontarkan buah fikiran tuan hamba sebentar tadi.”

Masha Allah, it’s hard to be offended if everybody can converse in that way, don’t you think? Everyone competing to top one another with regards to not only who can say the best of things, but who can say them in the best of manners!

To quote Imam Syafi’e “Never do I argue with a man with a desire to hear him say what is wrong, or to expose him and win victory over him. Whenever I face an opponent in debate I silently pray – “O Allah, help him so that truth may flow from his heart and on his tongue, and so that if truth is on my side, he may follow me; and if truth be on his side,I may follow him.”

With that framework firmly in mind, let us begin this discussion.

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So, how do Malaysian Health Care System compare to that of Australian?
Comparing two complicated health care system is quite impossible without the right direction of looking at things.

It’s not as easy as saying “They have this, they don’t have that. But we have this, and we don’t have that.” It would be too simplistic and not fair to either system.

For example, the internship program in Australia is characterized by careful supervision by your boss (registrar, advanced trainee or specialist). They don’t get to do procedures so much. They are more or less, a clerk. But then, they are not expected to be independent once they have finished their internship. Even if they are posted to other non-tertiary hospitals (our equivalent of district hospitals), they would still be supervised by their seniors. There is not much GREAT need for them to just go ahead and do procedures while they are an intern because those skills can still be learned under supervision when they are no longer an intern. Supervision is expected throughout your training. Besides, how MUCH attempts do you need to be supervised for before you are competent enough to do it on your own? Remember episiotomy? I have never done one as a student! But when I became a houseman, I witnessed two episiotomies, I attempted one under supervision, and then I did the rest on my own. The same can be said for peritoneal tapping, plureal tapping, peritoneal dialysis and so on and so forth. The dictum of “See one, do one and teach one” is true. So for the interns in Australia, there is no great need for them to do procedures because their health system is designed for them to be closely supervised until they themselves become a specialist.

But for us in Malaysia, the housemen must be able to do procedures after housemanship is completed because we will be posted in the district hospitals where there won’t be any specialist to guide us all the time.

So, for everything that they do or don’t do, and for everything that we do and don’t do, there are reasons behind it and it wouldn’t be fair to simply compare at face value. The reason lies on how the health system is designed.

That’s why you cannot simply mix and match one system with another.

You cannot aim to work like the interns in Australia with the aim of being an independent MO in the district. That would be dangerous. And, we cannot expect them to work like us with so many procedures to be done because they are taking care of a lot more patients than we do. While we only take care of a few patients in our cubicles, they are taking care of 30 patients scattered all over the hospital.

So it would be really difficult to compare without going into details regarding the reason that lies behind it.

Why don’t I simply tell you how they work over there, and you can make the comparison on your own?

The interns over there work in a team. The team consists of a specialist, a registrar (our equivalent of an MO), an intern and sometimes a medical student. So if you are doing medical posting, you will be with the same specialist and the same registrar for a few months. That’s your team! If the chemistry is right, you will enjoy getting to know each other and work together as a team. If anything happens to any of your patients, you know exactly who to call who would know about the patient in details.

Your patients are not in any particular ward. You cannot just say “Oh, now I am working in ward A”. Instead, your patients are scattered all over the hospital.And you will be taking care of them from the day they are admitted until the day they are discharged.

We have this term called ‘on-take’. So let’s say on Sunday, specialist A is on-take; that means any medical patients admitted on Sunday will be assigned to be under the care of specialist A…regardless of which medical wards the patients end up to be. So some of the patients may be at ward A, and some others might be at ward B, C, D and so on.

During office hours, the casualty doctors will call the registrar in team A to see the medical patients. But the registrar in team A do not have to be on-call at night. We have one medical registrar working at night in casualty who would see the cases and later pass them over to team A in the morning.

Team A will know about these patients because at 8.00 am every morning, there is a morning meeting (breakfast provided, too *wink wink*) where all specialist and registrars and interns would gather. They would discuss a few ‘bizarre’ case that was admitted that night, and passover the patients to the specialist who was on-take that day.

So on Monday, it would be specialist B who is on-take and each day it would be different specialist until you get back to Sunday.

So can you imagine how the work load is like? On Sunday, team A would have lots of new cases (their patients can be as much as 20-30)…but as the week progress they will be discharging a few patients already without taking anymore patients for the rest of the week. By the time they get to Thursday, team A may only have 10 patients. And then on Sunday, they will have another influx of new cases.

You will be given a list (printed by a clerk) of who your patients are and in which wards are they in. The list will have one empty columns where the interns can write what need to be done at the end of the rounds. If team A is also an infectious disease team, then team A will also round the infectious disease patients.

Clinics will be on the day when you are not on-take. So for Team A, clinic would probably be on Tuesday and Thursday. Not on Sunday.

All specialists will do the full rounds on the day of their on-take to know all the new cases and discharge a few patients to allow for some empty beds. Some specialists do rounds everyday of the week. But most would only do the full round 3-4 times per week. When they have clinics, they will do partial round, seeing only critical cases.

So your real best friend is the registrar who you will be with day in and day out. Sometimes, the registrars will help you with discharges when they are too many. You will do procedures with the registrars too. The registrar will help you out because you are a team….the smooth running of the team depends on both of you. If the interns couldn’t cope, the registrars will pitch in. Besides, during the day when your team does not have any clinics, what else would the registrar do after rounds, right?

Well, if the interns can cope, the registrar can go to the library and study, of course. Usually you are quite free during the days when you are not on-take and no clinics. It’s quite common to see registrars and interns studying in the library.

The interns start working at 8.30. The registrars sometimes comes at 8.30 too. The specialist comes at nine. The interns would update the investigation done on the previous day. At nine, they would go and see their patients together. Interns are not expected to know the cases well when patients are first admitted. But they will know the case well as the week progress, since they are seeing the same patients daily.

In one particular week, (usually Wednesday), there would be compulsory intern teaching from morning until noon. All interns would attend, and the registrar will take over the interns role for that day (except for the discharge summary, of course, but some even do that! Such registrars are angels in disguise!) so that the team will continue running. There is no need for the interns to sacrifice their teaching day just because they are worried that no one will carry out the orders of that day. The academic part of being a doctor is very much supported and they make the week as such that you will have one busy ‘on-take’ day, and then as the week progresses and a lot of patients under your team are discharged, you will become less and less hectic and will be able to go to the library and study.

As you can see, that kind of schedule is beneficial for everyone. We all have exams, right? The registrars can study as the week progress and become less hectic, the interns also have their own academic program without them having to worry about who will carry out the urgent orders for the patients, and the specialist can also have a few days of free times for their journal articles.

And they are able to do all these without feeling like they have not attended the patient properly; they are able to be ‘academic’ yet their mortality rate is better than ours who saw patients everyday (sometimes TDS!!) and work 36 hours straight some more!

They also have weekends off, except if it is their turn to do weekends call. They will be working the same amount of hours as the office hours.

After a few months of being in a team, working during office hours, it would be your turn to work afternoon or nights. If you work in the afternoon, you will start from 3.00pm to 11pm for a week. If you work at night, you will start from 11 pm to 8am and then attend the morning meeting for one hour. You will do this for a week (so that you don’t have to adjust your circadian rhythm quite so rapidly) and then go back into your team after 2-3 days of holiday. During pm and nights, you cover half of the medical wards (and the other intern will cover the other half) mostly attending unstable patients and do the brannulas. You don’t have to cover ICU, CCU, CRW….that’s the anaest’s kingdom and you are not needed. The anaest manage their patients by themselves.

Clerking new cases are already properly done from casualty. You don’t need to re-clerk the patient in the ward, as what needs to be done would have already been done before patient came into the ward. In the morning would be soon enough for the patient to be seen again.

For unstable patients, they have the term MET Call (Medical Emergency Team call). This is basically a 24 hour service system that rapidly responds to calls from medical staff about patients that meet the MET calling criteria. The MET consists of a medical registrar, intensive care registrar, and an appropriately accredited nurse from the ICU. There’s no need for you to call the medical MO who is busy clerking case in casualty. The RRT will come with resuscitation bag (like a luggage bag) where all the equipments are kept. They can come quite fast, less than 3 minutes.

But how do you know when to sound the alarm? Do you wait until the patient collapse first and only then sound the alarm?

Well, they don’t wait until the patient collapse before sounding the alarm, of course. They have rapid response criteria or MET criteria, which when I was a student I could remember quite well. But basically it consists of the vital signs that exceeds certain limits. The nurses will let you know about any patients that fulfill the MET calling criteria, you have to decide whether or not you need to sound the alarm. The decision bit is the hardest part as we try to encourage interns to treat the patients and not the numbers. However, you won’t get scolded for any false alarm as long as the patient meets the criteria because the aim of the MET call is to PREVENT adverse outcomes (namely cardiac arrest, severe respiratory depression, ICU admission) rather than to react to the outcomes. But you have to at least evaluate the patient’s baseline vital signs before calling the MET, and after having done that, you will be able to justify why you call them.

So I’ll feel safe working nights over there. I know if I am worried about any patients who may or may not collapse, I can always sound the alarm and the MET call people will come. They will first come and then ask what’s going on while assessing the patient. There’s no need for you to call the Anaest and present the case first, and then wait for the decision of whether or not they think you have justified yourself enough to call them. They will come first, and then later if they think the patient is fine, they will teach and discuss with you like academicians and professionals do.

When they discharge patients, they will discharge the patient back to the patient’s GP (In Australia, a GP is a specialist; like FMS). So you will give the discharge summary to the GP as well. All patients will have one GP. If they don’t have a GP, they won’t be able to access Medicare (their subsidized medical care). Usually, they’ll be seeing the same GP for the rest of their lives unless they move elsewhere and need to change GP. In that case, the GP will transfer the patient’s files and mailed it to the new GP. This is good in terms of we don’t need to worry about the follow up of the patients if it is a general medical patients. There’s no need to follow up hundreds of patients in the hospital clinics. Unless you think the patient needs special attention, only then you schedule the patient to see a cardiologist/chest/infectious disease/rheumatologist/ gastroenterologist etc etc. Otherwise, the GP is more than adequate when it comes to managing the patient’s primary health care. If the GP feels she couldn’t handle the patient within her expertise, she could refer the patients to the specialist clinic as well.

Actually it will take a whole lot longer than one post to talk about any health system. But I will just summarized what do I find different between our system and their system.

1) They don’t get to do procedures like we do. They have less clinical experience than us. There are pros and cons to this. It depends on which shoes you are on. If you are a patient, you will say I would like someone other than interns to do my episiotomy, right?  But as an intern, I would like to do as much procedures as possible, and I will do my utmost to convince the patient that I am confident to do those procedures (even while I am shaking in my shoes).

2) They have a lot of supervision until they become specialist themselves. While we are expected to be independent in the district hospitals.

3) They respect the academic culture. They don’t just tell you to go to teaching while at the same time leave you to worry about the radiological investigation that need to be done that they had ordered STAT!

4) They don’t have to work hard, missing the sunrise nor sunset, in order to be efficient.

5)You will be caring for the same patients from the day they are admitted until the day they are discharged. There is no such a thing where you have to suddenly be in charge of a patient whose file is already as thick a a novel and you have to study through them.

5) They would disagree with you, they are annoyed with you and you will know it too. But you don’t know it just because they scream at you. No, they can find other subtle ways of letting you know that you need to improve. Very creative, them!

I hope that this will give a clear picture of the working culture in Australia compared to in Malaysia. But everywhere you are, you get the good and the bad. Let’s make it a point to make sure that the good outweighs the bad.

Assalamuaaikum, and until the next posting, insya Allah, take care.

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