The Doom & Gloom Catastrophe: A final wrap-up

In psychiatry, catastrophizing has a specific meaning. It is an irrational thought a lot of us have in believing that something is far worse than it actually is.

 

I will give you an example of how catastrophizing occurs in the mind of juniors or HOs. A junior who was unable to set a brannula on a patient at her first attempt during her first day of housemanship and thus was given a murderous look by a senior HO when the senior HO was asked for help, may catastrophize the situation by thinking “Alamak, patient mesti menyampah dengan aku sebab cucuk dia banyak kali. I feel like crap. Senior HO tu pun dah marah sebab aku menyusahkan kerja dia. Bodohnya aku. I am NEVER going to be good at this. My seniors will ALL hate me for my incompetence. I am so incompetent, I will be miserable FOREVER. I better not come to work tomorrow.”

 

Or…a first poster may catastrophize a situation where she was very gently admonished by her specialist, by thinking “I will be targeted for the rest of my posting. This specialist already thinks that I am incompetent. I will never pass my assessment.”

 

So, she then did not come to work the next day. And when the day after arrived, she was worried that she would be scolded for not coming to work the day before, so she didn’t come to work for another day. And the vicious cycle continues.

 

This is HOW catastrophizing is counter-productive in junior doctors. In no way am I justifying her incompetence and her ELs and MIAs. I am showing you how terrible the effects of catastrophizing is. And how vicious the cycle can be.

 

Catastrophizing among senior doctors are even worse! Because they are in the position of power, their catastrophizing will actually affect others below them and how others see their juniors. Because they are in the position of power, their catastrophizing – if not done with careful deliberate conscience – will excite unjust actions and taunting remarks that will affect how the public view junior doctors.

 

 

Dear seniors (for very dear you are to us, juniors),

How can you –  in good conscience –  say with hundred percent certainty, that the first two years of a doctor’s training (a very, very, VERY small proportion in the timeline of all her training to come) would predict how good she/he is as a specialist later?

 

Is all her future training when she becomes resident/MO /registrars/trainee specialists later, won’t matter at all? Is the first 2 years ALONE will end up being the determining factor that would be the ‘be all and end all’ in someone’s future career as a specialist?

Think logically!

 

In good conscience, reflect! Think deeply on how fair your statement is, that you can make sweeping non-evidence- based conclusions and predictions, based on a very small proportion in the timeline of a junior’s doctors training in her initial years?  How fair is your statement?

 

Or do you think that what you said to junior doctors (as a whole) does not matter in terms of justice and fairness?

 

***

 

Changed Circumstances & Altered Scenarios

 

We are practicing medicine in the age where all cases are potential ‘lawsuits waiting to happen’.

 

Our public is no longer the kind who does not blame their doctors for all the morbidities and mortalities that occur in the hospital.

Once upon a time, we did not have enough doctors; and the juniors had many opportunities to perform all sorts of procedures with MINIMAL supervision. Even when the juniors ended up making things worst, no one was any the wiser. Patients would simply thank their doctors for the help that was given and would accept any mortalities and morbidities as a work of fate. Back then, they felt that doctors were their great helpers and all outcomes was in the hand of ‘qada and qadar’. Fate and destiny had dealt its hands, and they accepted it readily. The doctors could say “we try our best” and the families would nod their thanks.

 

Nowadays, they will say “your best is not good enough!”

Nowadays, even when adverse outcome springs out of nobody’s fault, somehow we are STILL the bad guys.

Nowadays, they demanded for ‘women doctors only’ in treating their wives. They knew their rights. In the situation where we were not able to provide what they demanded, they insisted and called the hospital director.

 

Like I said, this is the age where all cases are potential lawsuits waiting to happen. Or at the very least, potential embarrassment in the tabloid papers.

 

Let me demonstrate.

There was a case a few years ago (the individual, the nature of the disease, the departments involved and the hospital location won’t be disclosed) where a patient developed unilateral upper limb ischaemia a few hours after a HO had attempted a long line procedure. We are not sure whether this was due to the natural progression of the patient’s own disease or due to the adverse outcomes from the procedure itself. The documentation were all pretty hazy (another pitfall that would make the prosecutor laugh his way to court).

 

Imagine if this case went to court. Imagine if the family members were educated and well-off to sue everyone involved. How would this play out in court?

 

Prosecutor: So doctor. Tell me your name, your background and your years of experience as a doctor (make no mistake; the prosecutor has no intention of getting to know you better. He wants to poke fun at how your experience is not good enough.)

Specialist: (answer briefly; providing all the related information)

Prosecutor: Tell me, doctor. Who had performed the long-line procedure that had resulted in the patient’s loss of upper limb?

Defense Lawyer: Objection, your honour! The prosecutor is making conjectures and unfounded assumptions in his question. We have not yet established the cause of the limb ischaemia!

Judge: Sustained.

Prosecutor (smiling derisively): I apologize, your honour (without sounding at all sorry). Let me rephrase that question, your honour. So, tell me doctor, who had performed the long-line procedure on the day when the patient lost his upper limb a few hours later?

(it is, IN ESSENCE, the same question. However the defense lawyer can no longer object to it.)

 

Specialist: it was my houseman named ‘bla bla bla’.

Prosecutor: Oh, a houseman! So tell me, how many extensive years of experience has he had in doing a long-line? (voice DRIP with sarcasm)

Specialist: Ehem. He was a first-poster.

Prosecutor: (Pretend to show a surprised face) Oh! Wow! A first-posting houseman. And was he supervised?

Specialist: Yes, he was.

Prosecutor: Oh, that’s’ better. Was he supervised by a specialist?

Specialist: (squirm in his seat) No, he was not supervised by a specialist.

Prosecutor: (raised his eyebrow, a look of disbelief) Was he supervised by an MO?

Specialist (rub his temple in agitation): No. He was supervised by a senior HO.

Prosecutor (laugh quietly): So, how many DECADES of experience does this senior HO have? 10 years? No? Ok, 5 years maybe? ALSO no!? Perhaps 2 years at least?

Specialist: The senior HO was in his second posting at that time. But he was already 4 months into the department which made him a senior HO in the posting.

Prosecutor: (turn his whole body towards the judge in a dramatic manner, and then conclude in a firm voice) So our patient lost his upper limb after a FIRST POSTER HO had performed a long line procedure on the patient, supervised by a senior HO of merely 8 months experience! (pause for effect) No further question, your honour.

 

 

I don’t know how medicolegal cases are handled in Malaysia. I am not a lawyer! Never even studied law! But if I were the lawyer wanting to open cans of worms, I can imagine how it will turn out in court. This is only 5% of the torture you will face in court.

 

Do you think that the developed countries move away from the practice of letting their interns perform procedures, just for fun? No! But many factors and circumstances have forced them to train their interns this way – the so-called disadvantaged and lacking way, the ‘glorified clerk’ way. Their hands are forced to do so by the many factors that have changed in the public sentiments and the health scenarios of their countries. But rather than complaining and whingeing about it, they found solutions on how to make sure their interns graduate into good specialists, regardless of their initial training.

And that’s what we need to do!

 

Did you NOT notice that our public has become quite vindictive towards doctors, lately? At least in the West, the public are educated enough to know NOT to sue when it is clearly not warranted. But our public is only starting to realize their rights, but WITHOUT the good knowledge that is needed to exercise those rights responsibly. It is like using a weapon without really knowing the damage that can be done. The public are only aware of their rights…but not their responsibility (for example their compliance to treatment and follow up are atrocious!).

 

While the public has become more aggressive and demanding, no one is defending doctors. And at the same time, doctors are divided into seniority and sects (my specialty is better than your specialty and on and on they go!)

 

Give it a rest!

 

Are you sure you still want the junior doctors to do all sorts of procedures supervised only by their senior HOs in this current scenario of constant litigation? Are you sure you still want to adopt the attitude of criticizing our junior doctors for their lack of exposure without really helping them realize their potentials?

 

Do you think the junior doctors do not lament the fact that they are deprived from learning to do all sorts of procedures as a result of changing environments + public expectations + unfortunate policy choices in the past? Do you think that the junior doctors are actually happy about how everything is turning out to be, which by the way, happen through no fault of theirs?

 

No, we are not happy either. We are all in the same boat.

 

People been saying that I shouldn’t compare our health system with developed countries. Well! At least, I compare the current practice in Malaysia, to another practice that is ALSO CURRENT, in a more developed country, for the specific purpose of learning to do better.

 

But when YOU compare our current practice, with the training that you had ‘DURING YOUR TIME’, and ignoring all the altered circumstances that have happened, how is it going to help us? It’s not like we have a time machine to turn back time, right? Please, stop being counter-productive.

 ***

Quantity Vs Quality

It is so easy to say that junior doctors nowadays are low quality; not tough enough and always perform the ‘invisible act’ of  MIAs and ELs.

 

But guess what? Someone senior in PDRM had told me that “nowadays the junior police officers are very undisciplined. There are many of them and it is hard to supervise and control everyone.”

 

Quantity and quality has the time-honoured tradition of being directly related.

 

When there were not enough doctors decades ago, you may see one or two undisciplined doctors out of ten. Now, there are way too many junior doctors (not our fault!). Thus, you will see 10-15 bad juniors out of 100! You can ignore one or two bad juniors DURING YOUR TIME. But you can’t ignore 10-15 bad juniors during our time. That’s why their mistakes and their faults seemed highlighted and glaring, and increasing.

Not because your generation was better than ours.

 

And let’s not forget how many SOPs have been created since 20 years ago. Every time something untoward happens, we will perform a root cause analysis that would produce another checklist, and another SOP. Doubling up our documentation even more! More checklist and more documentation DO take time away from actual contact with patients.

 

Once upon a time, nurses can do blood taking and brannula settings. Once upon a time, nurses can do artificial rupture of membranes. Once upon a time, they assist doctors in procedures, rather than asking the student nurses to do so, just because they have not yet completed their reports in the computer. But now, nurses have to be knowledgeable in IT to manoeuvre the E-HIS system rather than do anything else. I am sure if you ask around, you will find senior nurses lament the lack of procedures performed by junior nurses.

 

Who do we blame? Do we blame the IT and the technology for daring to emerge in the 20th century?

The fact is, a lot of things have changed. We don’t practice medicine the way it used to be practiced anymore and this is not only happening to us, doctors. But also to nurses and MAs.

 

Finding someone to blame is easy. But try to find the solution to adapt to the changing circumstances, now that’s difficult!

 ***

 

Procedural Skills

 

A senior HO will be much better at setting a brannula to grossly oedematous/anasarca patients than a specialist who hasn’t had to do it for years and years. Not because the specialist is not good. But because the HOs has been setting brannulas day in and day out for months.

 

We are human. And thus, our skills become rusty without practice.

We are human. And thus, we forget knowledge that we have not revisited for quite some time.

 

That’s normal. That’s nothing to catastrophize about. All it takes is for you to practice when the time comes for you to specialize. All it takes is for you to know how to re-learn something you have forgotten. In the days of the internet, that is easy peasy. Besides, relearning something you have already known in the past, is not as hard as learning it for the first time. This is because all our brain need to do is to strengthen the synaptic connections that have already been formed.

 

The fact is such that we are practicing medicine in the age where everything is subspecialized. Once upon a time, it is crucial for a medical specialist to know how to insert IJC for the purpose of dialysis, as well as how to do bone marrow aspiration, as well as how to do OGDS. Now you have the nephrologist, the haematologist and the gastroenterologist to do each of those procedures. It is no longer quite so imperative for a nephrologist to also know how to do BMA, other than for his own self-esteem in knowing that in desperate circumstances, he will be able to do it. It is not quite so imperative for a haematologist to also be competent in doing OGDS. You will learn to do all these procedures while you are learning to become a general physician. But once you have subspecialized, that’s it!

 

In this highly legal environment, if something had gone wrong while you are doing a procedure that is outside your sub-specialty, the irritating prosecutor will ask you “I know you are a specialist too, but why didn’t you refer to the right sub-specialist?”

 

This is the answer to why the interns in the West can still become good specialists despite of their lack of procedural skills during their internship. They focus on learning the procedures of their subspecialties MOSTLY. And why not? This is the environment that we are living in, after all! The good old days is gone!

Finito!

 

This is the current reality. Help us deal with it without telling us that we are all doomed to be future failures.

 ***

 

Knowledge

 

I knew that my previous blog post was only positively received by the juniors. Not really the seniors.

 

The thing is, I find the line of seniority becomes a bit blurry as you move up the ladder of seniority.

 

I am from the batch of Housemen who spent 75% of housemanship during the time when we had to do on-calls. The only postings where we consistently work in flexi-hours system was paediatric posting. A&E doesn’t count because everyone (regardless of which batch of housemanships) work in shift in A&E. The rest of my postings are done in on-call system because at that time, we did not yet have enough HOs to do the flexi-hours system.

 

Even so, I never dream to say that “the current HOs now are not going to be as good as me, just because I spend two years doing more procedures and devote more hours in the hospital than they do.” And I am not embarrassed to admit that I have forgotten some of the procedures I have learned.

 

Isn’t it a commandment from God for us not to belittle others, as reminded by my good friend, recently.

Let not a group scoff at another group, it may be that the latter are better than the former; nor let [some] women scoff at other women, it may be that the latter are better than the former….  (Qur’an 49: 11)

 

Dear doctors, we are turning into groups that belittle one another, just because our circumstances have changed and the time has changed. Isn’t it sad?

 

Someone who is only one posting and a half (about 6 months) my senior actually thinks that she is ‘senior enough’ to also condemn the juniors. She basically pointed out that I  – supposedly –  do not know how difficult it is for ‘them as seniors’ to train the juniors. She said that they are speaking as ‘clinicians’.

 

I HAD to laugh.

 

What did she imagine a PSY MO do? Not seeing patients? Not a clinician?

 

So she is a clinician, and I am not?

 

I see…So, this is how arrogance is inherited from seniors to juniors! It is astounding that someone merely 6 months my senior spoke like she is NOT also a junior. Wait until she does her MRCP and have her specialist tell her that HER MRCP is not as worthy as the specialist’s MRCP, because ‘during her specialist’s time’ the MRCP was much harder and the examination was tougher and more discriminating.

 

And this is the same MO who had said that a patient had NMS due to SSRI. When her HO had asked me to change her SSRI to prevent future NMS, I was speechless. Since when does SSRI cause NMS? It was a very rare phenomenon for SSRI to cause NMS. Cases reporting SSRI causing NMS are usually confused with Serotonin Syndrome. And in this THIS particular patient, it is her antipsychotics that are the culprit.

 

But did I ever go to her and say “which university did you come from that you don’t know NMS is caused by antipsychotics? NOT SSRI which is an antidepressant! NMS is a medical emergency and it is NOT acceptable for you not to know. Serotonin excess vs dopamine blockade is a huge difference and you confused the two???”

 

See? It is not my practice, nor is it my principle, to rub it in people’s face and belittle them every time I have the chance. I fully recognized that the last time she had to study psychiatry was when she was in 5th year. Thus, her lack of knowledge (though embarrassing) is understandable. Everybody forgets. They have to re-learn things they have forgotten. So, no need to show your arrogance.

 

We as PSY MO, refer patients to the related departments when they have other non-psychiatric illness that require attention too. For example, when a patient was warded for NMS (on the background of prolonged immobilization), she developed DVT which was not detected until she presented to psy clinic for follow-up after discharge. We referred her to casualty for DVT, which as we all know, can be life threatening if it proceeds to Pulmonary Embolism.

 

PSY MOs not only talk to patients, they examine them in other ways too whenever patients complain of other non-psychiatric symptoms.

 

So, am I still not speaking as clinician?

 

This is what I mean when I said that people are snobbish in thinking that their specialty is more clinical than others and thus, they are the only one who can speak.

 

Isn’t it already time that we bridge all these unnecessary gaps of seniority and specialty snobbery? What is the use of MMA, if outside it, doctors are still blaming each other rather than work towards a better future?

 

***

Message to beloved juniors

 

I have had enough of championing the junior’s cause. If someone in my batch can talk like she is so senior, then maybe I should start acting like a senior and distance myself from your struggles. Maybe, I should just let the current juniors fight their own battle.

 

But witness that I have done my part for my juniors. And it was because when I was a HO, I had felt strongly about things that were said to us, the HOs. But you guys had it tougher than I had in terms of criticism, because the flexi hour system is fully established already in your time, and thus it became their main attacking point towards you.

 

I have other things to focus on, now that I have left my housemanship for almost two years already.

So, I am done talking on your behalf.  :P

Good luck and all the best. Be the good specialist you are meant to be later. Don’t go MIA. Minimize your ELs. Go to work and face your fears. What is the worst that can happen, after all? You can do it!

 

I have full faith in our future.

 

P/S:

If I ever get tired of being a doctor, I will take up law and specialize in medicolegal. I am going to be the kick-ass prosecutor. Haha. It would be so much fun to see one another in court, don’t you think?

 

 

 

 

 

 

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