Reducing Working Hours Without Increasing Efficiency Would Only Be A Utopian Dream

I was asked by people about my opinion on the accident involving Allahyarhamah Dr. Afifah when she had driven home after her busy on-call. Some had PM me on Facebook to ask what I think and want me to write about it. 

It’s not that I don’t want to write about the incident involving Allahyarhamah Dr. Afifah, may she be granted jannah. But I am trying to imagine how I would feel if the death of someone very dear to me is being widely commented in the social media (which in our generation is the mainstream media, anyway)

I am also afraid that I have nothing more to add to whatever it is that has been spoken about what has happened. It was a tragic accident. Whether or not it happened as a result of lack of sleep is subject to speculation, as none of us will ever know. 

I pray that her husband and family will be granted patience and endurance in dealing with her sudden passing so very close to the Eid celebration. 

***

I believe that there are many cases of MVAs and near misses secondary to lack of sleep and being post-call. I myself had experienced two MVAs in housemanship alone, not counting the many near misses as well. Alhamdulillah, nothing really traumatic happened to me.

(Please fill up the survey of MVAs post-calls H.E.R.E)

I have known a few doctors whose involvement in MVA had caused total lost of their cars. It really does happen. 

It really IS a problem. 

But fighting for reasonable working hours is immaterial to whether or not it is a risk factor for MVAs, in my humble opinion. It’s just that MVAs among doctors only spurred on the social pressure for the government to actually DO something. It is a catalyst to hasten things for the better. 

But at the end of the day, we fight for reasonable working hours because that’s our basic rights as a human being. The rights to have a good rest and sleep to fight another day. Some people told me that “being able to wear whatever length of skirt I wish” is a basic human right. I believe that to fulfill a physiological need is even more worthy of being categorised as basic human rights.

I have written the same thing over and over again ever since I was a HO.

I stop caring what my older generation seniors would think of me for what I had written. I have accepted the fact that we shall never agree and I will not waste my time convincing them otherwise. In any case, what I really think can be read freely and openly in my blog. 

The only posting I’d worked fully in the shift system was in paeds. A&E has always been done in shifts, so it doesn’t count. The rest of my postings were all done in the oncall 36 hours straight (or more) system.

So, if I (and my fellow doctors of the same batch) complained against this system, it is NOT because we couldn’t do it, too ‘lembik’, manjalitis and what nots. I could do it (still doing passive oncalls now) but I prefer not to. Because I prefer work-life balance. Because I can give more of myself when I am at my most optimum.

We preach sleep hygiene to our patients but at the same time we glorify our “during my time” days. Seniors like that are really annoying. Honestly speaking. People never told you so at your face but they sure think it.

Now, we are all telling you straight. Everyone should fight for reasonable working hours. It is some sort of grandiose delusion to think that the system will collapse without you having to be there for 36hours straight.

The old system is not sustainable. It shouldn’t.

***

But changing the working hours without changing other parts of the system will yield chaotic result; as many of our HOs have experienced at the start of the initiation of the flexi-hours system. 

Our system is (sadly speaking) about “doing more things without necessarily improving the outcome”.

But if we really want to implement lesser working hours, we need to revise our efficiency as well! Otherwise, of course the prediction that patient’s welfare will be compromised would be true. 

Let me give you an example in the form of the patient’s words I have come across numerous times: “This morning at 6.00 am, you have asked me this question.(Ho rounds) Then at 8.00 am, you asked me the same thing again (HO rounds with MOs). Now at 9.00 a.m, I have to repeat my answers again (HO and MO round with specialist).” 

In the patient’s head (my father has asked the same thing when he was admitted for UGIB), “Aren’t you guys communicating with each other?”

I told him, “That’s how it is, father.” 

Imagine, if the department practice TDS rounds? The morning rounds alone is 3 times already!

In Australia, interns round with the whole team! You don’t do TDS rounds for ALL patients, only for those you feel required extra attention. We came at 8.00 (check all the blood results we took previously so that we have the answers ready when asked) and the round started around 8.30 with the specialist and the registrar. Together! Discussing it together! Finding out things together! Teaching happens at the bedside. 

Some seniors had wondered out loud, what the hell is the HOs doing when they say they are so busy? Why can’t they discharge the patient as soon as possible to give us more beds for the cases stranded in the casualty to come up? 

Because!! After the rounds, we have to do blood taking and referrals and procedures and check  the results of our blood taking. Before you knew it, it’s already time for PM round! The patient who was discharged in the morning still couldn’t go home because her/his discharge has not yet been done. After the PM round, it will already be around 3.30 to 4.00 pm…you still have to carry out the PM round orders. 

So again, discharges have to wait! Sometimes it has to wait until 5.00, after all ward work are done. At the same time the A&E colleagues will keep on calling “When can we admit our patients? They have been stranded for two days in my department!” When I was a HO, I felt so harassed that I shouted into the mouthpiece “Dah rounds habis lewat? What can I do?” and slammed the phone down.

“During your time”, the discharge summary was short and sweet without having to fight for the use of the computer with the staff nurses. Welcome to the 21st century where Malaysians LOVE to use IT,  that  even for daily reviews they wanna use E-His.

Don’t get me wrong. It makes sense for us to use IT for discharge because it is a brilliant reference for the patient’s future admission. But some departments even cause further delay in work efficiency by forcing the nurses and HOs to document even the daily reviews in E-His.

Below is a revised excerpts of something I had written when I was a HO:

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 some hospitals with IT system, 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.

If we spend  the bulk of our time being doctors rather than clerks, lesser working hours will NOT cause severe lack of training. 

If we let the nurses spend their time doing nursing work, if we let the nurses write the reports in the file by the patient’s bedside (instead of at the computer at the nursing counter) then there will be less complaints by the public that the nurses are not helpful and simply ignore patient’s request. 

We have to know how to be efficient! We have to know what steps we could skip and what we should adhere strictly. It seems that with technology, we become dumb at prioritising!

This is one of the reason I enjoyed my A&E posting the most. I couldn’t ‘digest and decipher’ the need for rounds to start without the consultant and MOs being around together. What is the use of this hierarchy-based starting round? The more junior you are, the earlier you start the round…it’s ridiculous!

When there are many HOs now, suddenly nurses are no longer the ones who set the brannulas or do venepunctures. I wish there will be more senior nurses saying “During my time, I can do brannulas and venepunctures. I do ARM too.”  Hahah.

Dear senior doctors, you don’t work in the same manner that the Housemen do now. So, if you think their job is much lighter than yours when you were a houseman, you are delusional! The nurses were a lot of help during your time in reducing the burden of your ward work. 

The excessive use of computers that delay your ward work, were not there. The excessive forms and reportings were not there during your time. 

If their clinical skills are compromised by the flexi hours system, it is because they spend their time doing non-doctor things! And nurses spend their time doing non-nursing things!

***

In Australia, their primary health care is very functioning and very efficient. And therefore, their clinics do not have as much patients as ours. I guess, that’s why the specialists then have more time to spend during the rounds to teach their subordinates. Maybe that explains why they can all go do the rounds together in a team with coffee in hand, mostly stress-free. They didn’t have to rush to the clinics.

In Malaysia, we don’t have a system where one whole family see the same GP throughout their lives. We don’t always discharge our patients to GP. GP don’t interact with doctors at the tertiary centre, as much. 

So we cannot talk about reducing working hours without taking all these factors into consideration. We cannot reduce the working hours without increasing our efficiency in other aspects of our health system.

It takes a health reform. A health system revolution. Doing things in halves spell CHAOS. If we are serious about reducing working hours, we MUST, MUST improve our efficiency in doing our daily tasks. We MUST, MUST improve our primary healthcare, which will in turn reduce the number of admission secondary to exacerbation of chronic diseases, which in turn can afford us more time for bedside teaching with our housemen because we don’t have to rush to our clinic. The number of patients in the clinic can be reduced if we strengthen our primary health care.

If we don’t do those things, then reducing working hours will only be a Utopian dream; sounds idealistic and nice on paper, but impractical and unfeasible in reality. All aspects of the health system have to complement each other in order for us to reduce working hours.

In the mean time, what we can do is to ACKNOWLEDGE that working hours IS a problem, without criticising and belittling our juniors in a holier-than-thou manner. This is the critical point where our generation cannot see eye-to-eye. This is where we lost each other.

I can agree that reducing working hours in the current situation will compromise patient care (due to our own fault of inefficiency, in the first place). But the seniors cannot even meet us halfway by saying in a kind manner that “I understand. I will support to help make junior doctors’s life better. I know that just because I train that way, doesn’t make it as the only way to train. I know I wouldn’t want my kids to work the way I did during my time.”

Sometimes, offering a kind word and understanding is all it takes. 

*** 

A schoolmate of mine shared the news of the death of Dr. Afifah into our Newcastle Uni batch whatsapp group.
I told them, “Insya Allah bila kita semua dah jadi pakar, we should all fight for work-life balance. Jangan jadi macam “during my time” generation.”
We agreed.
It’s our pact to keep, Insya Allah.

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Let’s see how far we have come (or regressed)!

On June 26, 2015 something momentous had occurred in  the United States of America. The US Supreme Court ruled that the US Constitution guarantees the right for same-sex couples to marry in all 50 US states.

The US LGBTQ community finally wins after decades of propaganda and fighting.

Little by little they changed the social construct. 

Lao-Tzu was right: A journey of a thousand miles begins with a single step.

They were persistent and tenacious, out-spoken and courageous, organized and systematic, unified and integrated.

They launched their mission and attack using an impressive holistic step-by-step approach:

  1. Romanticizing the act of ‘coming out of the closet’ by praising these people as brave, and criticising those who oppose them as bigots. They romanticised the whole concept of love, saying how it is a beautiful thing regardless with which gender the love is directed at. 
  2. Propagating their agenda by getting celebrities and influential people to support LGBTQ. 
  3. Getting scientist to endorse that being gay is natural. In fact, it is said to be in the genetic make up. They spread this ideology straight into medical schools all over the world (mine included; gay counsellors are given one hour lecture time when we learned about sexuality in 3rd year). So we have the world’s brilliant people who most of them support LGBTQ as something natural and biological. If you cannot believe your own doctors when they say gays are natural, then who can you believe, right?
  4. Once their social standing is high (due to the aforementioned support of celebrities, influential people, scientist of brilliant minds), their ability to exert social pressure is increased.
  5. When they are able to exert social pressure, the politicians had no choice but to listen to them. They lobbied politicians (and powerful ones too) – Hillary Clinton and Obama, just to name a few.
  6. The politicians are policy makers! Do the math! And see the outcome now. 

They won. Finally. After decades of fighting. 

The silent majority lose because their protest was not systematic. The silent majority lose because they were silent. They couldn’t be bothered to STRATEGICALLY plan a counter-attack. 

I notice this sort of malaise attitude in the Malays, I am sorry to say. They just couldn’t be bothered to oppose vehemently, write scathingly, advocate forcefully and fight strategically for whatever cause they believe is right. They easily gave up at the slightest hurdle. They wouldn’t complain of ill treatment by superiors, wouldn’t stand up for themselves when they were bullied, and will also not back up their friends who were bullied. Even if they start the process of complaining to the higher authority, their effort can easily be vanquished at the slightest reprimand by the higher authority. They couldn’t be bothered to go higher up in the hierarchy chain until they get what is righteously theirs. Their burst of momentum only enough to move them a step forward, but no further. 

I lamented this sort of passivity among my own circle of friends. If they don’t even care to fight for themselves, how can we expect them to care about higher ideals and universal truths? How can we expect them to care for the justice of others if they don’t even care to defend their own selves!

In Islam, advocating for righteousness is an ethical and moral obligation, regardless of whether or not it directly concerns you. 

“If one of you sees something wrong, let him change it with his hand; if he cannot, then with his tongue; if he cannot, then with his heart and this is the weakest faith.” Some versions add: “there is no part of faith behind that, not even so much as a mustard seed.”

Readers, let’s talk about doing good. Call out to those who say something that is against the established moral and ethical principles even if it is being said by the most influential people among you. Talk about universal truths. Write about it. Spread it in the social media. Viral it. Lobby your MPs to fight for what is right. Be as courageous, as vocal, and as systematic as the LGBTQ movement when we are promoting good. 

Because Sardinia Ali r.a had once said “Truth unplanned shall be defeated by organised falsehood” 

In Malay,Kebenaran yang tidak terancang boleh dikalahkan oleh kebatilan yang terancang”

But the silent majority prefer deafening silence to the exclusion of nothing.

Because the silent majority gave up and said nothing for fear of being labeled ‘bigoted and backward’, now the LGBTQ is legalised in the US.

 ***

In germany, another sort of decadence rear its ugly head.

Mere days after the legalisation of LGBTQ in the US, the news about how the Germany’s National Ethics Council has called for an end to the criminalisation of incest between siblings reappeared in the social media. 

Screenshot 2015-07-09 20.55.47

This would have been unthinkable among the general public merely a few years ago. But now, a freaking ETHIC COUNCIL has called for its legalisation. If an ethic council can be this unethical, what hope can we place on the general population? I shuddered in my boots simply thinking about how the world’s morals have deteriorated to the lowest low it’s ever been.

I was interested to examine the reason given by the Germany Ethic Council. Apparently, they came to that decision after looking at the specific case of Patrick Stubbing who was adopted as an infant and met his sister, Susan Karolewski for the first time when he was 24 and his sister was 16.

And they went on to have four children! Two of them were disabled though whether incest was the cause is not able to be determined. 

In 2008, Peter Stubbing was convicted of incest but continued to appeal for his rights to a family life. 

What’s next? Legalization of pedophillia? 

Are we going to support for an absolute “right to sexual self-determination” at the cost of the society?

Screenshot 2015-07-10 07.05.36

***

Some might ask, why should the society care anyway? My life, my rights, my risks! Everyone is entitled to their opinion and their rights to freedom, say them.

Wrong! 

Your freedom is limited by your rights. In turn, your rights are limited by another person’s rights. 

Your rights end where another person’s rights begin. 

I repeat, your rights end where another person’s rights begin.

The society has to care because it involves children. The impact that gay marriages would have on children can be devastating. The impact of incest on normal development of children would be huge. It would cross all sorts of boundaries and confuse things that are already chaotic. The children that are produced from incestuous relationship would always feel different, ashamed and would have identity issues.

Is my father actually my uncle? Is my mother actually my aunty? Are they both my parents and also my aunt/uncle?

Imagine the sorts of jeering taunts the children will have to endure? And we have not even gotten to the topic of illness and disability of the children of an incestuous relationship!.

These children have rights! Your rights should not trample all over theirs. 

Just like the children of gay couples have rights,

Read this confession of a daughter of a lesbian couple H.E.R.E. The sort of emotional internal struggle she had to endure is very heartbreaking. 

Screenshot 2015-07-10 07.58.12

Yet, these people still choose to say “Everyone is entitled to their own opinion,their own lifestyles etc etc.”

***

In Malaysia, another form of sickening illness is brewing. We are like jack of all trades, master of none. We dabble in all sorts of dubious activities without any discrimination. 

Since a picture is worth a thousand words (for truly, I have run out of them), then these are the pictures that will tell you more eloquently the sort of sickening illness I meant. 

In Politics, corruption is rampant.

Screenshot 2015-07-10 08.03.01

In economy, we are getting all sorts of financial pressures, right, left and centre.

Screenshot 2015-07-10 07.24.06 Screenshot 2015-07-10 07.24.48

And a helpful person went on to brilliantly and kindly suggest that we can save up by not ‘balik kampung’ for raya on national TV. Speechless. 

Screenshot 2015-07-10 07.27.47

In religious and social aspects, the Malays are number one in decadence. Ridiculous over-religiosity and over sensitivity such as have occurred when a teacher in Sg Petani had forbidden the non-muslims primary schoolers from drinking and eating in front of their Muslim friends, and then jokingly talk about drinking their own urine in the toilet if they got thirsty:

This was my own facebook status that I wrote at the start of the Ramadhan.
This was my own facebook status that I wrote at the start of the Ramadhan.

And even more ridiculous, we became paranoid and scared of our own shadows with regards to the Christians brothers and sisters.

Screenshot 2015-07-10 07.35.04

I just couldn’t ‘brain’ this! It is humiliating and degrading to us, Muslims when a minority of us behave stupidly. 

At the same time of ridiculous pseudo-overreligiosity, we also have people who commit heinous crime against each other that we would never have done to stray cats in the street. Again, they are mostly Muslims! We are the master of contradictions. 

Screenshot 2015-07-10 07.20.38 Screenshot 2015-07-10 07.22.07 Screenshot 2015-07-10 07.22.52

Recently, there was also a debate regarding the length of a woman skirt, for God’s sake. I reiterate that to me, rules are rules! I will not deny anyone their rights to wear whatever they like…but if it is against the rules of the place where they wanted to go, then they shouldn’t cry when they are not allowed to go in. 

I think we have blown things out of proportion over such petty matters: on BOTH sides of the debate. I have debated this matter in a lengthy and tiresome manner in the Dobbs Facebook page. Enough has been said about it and I am not going to continue the rant further in this post. 

Screenshot 2015-07-10 07.12.43

***

In my family, I was brought up talking about politics, economy, ethics and morals. When we don’t talk about those, we talked about books. Those are our light topics. It’s been that way since I was in primary school. The years of my primary school was the beginning of an exciting political era in Malaysia with the sacking of the then Deputy Prime Minister Anwar Ibrahim. And there was also the Great Economic Crisis of 1997 and 1998. I was a very ardent newspaper reader back then too. My father at that time taught me English by buying me English newspapers and picked some suitable articles for me to translate into the Malay language. That way, I learned BOTH proper Bahasa Melayu and English. Until now, language is my favourite subject. The articles that my father picked for me were always mostly about politics; never about entertainment (to my despair). I had to do those translations daily; one article per day. So, at that time, I can say that I was arguably the most politically and socially aware standard 5 student in the class. 

I cannot remember talking about much of anything else with my family other than politics. Until now, we can argue and not talk for days with each other simply because of a differing opinion in politics and (un)ethical business approach. 

As a result, I am not very socially-apt in conversing on other matters. Makes me a socially awkward person most of the time. 

There are times when I wish I could be less serious, and can think of more lighter topics to talk in a social settings or write about in the social media.

But, I can’t. 

You see, serious matters are….well, serious, They tend to generate strong views and opinions. They tend to cause me to talk vehemently, righteously, and yes, annoyingly. In a “hang asyik rasa hang betul ja, Afiza” way.  The problem is not that I cannot accept other people’s opinion. The problem is that their opinions are wrong and therefore, unacceptable. (haha, yeah I am annoying. I have pretty good insight about how annoying I can be)

If we are talking about favourite colours, favourite food, favourite type of homes, favourite dresses, favourite cars (which are the things I don’t talk about much), then yes your opinion is always acceptable. 

But sometimes, we are talking about something that is more crucial than that. We are talking about justice, rightness, equality, fairness, moral and ethical dilemmas. In these sort of topics, you should try to THE BEST OF YOUR ABILITY to arrive to the most accurate stand. You cannot simply end your argument with “everyone is entitled to their opinion” because that is just plain lazy. You trivialise the matter to the same level as “favourite colours and favourite food.”

How could you simply shrug your shoulders like that?

Maybe because some people don’t really care. But they want to be seen to have an opinion anyway. So they come up with one. And when we criticise that opinion, they can simply say “you have to respect my opinion,”

I learned eventually to not even start an argument with them. Because they are not really interested in arriving to the truth. They only have something to say about it, so they say it. And then they leave the argument never thinking further about it. 

I am the sort who ruminate on a problem until I am convinced that I have arrived to the most righteous, just, ethical conclusion. And once having arrived to that conclusion, I want people to know it and advocate it with me. That’s me being an INTP (if you google INTP, you will understand why I am this way. I only just understand why I am like this, after all these years. MBTI is brilliant!) I get frustrated when people don’t ‘get’ it!

I invest my intellect and my emotion in these sorts of issues. And I guess, that’s why I cannot control how frustrated I feel when people don’t see something that seems so plain, to me. 

Now I have learned to pick and choose with whom I can talk about these things with. I can only talk about these things with those who are not easily offended by my choice of words when I disagree. I can only talk about these things in depth with family and close friends who possess the same sort of inclination as I do.

But I will continue to write and spread awareness that we should be less passive and more vocal when promoting what is good and right. Because “kebenaran yang senyap tidak memberi impak.” Because being silent does not exert the sort of social pressure needed to get the politicians to take notice and create good policies. 

Because “kebenaran yang tidak terancang boleh dikalahkan oleh kebatilan yang terancang.”  

***

This used to be my favourite song for studying when I was a 4th year medical student. I think it is very apt to be sung in the current days of confusion, decadence, and moral disintegration. 

Let’s see how far we’ve come, folks! And how far we have regressed. 

Screenshot 2015-07-10 07.54.54