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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