The End & The Beginning

05/03/2021

Assalamualaikum and hello everyone!

I hope this post finds you in the greatest of mood as I am currently in now.

Alhamdulillah, this month I have officially started doing specialist on-call. No more rushing to the ED in the middle of the night for yours truly. Unless for high-profile and super-complicated cases, me and my pillow will not be separated in the middle of the night ever again. Yippeee! Haha!

So that explains the good mood I am currently in, LOL.

Having said that, I am also quite anxious about where my placement will be after this. I’ve just had the Temuduga Pakar on 4/3/21, the result of which will determine the place I will be working as a psychiatrist for the next few years. Needless to say, I requested to remain in my hometown or at least in my own state, OF COURSE. But should the board decide that they need my service elsewhere, I will go there, Insya Allah.

I personally had made supplication to Allah to place me somewhere that is best for me; best for my religion, best for my worldly affairs and best for my hereafter. And I trust in Allah’s plan. Wherever the board places me, it must be the best for me according to Allah’s plan.

So… I will take it and make the best out of the situation. Just like I always had in the past.

pray

Let’s take a moment to appreciate how Allah answers all of our prayers in the end. There was a time when you had prayed for the things that you are enjoying now, remember? And we will continuously be in need of His grace and mercy.  Allah is indeed Al-Mujeeb… the Answerer of Prayers.

When I was a HO… going through the ups-and-downs of a HO life, I had prayed for time to pass swiftly so that I could become an MO who can make my own decisions without having to consult anyone for every single thing. I have always been addicted to independence, you see. As an HO, even if you know what to do, you are still expected to inform your MO… and if you happen to be on-call with an MO who is constantly at a mercy of his/her unstable hormones, you will have no choice but to bear with his/her crazy mood swings. What a torturous on-call it would be!

When you become an MO, you can make your own decision most of the time especially when you are already a senior MO. But still, there are some things that you cannot do such as signing the OKU form, starting a medication that is subject to quota, decision on whether to admit or discharge a patient… and disagreeing with your superior’s diagnosis and management is an awkward situation for any MO to be in.

But remember, you work for yourself…which means you need to feel satisfied with what you do… which means you won’t feel satisfied with yourself if you don’t do what is the best for your patient. So if you have to disagree with your boss at times… just do it… politely, of course. But do it.

You are the one who go to the ED and examine the patient at the bedside… your opinion counts! If you disagree with the specialist’s decision given to you over the phone, you must be able to state why and give more details to your specialist so that your specialist will have a chance to reevaluate his/her management. Do not simply swallow your doubts and then just follow a certain plan that you feel doesn’t make sense.

Heck, the specialist is probably still in the groggy phase of being woken up by your phone call and has missed a large chunk of your history before she finally wakes up properly. So, always double check and state your reason why you are hesitant to follow the plan that your specialist has given.

I personally will trust someone who double checks my plan and questions me than someone who simply follows what I say every single time. It shows that his/her brain is engaged.

However, knowing the timidity and shyness of most Malaysians in questioning their bosses, I know I cannot rely on them questioning me even if I might have given a wrong plan (perhaps because I had missed or brushed off some important details that they had told me because I was still groggy from sleep).

So what I usually do is, even if I usually already have my own plans after my HO/MO discusses the case with me, I will still ask them what are their plans for the patient. If their plans differ from the plan that I already have in my head, I will ask them why they have that sort of plan? That might trigger them to tell me some portion of the history that I might not hear properly or the part of the history that they forgot to tell me. If they are able to answer why they have that sort of plan by providing me with better history, or a clearer risk assessment, then I will follow their plan. But if they also cannot give me any good reason for their plan, I will give them my plan… and I will ask them, do they agree? If they don’t agree, I will be interested to know why, because they know the patient better than me! They saw the patient with their own eyes and actually examine the patient by the bedside. That is a HUGE factor to consider.

When I was a new psychiatry MO, I followed every plan that was given by my superior… because I didn’t know any better then. As I became more senior, I started to second guess my superior’s plan because I knew better by that time. I knew my superior wouldn’t have come up with this plan if only he/she knew what I knew about this patient. And so, I knew that I simply would have to emphasize on some parts of the history again, and express my concerns. To me, I was giving the specialist an opportunity to make an informed decision. We have to be fair to the specialist… we shouldn’t let the specialist make a wrong decision just because WE didn’t present the case properly.

Most specialists in Alor Setar are kind and open-minded… they take it nicely when I have a different plan. If my plan was wrong, they would nicely make me understand why without ridiculing me. If my plan was right, they would let me execute it. But some specialists somewhere might feel like you are disrespecting them when you express your doubts, even though your intention was just to make sure that the specialist is informed of all the pertinent details about the patient before he/she commits to a faulty diagnosis or a faulty plan. Alas, some superiors have ego issues and will not take it well when you voice out your concerns.

I am so lucky that my training is in Alor Setar where superiors are supportive and nice. I have heard some crazy horror stories somewhere else, I shudder in my shoes.

This is my opinion regarding how important it is to celebrate your juniors second-guessing your plans:

  • If the MO has a different plan, and she is able to support her plans by giving the specialist the part of the history and risk assessment that warrant such plans, then the specialist will be responsible if he/she insists to disregard the MO’s concerns out of some imprudent notion of ‘specialist’s ego and pride’.
  • But if the specialist had come up with a wrong plan because the very junior MO did not tell a good history and did not know any better to second guess the specialist’s plans, then BOTH of them must bear some responsibility of that faulty decision. But the specialist should have known better and ask for greater details in order to make an informed decision. If in doubt, go and see the patient yourself, especially if you are on-call with a junior MO.
  • But if the MO is already a senior MO and she did not make sure that the specialist understands the history and the risks properly (especially when she inwardly disagrees with the plan given to her by the specialist), she is responsible for any faulty decision given by the specialist. As an MO who actually SEE and assess the patient…. you should be on the side of the patient. That means, even if you risk offending your specialist, you must express your doubts and your concerns and make sure that the specialist understand why you disagree with your specialist’s plan. Unlike the junior MO, you have NO EXCUSE not to prevent your specialist from making a wrong decision especially when you REALIZE it is a wrong plan. Like I said, the specialist might still be half-asleep when you are discussing with her over the phone. You as the lucid one who know more about the patient have the responsibility to do the best for your patient. If your specialist is a rational person, instead of being offended, your specialist will thank you for second-guessing him/her. If you keep your silence when you have issues with your specialist’s plan, the fault is on YOU! But if you have already spoken up and done your part, the fault will be on the specialist. So if your specialist is being prideful and stubborn, just document everything properly, okay! Cover your backside.

In one of the places I had worked at as a Psychiatry MO, there was one incident in which I was so upset at my specialist for refusing to admit my patient until I had raised my voice to her over the phone. The specialist ended up agreeing with my plan, but with SUCH obvious reluctance, it irked me for days! Luckily (or unfortunately), he was so aggressive in the ward that he broke one of the doors in the ward. His aggressive action had helped justify my insistence for admitting the patient and in my opinion, it justified me raising my voice to the specialist.

As an INTJ, one of the things I CANNOT abide is when I have given you REASONS, and yet you did NOT listen without giving me any justification. I don’t take it well. I don’t need you to listen to me because you like me or trust me or personally think well of me. Our feelings for each other is immaterial to the issue. I need you to listen to my REASONS…. And if you disagree, you give me YOUR reasons.

If you are not a reasonable person, I will NOT respect you no matter who you are in the rung of leadership.

I have said it before, I work for ME! For my own satisfaction. And I won’t be satisfied if I feel my patients are short-changed. I do NOT work for my boss even though I respect all my superiors (within limits). So if you disagree with me, give me your reasons. Regardless of whether I like you or dislike you or indifferent towards you, I ALWAYS love good reasons no matter from whom they come from.

I myself, had been a HO, a junior MO, a senior MO, a psychiatry trainee and now Alhamdulillah, a specialist. I love my work best when I was a senior MO and a trainee. I feel empowered when I know what I am doing and why I do what I do and why the plan is the way it is.

So my take home message is… if you REALLY love psychiatry, get into your training ASAP. You will love your work even more. You will feel more confident. And less lost.

Found-you-lost-and-guided-you

This post marks the end of my MO-ship and the beginning of my journey as a specialist. With Bismillahhirahmanirrahim, in the name of God Most Gracious, Most Merciful, I pray that Allah will bestow upon me wisdom and protect me from making mistakes that would harm my patient, either intentionally or unintentionally, and guide me in making my decision for my patients.

“Ya Allah, perbaikilah untukku urusan ku semuanya, dan janganlah Engkau serahkan aku kepada diriku walau sekelip mata”

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