Hey I Know Someone!

Today, I had an aquaintance with Mr Q, which is a local mobile phone dealer with an attitude. He has a grandma who was admitted with a diagnosis of chronic AF with overwarfarinisation. Her INR on admission was 3.8 - which is slightly above the recommended upper limit of 3.5.

She presented with haematuria of 1-week duration. She also feels tired and has lost weight and appetite. Upon further questioning, it was clear that her active problem was the least of a primary cardiac one. She has been diagnosed to have carcinoma of cervix and she had been under the surgical colleagues for an episode of intestinal obstruction. I gather that the staging of her carcinoma would at least be II or III depending on the local tissue infiltration. I hence told him that I would call upon the help of my gynaecologist colleagues to give their expert opinion. At the same time, I explained to him that my department would continue to monitor his grandma but there would be no active management on our side.

He was puzzled and asked me why would his grandma been admitted into my ward instead of gynaecology ward. Before I could react, he proceeded to demand that my department be held responsible for everything and that he would not tolerate any delay in treatment of her grandma. He also threatened to bring this matter up to the hospital director AND to the local politician, as he claimed to know someone 'important' in the state Excos.

I smiled and tried to explain.

I reiterated that the doctors and supporting staffs here were all-out to help her grandma to recover, nonetheless, the expertise in treating the underlying primary disorder, unfortunately was not our specialty, and hence a referral and consult with the gynaecologists would be mandatory as part of the holistic care.

After much explaining and exchange in words, finally he settled down and accepted my terms.

I curiously asked: 'Who's the local politician or state Exco that you know?'

He hesitated for a moment and blurted: 'Actually I just happened to have sold a handphone to him and got his name card. I don't know him that close lah.'

Moral of the story: Claiming to know 'someone' to get 'something' done is a rather common phenomenon the local setting. Doing favours and returning favours are part of Asian culture for centuries. Nevertheless, at times, it could be quite condescending and to a larger extent, unethical, if the favour is done at the sacrifice of other patients interest, especially so in the public healthcare system.

The Odds of Uncertainty

A couple of weeks ago, I encountered an interesting case referred by my medical colleagues for review. The patient initially presented to a private hospital for fainting spells. He was seen by the cardiology service and was subsequently referred to a government funded hospital because of financial constraint.

The on-call physician saw the case at 4pm and wrote in the notes: For urgent cardio referral cm.

The 'coming morning' was in fact on a Saturday. My medical officer received this referral early in the morning and narrated the case to me. We went to see the patient together and I must say, I was amazed at the subtle signs of uncertainty displayed by my medical colleagues.

The patient was diagnosed as having non-ischaemic dilated cardiomyopathy with an EF of 20%. The private cardiologist's assessment was that this patient might have recurrent ventricular tachyarrhythmia hence causing recurrent syncopes. They did an MRI to rule out an intracranial pathology. The MRI showed an incidental benign cyst which could not have accounted for the symptoms. But because of the 'obvious' finding on brain MR, the patient was 'siphoned' to the neurology service.

The physician in-charge of the neurology ward was almost certain that the incidental benign cyst would not have accounted for a more serious problem. On the other hand, it was quite clear that she hesitated on the 'urgency' of referral to the cardiology.

It was half past four in the afternoon, I must admit that it is a 'semi-taboo' to make non-urgent referrals at these hours. People are packing up, preparing to take rest after a long day work. Any non-urgent referrals at this time are pretty much unwelcomed.

Nevertheless, URGENT referrals must be made instantly, regardless of the time of the day!

The very fact that she chose to write: Urgent referral coming morning, simply reflected the uncertainty of urgency in that sense.

Well, to me it's simple. We all will become uncertain when confronted with problems out of our specialties. The solution is simple. We walk to the nearest phone, pick up the dialer and ring up the specialty in regards. One call would clear out the uncertainty.

Unless, of course, ego and pride set in to hinder that walking up to the phone, picking up the dialer and engaging in a consultation.

Unfortunately it happens all too often in the service, sad to say.

Hidden Agenda

Very often, we're faced with patients and relatives not telling the truth in the first instance. The reasons are plentiful. Some of them might need more time to develop trust. Some might simply prefer not to tell the truth. Some will not like that particular doctor for no apparent reason, and will promptly tell everything to another. For some, there are hidden agenda..

Well, I must say, the word 'hidden agenda' is sort of a magic word for us the Membership holders. We're forced to adopt the thinking that hidden agenda are there to stay for every Ethics & Communication Skills cases. Hidden agenda is hidden concern by the patients or relatives in regards, which serves to be the key to open up opportunities for further discussion or sometimes, it might well be the prerequisite for task accomplishment.

Allow me to share an atypical 'hidden agenda' incidence which was experienced by one of my colleagues days ago.

A young lady was admitted for allegedly ingested detergent liquid for parasuicidal attempt. She was otherwise well apart from some epigastric discomfort. A lavage and all other proper management measures had already been undertaken. My colleague needed to move on to see the rest of the wards before moving on to run the clinic.

As an MRCPian with extensive 'awareness' on the issue of hidden agenda, my colleague of course had elicited the very reason behind her parasuicidal attempt, ie, she found out that her husband was having an affair (Of course, this is after some repeated questioning, not volunteered). Her relatives were practically encircling her with intense concern, asking repeatedly about her conditions. My colleague practically failed to carry out his ward rounds, in the presence of so many visitors. Worse still, the relatives at one point were trying to suggest that NO EFFECTIVE treatment had been given, and threatened to take this matter to a complaint.

Nothing happened eventually. But an interesting point to illustrate here.

The patient committed suicide because of his act of seeing another women. You brought her looking for help and treatment. We gave help and treatment. You still have guilt (logically, he should). The patient refused to talk to him. He sensed a even stronger share of guilt and wanted a way out. The way out is simple - repeatedly showed concern by questioning the medical staffs, even to a point of irrelevance. And if they refused to hear anymore, it's their fault! Not my guilt anymore! How about the care of other patients? Don't care, not my problem!

This might be a over-simplified attempted deciphering of his thoughts. Nonetheless, one should recognise that some patients or relatives are just inherently selfish. It's their nature. Especially so, at the very juncture of escaping from guilt.

To Ministry With Love

Of late, I have reason to believe that this blog has been perused by the Ministry people. A close friend of mine had told me. To be honest, I am very pleased by this fact, as one of my intention of writing this blog is to get some attention from the ruling party ie the Ministry policy makers.

I told my friend that the primary aim of this blog is indeed to tell the relevant people the various interesting events happening in a hospital, whether too smart or too lame..

More importantly, I was also 'warned' not to write on issues criticizing the system again. Frankly, I wasn't surprised at all. This system has always been one with people yelling high speeches of democracy, freedom and human rights on the outside, but in reality, a lot of things we are expected to keep quiet and cease public discussions.

The people in support of this would say that it's for the greater good. Hmm.. sounds familiar isn't it, and how about some addition of words to the sentence that goes like this: 'For the greater good so that we could maintain the state of peace, harmony and prosperity!'

Sweet deal and a real music to the ears! While I am totally a peaceful person, nonetheless, I think keeping quiet all the time and taking no heed on the reality is not something that we should be endorsing in the long run.

I think the Ministry is able to do better than this. Some helpful voices from the inside and some sincere comments from the outside would be good.

I have come across very high-ranking officers in the Ministry who is much willing to accept critics and views. If one who is at a higher post is willing to accept, why shouldn't his subordinates?

That is absolutely a useless attribute to hum and sing 'I wanna know the truth' day in and day out, but in reality stays contented with a world full of lies and illusions. Someone is already on the verge of getting his final paycheck. Would you be the next?

A New Wave Of Change

The recent nationwide general election results took us by a surprise. Nothing medical here. At least not directly related. But I must admit that everything and anything is essentially connected, in some ways, to politics in this modern civilisation.

Rather often, we clinicians do find ourselves in a tight spot to fulfill some special 'uninvited' demands from the local politicians. Some might not be the politicians themselves, but they were their friends, neighbours, relatives etc.

Queue-jumping, requests for early consultation, early appointments, special attention, demand for the 'best' medicine available... these were invariably some but not all the things that were happening over the years that I've been serving in the ministry.

Worst still, when I was serving in one of the smaller district hospital years ago, I was repeatedly confronted by outpatients who claimed to be the close friends or neighbours of our Prime Minister!

"Best medicine for me, I'm his close friend." This statement was utterly too familiar to hear.

"Don't worry sir, I am already giving you the best." Admittedly, not much of a choice, I need to use a rather 'political' statement as well. Interesting, isn't it?

I do hope that this new wave of change be served as a humble awakening to all, not just the local politicians, but also the people who endorsed them.

The 'Take-over' Conundrum

I believe the talk of taking-over patients from the periphery establishments has been on for centuries ever since the decentralisation of the service.

I personally believe that there are 2 types of referral in our medical world, I would arbitrarily call them type 1 and type 2;)

1. Type 1 referrals - Referrals made on clear clinical grounds. Diagnosis is clear and the reason for referral is for the referred party to offer treatment modalities which are not available in the referring centre. Classic examples would be STEMI failed medical thrombolysis needing rescue PTCA, relapsed nephrotic syndrome needing renal biopsy, and acute subdural haematoma needing surgical evacuation.
2. Type 2 referrals - Diagnosis is not clear. Referral is basically made to seek for opinion on a higher level. No clear plan outlined by the referring party. The referred party is hence asked for a suggested plan of management.

I've always emphasised to anyone that both types referrals are indicated and would probably deserve some respectable attention from the referred party. Type 1 means you have a rightful duty to be carried out. Type 2 means one of your other colleagues is in trouble and hence need help. Help in our medical fraternity is so vital that no single medical personnel can operate effectively without some collaborative strategies.

But the question comes always is that: "Should we take over all type 2 referrals and hence embrace all responsibilities?"

Unfortunately, there's no simple answer to this. It is, rightfully so, of a case-by-case basis.

Let me illustrate this further by referring to a referral which I'd received just yesterday from a district hospital.

A senior medical officer had called in to consult regarding the management of a patient with acute STEMI. After a long winded story, she in fact wanted me to take over this case to my hospital. I told her to thrombolyse on the spot as time was of the greatest concern in MI. She was reluctant as she had little experience in treating acute STEMI before. I was amazed by this very fact!

And then after much questioning and answer, I also found that she wasn't so sure about the diagnosis of MI! Patient hadn't got any chest pain. She admitted to me that she wasn't so good in looking at ECG! She told me that there was some funny changes in the ECG which could be an MI. She in fact was totally clueless of what's happening!!

I was speechless as to what I could offer to help. Obviously she probably needs to go back to medical school!!

This is somewhat I called a type 3 referral. Nothing fancy. Just an exaggerated form of type 2 if you like:(

Totally clueless, and hopefully you could dissect the case in the matter of minutes through phone conversation. Sorry, you don't have the luxury to examine the patient, let alone to take a history. Your diagnostic tool is just the strings of voices from the telephone!

Admin Veteran At Work!

Well, not surprisingly, I ran into some disputes with the admin people again after a while in district. Just like my days when I was in another district hospital. It seems pretty clear to me that the climate of false sense of superiority among the admins haven't changed a bit through the years. Rather disgusting I must say.

This admin doctor is one of the senior locals who chose not to specialise at all in anything. I guess she must have been quite contented with her senior status and true enough, her monthly pay at her current ranking in the ministry is no small business at all. Approaching a 5-figure number in the local currency. That's something that a lot of us (including the smarter ones) couldn't get in years to come!

This fella even left her husband with a congenital cardiac lesion at a pretty late stage before asking me to intervene! I quickly referred him for surgery and thank goodness the lesion was not irreversible even though he's at his 40's.

I thought we have a rather good relationship to start with but guess what...a worse package of repayment is kept in store for me!

An employer of a schizophrenic who had defaulted treatment called her to clarify the diagnosis. I was keeping the folder with me as I wanted to summarise the case for the department. To be frank, it was a rather challenging case as he had a good red-herring which could be deceptive even to the best A&E doctors!

One of my colleagues had referred him earlier on for pacemaker insertion for symptomatic bradycardia of 50/min! In retrospect, the 'syncope' was in fact due to the psychiatric manifestation (panic attack)! The recurrence of syncope in the face of functioning pacemaker made the diagnosis clear, and at the same time rendered the earlier assessment rubbish and resource-wasting. (The history of schizophrenia defaulted treatment was not elicited upon referral!).

The employer must have been a little bit harsh on her. She was panicky when she approached me for the folder. I said I would look for it and hand over to her by the same day. I reassure her not to worry too much.

She became quite agitated:"You know you shouldn't have take the folder out of hospital see. They ask..2 days already. Now angry to me...Want explanation you know" She said in a stammering tone and half-broken English.

Later I found the folder in the on call room and handed to her in the same afternoon. I even gave her a clear viewpoint of this case (knowing that it's quite clinically challenging). I thought the issue was over for me but then..

The next day, my HOD called me and told me that the hospital director had known about this and had complained to him.

I was rather amazed by this very fact! A few points to highlight here.

1. A stranger called up the hospital looking for a clarification of a diagnosis of another patient. This clearly violates the principle of confidentiality! We can't even be sure whether the person over the phone was in fact the person that he's claiming as! If you'd told him everything over the phone, then I must say you must go back to med school to learn the basics.
   
2. Obviously, when looking for clarification of diagnosis, the admin people would not be the best person to approach for. I wonder why this issue was not passed to any of the physicians in-charge (including me of course). Clinical questions should be answered by clinicians, and not administrators! Period!
3. I helped her to locate the folder which was in the on call room. Lodging a complaint towards me is a counterintuitive measure, even for a 10-year-old. Unless, of course, her mental status was worse than a 10-year-old (which is, sad to say, quite a common ailment manifestation amongst the admin people in the ministry!)
4. Lastly, I was quite disappointed that my HOD didn't even listen to my side of the story before telling me off. He thought that I gave him trouble by keeping the folder! I'd forgive him for one fact - that he might be a bit intimidated as he's employed under the ministry on a yearly contract basis. The plight of the contract doctors?
   

Too Much 'Service-only' Mentality

Recently I have been observing the behaviour of my junior colleagues in treating certain common medical disorders.

One of which is hyponatremia . Well, it seems pretty obvious that most of them have taken this seemingly common abnormality quite lightly. During my round, I often question the provisional cause for the abnormality. Usually without failure, the answer would be: "Oh, the sodium is low and we're investigating it." But the key question is the provisional diagnosis, not that whether the hyponatremia has been investigated or not. Further more, I was totally upset when I found that most patients had been in the ward for almost 3-4 days, and yet not a single clue in the case note about the provisional cause.

Without having the slightest clue of the provisional cause, almost all patients would receive what I call the 'knee-jerk reflex' treatment of iv normal saline! I've always emphasized that the treatment for hyponatremia is not normal saline! As a matter of fact, if it turns out to be SIADH, then you're actually worsening it!

Of late, I caught hold of a few patients being discharged with the sodium level of 125-128mmol/L. Without a diagnosis or provisional diagnosis! When I glanced at the diagnosis column, it was written as: "Hyponatremia for investigation". No further plan pertaining to hyponatremia had been written. Some of them were even discharged to peripheral clinic, without a diagnosis.

Reasonably, these patients of course will present again for recurrent admission, pretty much due to the persisting disturbing symptoms of hyponatremia!

A few of my colleagues had a protective argument towards this phenomenon. One of which is quite classical.

"Well, we can't just keep patients too long in the ward. We need to discharge those 'stable' patients or patients with abnormality which can be investigated as outpatient."

I must say, I totally agree with this statement. But with a pinch of 'extra' salt. Suffice to say, we are in fact being overwhelmed by patients most of the time.

Excuse me though, I don't think hyponatremic patients with a sodium of 125mmol/L are considered stable. Furthermore, I think we should at least have a clue about the provisional cause for the low sodium and a clear plan of investigations outlined for future colleagues to follow.

Not discharging patients without a clue and expect somebody else to work out the cause for you, and in the meantime just pray hard that those hyponatremics won't come back again during your on call days!

This is what I strongly perceive as "service-only" mentality. Patients get admitted. Stayed for a few days. Some bloods were drawn. Cause of abnormality not sure. No provisional diagnosis. Not a clue. And yes, time to discharge the patient as we have more patients coming in. Must service other patients already. No time for 'academic' search for the cause. As long as it's not immediately life-threatening - discharge!

Finally, some of the patients in fact had very obvious causes. If only you care to ask. Some might not even need fancy diagnostic work-up. Just the plain old bedside tool of taking a good history!

The 'Clinical' Implication Of General Election

Last few days ago, our hospital has been in the hot seat for most local newspapers. The reason being, the husband of a deceased patient went on to the local politician and started whining his version of story. I had reliable information from my resident officers saying that their family (with the in-laws) had been in a state of discordance. And the act of going on to make a public complain might be a manifestation of that discordance.

To be honest, I don't really know if that's true. But one thing for sure, the local politicians sure gonna love this to the max, much for their own publicity.

Well, that's the typical local political climate. Whenever election is near, the politicians will line up with a hope to appear more often in the headline of newspapers. Sometimes, things might be trivial, nonetheless, they would not hesitate to go to the extra mile for publicity.

I think most of the time, we doctors are in the hot seat of being easily victimised.

After all, doctors only form the minority of the votes. Pathetic?

Good Boss, Nice Boss

After some time in the district, I begin to appreciate that being a good boss is no small business. On the other hand though, being a nice boss is relatively easier, and less taxing.

It might be hard to define what's good and what's nice. Let's put things into some common perspective first.

A good boss is one that carries enough qualities that permit him to be efficient to his work and towards managing his subordinates. He might have pissed off some of his subordinates from time to time for the sake of betterment of the system. Overall, he would still be welcomed by most of his subordinates. The support might be variable, nonetheless the system improves.

A nice boss is one that carries enough tolerance to his subordinates that allows him to be championed by them. He might do very little to improve the system but the support that he gains might be tremendous. His subordinates like him a lot because he would say 'Ok' to all their demands.

I think in our country, most bosses tend to adapt to the crowd well. They would become nice bosses eventually. The system, on the other hand, would be static and remain status quo for a long time before an occasional good boss decide to change.

Any good bosses up for the job?!

'Nothing To Lose' Mentality

Back in a couple of days ago, my senior MA told me of an interesting and yet distressing event in our clinic.

A patient suddenly ran amok and got into an heated argument with my MA and nearly punched him in his face. When asked what was the precipitating events, rumours said that it was due to a misunderstanding of appointment time given. The patient wanted to be seen right away. It wouldn't happen, and hence the cascading mishaps.

Another contrasting incidence happened quite some time ago in my in-laws house. My sister-in-law had just come back from her follow-up visit to a gynaecologist from a local private hospital. She was in the state of very remarkable anger. When asked what was the problems, she told me that the doctor was extremely rude to her. Rumours said that it was due to the fact that my sister-in-law had misplaced some tablets that were prescribed, and she wasn't following exactly the prescription. The gynaecologist had scolded her right in her face.

"Well, you could have just complained to the hospital admin, if you think he's rude. That's your right. You're in a private facility. Customer's satisfaction is their prime concern, for business." I suggested this, intending to calm her down.

She thought for a moment.

"No, it's no good making an official complaint."

"Why is it so?" I was rather amused by what she said, frankly.

"I waited so long and I've paid so much to see him. I can't just complain. It's not worth it. You'd never know whether he would change the treatment... or something like that. As long as the medicine is still working, it's ok."

As much as I can gather, most probably she didn't even dare to wink her eyebrows too excessively in front of that private gynaecologist. Let alone to mention about punching someone in the face;)

Ladies and gentleman, boys and girls, as you can clearly see from these 2 extreme examples that I managed to recollect, the contrasting facts are just quite self-explanatory!

The first case was a patient who paid around 5 bucks to see a specialist. He was angry because of a long waiting time, and he ran amok without much hesitation.

The second case was a patient who paid around 200 bucks to see a specialist. She was angry too because of a long waiting time plus the fact that she was scolded for poor compliance. Nonetheless, she was careful not to show too much of her anger in front of the doctor. And definitely no running amok kind of behaviour!

In the first case, there is this deeply embedded 'nothing to lose' mentality. Probably what he thought was that he had nothing else to lose except the 5 bucks. He walked out of the clinic in giant steps and style.

In the second case, 200 bucks is "everything to lose", for most people.

It's rather sad to conclude this way. Amidst the striving effort of government health care staffs to provide free or near-free service, the signs of appreciation from the crowd are still generally lacking. There are some who would show appreciation, but most would take it for granted.

Suffice to say, cultivating and nurturing the 'nothing to lose' mentality amongst them is not a good strategy in a long run.

One must have something to lose, else he has nothing to protect, not even his own integrity.

5-star Downgrades To No-star!

I stayed over the weekend for a wedding function in one of the supposedly 5-star hotels in the capital.

What initially thought to be a pleasant stay soon turned out to be a mess. Firstly, upon checking in, I found that there's no towel provided in the room. I called for an urgent supply. That's not the 'best' part, I later came to know that my 'debris' could not be flushed away in the toilet. I flushed repeatedly but it seemed that the pipe system had been engaging a bit of strike against the hotel. I called again for a fix, also reminding them about my towels.

I waited for an hour. I finally decided to go out to get things done by myself. I met with one of the service boys in the elevator and managed to get a towel. Lucky me.

I called for the third time regarding my complaints, stressing on the 'floating' debris that was more distressing than any other things. They didn't come, not until the late midnight. They apologised, saying that the whole hotel was fully housed with guests and they just couldn't cope with the demands. I said I understand.

A 5-star hotel gets downgraded (at least, in terms of rapidity of service) to a lesser grade.

Not that the hotel management did it on purpose.

Nor did the guests actually purposely overloaded them with demands.

It's just the way of the service industry works.

As the number of guests/ customers increases, the ability of the system to cope with the demands would largely depend on its available resources.

The same principle applies for medical health service as well.

It's even more staggering true in the context of public health service in this country.

Near-zero charges and an ever mounting number of patients.

The public needs to learn the necessity and the art of 'waiting', for a free service, run by just a handful of sorely underpaid staffs, under a system which is imperfect in many ways.

Build A District Empire, I Must

Yet another interesting gesture by some of my district colleagues.

My soft-spoken SHO, Dr AR, has complained to me recently about an incidence that involved her and one of the relatively more senior SHO from another department.

My SHO was tearful after being 'reprimanded' heavily by the so-called senior colleague.

The details of the incidence was not known to me, as my SHO was reluctant to carry the agony of going through the details once more. But I gathered that she must have been 'made' to given in to the incidence after being taken under heavy fire for some time. She wanted to make the incidence as 'personal' and 'off the record'. As per her soft-spoken character, I respected her decision.

If not, by virtue of my usual character, I would have summoned the 'senior' SHO for a mutual discussion.

As I was continuing my round with another SHO of mine, she told me that it was definitely not the first time that the 'senior' SHO in regard had acted this way.

"If you think she's been unreasonable, why not fight back?" I asked.

"She's more senior and her bosses cover her very well. Their department is stronger."

I was pretty much amused and subtly surprised by her comments.

I had to admit that though. My department has been a place with rapid shuffling of manpower and staffs, especially of the higher ranking ones, such as the head of department. The SHO pool was rather stable in a sense. This is partly owing to the fact that most physicians posted to the district will tend not to stay too long. They would stay for a year or so, and then got transferred away for subspecialty training.

On the other hand, there are 'hardcore' specialists in other departments who would stay in the same hospital for a long long time, thus cultivating and nurturing their own 'district empire'. Not only then, their SHOs would tend to follow suit, thus rendering an environment which is 'not intentionally' hostile, but 'much potentially' condescending for the lesser ones.

Having said so, the culprits are made up of merely a handful of them. Nevertheless, a handful is sorely more than enough.

No! You Can't Follow-up Your Old Patients!

I am not sure since when this phenomenon has prevailed. I picked up this comment while I was sitting in a combined clinic (obstetrics and general medical clinic) in my hospital.

After becoming a physician, I was posted to a district hospital pretty much near the vicinity where I live. Considering myself lucky, I accepted the 'offer' quite happily.

It has always been my style that I'd like to review patients that I've seen earlier on, so that I can keep track of their clinical response to treatment and intervention. I have been doing this alright with no problem at all..until I met with this old lady obstetrician in my district hospital.

It was a fine day. I walked into the consultation room. Happily browsing through the folders that laid in front of me, I asked one of the nurses: "How many patients are there for us today?"

"Why?!" The old obstetrician raised her voice, even before the nurse managed to throw in an answer. For a moment, I thought she was not yelling at me. I ignored.

"Hey, why?!" She blurted again, much in a stiffer tone of voice. I had already start noticing some gestures from the nurse.

"Oh, I would like to know the progress of the patients that I've seen during the last visit."

"No, it is IMPOSSIBLE!" She dragged the word "impossible" as though as I would not understand the word if she hadn't done so.

I walked away, went into another room sitting with another obstetrician and start seeing patients. I asked the nurse in the room for a favour: "Could you please walk to the next room and look for the cases that I've jotted down 'to see me on TCA' and bring them to this room?"

The nurse went. Minutes later, she walked back with 2 folders.

I went according to the queue number and saw the 2 patients in turn.

I had a short discussion with the O&G head of department later regarding the incidence. He was more approachable and agreed on my move to review previously seen patients.

There are 2 points to highlight in this particular incidence:

1. Following-up patients with regards to their management and outcome is just like doing a small 'cohort study' whithin yourself. It not only benefits the patients, but also the clinician himself as it invariably sharpen their clinical acuity over time.
2. 'Chronic' specialists residing in the districts can become complacent with time as their decisions tend to become 'unquestionable' by more junior colleagues. This cultivates a sense of false superiority in them. I call it the pseudo-superiority complex, as it collapses easily upon careful scrutiny by more experienced consultants from tertiary centres. I hope, one day, she will be scrutinised.
   

"Wifi"able My Clinic Area

Today, I made some improvements to the 'techie' aspect of my hospital clinic. I installed a wireless router onto the medical outpatient clinic.

Finally, I can get my hands on the internet for any information needed, in realtime that is ;)

Hopefully, that should also fix my relatively 'not-so-often' blog posts. Hehe.

I Want My Warranty!

Recently, a patient with a history of MI saw me during a stress test visit. He completed stage III without any complication. I told him that he had made an excellent recovery nonetheless keeping in mind of life-long adherence to medications and life style modification. I extended to him that a coronary angiography might be an option if he becomes symptomatic and interventions of either surgical or percutaneous route would be needed.

I routinely explained to him regarding the small but significant risks of on-table MI, stroke and death during angiography. He backed off after my explanation. It was as expected. I reassured him that medical therapy is as good as invasive interventions in face of asymptomatic status. He accepted and left my clinic happily.

I thought I have managed to convince a patient, but then..

10 mins later, a man busted into my room. Claiming to be one of his cousins, he demanded me to explain to him again from scratch. He told me that he knew Dr Z and Dr B (2 consultants in the hospital) well, and they always went out for drinks together.

Fortunately, I didn't have any more patients left and hence patiently I re-explained everything to him, in the presence of that patient. I reinstated the need of intervention in the future if he becomes symptomatic and the risks involved. I also told him that I have already made an informed decision with the patient.

"How do you be sure that he's ok if you don't do an angiogram on him?"
"I want an angiogram to be done on him."
"You know, if anything happens to him, YOU ARE responsible you know!"

I practically felt like being threatened and/or blackmailed by him!

In my clinical experience, I find that sometimes patients or patient's relative demand 'warranty' after a course of treatment. Well, the fundamental problem is that, THERE IS ABSOLUTELY IMPOSSIBLE TO HAVE WARRANTY IN CLINICAL TREATMENT!

Really, off-hand I can't recall any clinicians that have ever given out a 'warranty' to patients before. Enlighten me if I'm wrong ;)

That cousin of him really served well in 'sabotaging' the good doctor-patient relationship that I've strived to establish. Maybe one day, he could finally understand this when he's out drinking with either Dr B or Dr Z?

On second thought, maybe not...

I Say Oyster...

This post is specially dedicated to my dear comrades in my hospital who strive so hard in the path of becoming an MRCPian.

They are all taking the February diet in UK. I wish them all the very best!

Traveling in UK is a bliss. I'd had no problem at all in moving around the metropolitan. I don't work for TfL but I must say that their oyster card concept has been a great advantage for budget travellers like me.

You have the options of buying a flat-rate card for 1/52 travel or pay as you go etc.

Remember, my dear friends, YOU ARE JUST ONE STEP AWAY FROM BECOMING AN MRCPIAN!

A Whole New Experience In UK Hospital

I'm privileged to have the opportunity to be a clinical observer in one of the local hospitals prior to my exam.

I must say it was an eye-opener as one could really appreciate things differently.

People here tend to express themselves more openly. I must say I like that very much in fact ;)

Will share more experience upon touching ground back in my 'waterland'.

Cheers mate ;P

Encore! Another Round?

Of late, I had an interesting conversation with one of my senior colleagues in another department.

We were discussing about the number of ward rounds per day that should be fulfilled. In my department, we only had 1 official round per day. Altogether bosses, SHO's and HO's would do round together and settle clinical issues as they arise. Of course, unstable patients will be kept in mind for more reviews in the late morning or afternoon, keeping in view of passing over to the on-call team for review after office hours.

My senior colleague had proudly told me that in his department, there is no such thing as daily round. Ward rounds are carried out in a tds (3 times a day) or at least bd (2 times a day) basis, and that is compulsory!

He suggested to me that maybe my department should follow their 'noble' path as well.

;)

Ward rounds are designed to pick up clinical problems, so that appropriate clinical action can be taken. Imho, ward rounds should NOT be routine or compulsory, as there are no such thing as 'routine' clinical problems in all patients. Unstable patients should be given more attention and hence more reviews (I won't even call it a ward round!). On the other hand, doing a routine round on a stable patient would be mean a wastage of manpower and resources, which could be channeled elsewhere more needful.

I end my blog by giving you my own experience when I was a paediatric HO.

In the morning, I was following the ward round.
HO:'Day 3 of life, admitted for NNJ, now on single phototherapy...'
While examining the child, the specialist murmured:'Active, not tachypnoiec, jaundiced. CVS no murmur. Lungs clear. Per abdomen, soft non-tender, liver palpable 1cm. Moro's complete. OK, continue the single photo.'

At noon, the same baby was reviewed.
HO:'Day 3 of life, admitted for NNJ, on single phototherapy...'
The same specialist:'Active, not tachypnoiec, jaundiced. CVS no murmur. Lungs clear. Per abdomen, soft non-tender, liver palpable 2cm. OK, continue the single photo.'

Right before going home late in the evening, another round.
HO:'Day 3 of life, admitted for NNJ, on single phototherapy...'
Again, the same specialist:'Active, not tachypnoiec, jaundiced. CVS no murmur. Lungs clear. Per abdomen, soft non-tender, liver palpable 1cm.'

As you can see, the only changes were that of the liver size, which grew to 2cm and shrunk back to 1cm in the same day!

Switched Folders, I Have

Shortly following my blog on the public health equation, I am privileged to have picked up yet another interesting gesture by some patients.

My patients just hate waiting. Well I guess most human being dislike waiting, in particular, waiting for no reason. Nonetheless, I think waiting in a queue to be seen by a non-stop performing doctor is a justified act... suffice to say.

It was a fine morning clinic session. I was seeing a long queue of patients. Some were stable enough to be seen quite fast. Some would need more meticulous consultation and hence more time spent. There was this 68-year-old uncle, who was an ex-teacher, came for follow-up for his chronic stable angina.

I had just finished seeing the 32th patient. Owing to the lack of manpower, the folders were arranged in a row near the entrance to my room, and I'd have to walk in front to pick up the next folder and call the corresponding patient by myself. I had noticed some peculiar stigmata when I saw that this 68-year-old uncle had switched his 36th folder to the top, covering the 33rd.

Honestly, I wasn't happy at all. I then told him:" I'm sorry uncle, it's not your turn yet".

He quickly retorted me:" You know how long have I been waiting? I'm an old man. I can't stand waiting for too long!"

I said:" I understand that you've been waiting. But the queue is moving. I'm afraid you'd just need to wait for your turn." I added:"Most of my patients here with heart illness are elderlies anyway!"

He retorted further:" You don't talk to me like this young man. I was a faithful government servant that served this country before you were even born! I deserve to be treated nicely! You are very rude you know young man"

Somehow my conscience told me that any further arguments would not be fruitful anyway. To me, we were seeing things in 2 extreme perspectives.

I quickly glanced through the 33rd patient's folder who I should be seeing in queue. I was instantly struck by an inspiration...;)

I called the 33rd patient by name and summoned her into my room.

She was a 82-year-old lady with history of multiple embolic stroke being followed up for chronic persistent AF with anticoagulation. Her daughter was wheeling her in on a wheelchair!

I told her that this 68-year-old senior gentleman was trying to jump into her queue, because he couldn't stand waiting anymore.

She became agitated and almost cried:" I was waiting for a long time also. Doctor, can you please see me first?"

That 36th uncle, red-faced, walked away. He didn't say a word, not even a word of apology.