Becoming a physician

I'm currently undergoing the processs of gazettement to be an internal medicine specialist. Call it a probation period if you will. Here in Malaysia, there are two pathways to become an internist. The first is to undergo a four year Masters program in one of the local universities. One can apply for Masters program after serving three years in government service (2 years as HO, 1 year as MO) and he must achieve a SKT mark of higher than 85% for 3 consecutive years. The second way is to go through the so-called "parallel pathway" and obtain one of the certificates recognized by the NSR (National Specialist Register). As I did the latter by sitting for the MRCP (UK) examination, I'll be talking solely about this exam.

MRCP (UK) consists of three parts. The first two are theory papers and the third is an assessment called PACES of which the candidate's clinical skills were put to the test. One of the mat salleh examiners described it as "making easy daily diagnoses difficult". Sounds about right.

Part I is made up of two papers consisting of 100 questions each. Each paper was three hours. I took my exam in Universiti Malaya some time in September 2014. It was during my final posting as a house officer in anaesthesiology. I subscribed to Pastest which had a bank of 5000 or so questions. I also used Phillip Kalra's "Essential Revision Notes for MRCP". The money spent on the revision materials is worth it. It might seem pricey in the beginning, but it's definitely much cheaper than resitting for the exam!

For part II, I used Pastest again - There were only 2000 odd questions for part II. A book you'd want to invest in is Sanjay Sharma's Rapid Review of Clinical Medicine. The exam was held in NUS, Singapore. This time around there were three papers each consisting of a hundred questions. By the end of the second paper, my mind was so fatigued and all I wanted to do was sleep. Following that was another time lag before the college announced the results.

After passing the first two theory papers, you'll reach your final hurdle. PACES is no joke. It's like the prospective father-in-law you don't really wanna see, but you still have to face the music because you wanna marry the girl. You can put in the hours and do everything in your power to prepare yourself, but there's no guarantee that you'll succeed on your first try. Or ever.

For those preparing for this exam, some general tips I could give are:

• Apply to a hospital that is geared for the MRCP exam. I worked in Hospital Seremban where most of the physicians were MRCP trained. The consultants were very kind to organize weekly classes for us on Friday evenings and they were all very encouraging. It helps to be in the company of like minded people.
• Form a small study group of 3-4 people. Any more than that and it takes too much time to examine patients together, and your discussions might go off on a tangent. Be accountable to one another, practice together as often as possible.
• Work in clinics often. This simulates the history and communication skill stations, and also helps with picking up signs in the clinical exam stations. I found rheumatology clinics to be VERY helpful for brief clinical consultation stations.
• Go to opthalmology clinic to look at diabetic and hypertensive patients' eyes.
• Go for as many mock exams as you can afford, and be a candidate. Don't just be observers. Simulate the stress and sinking feeling in your gut of the real exam. It helps to get used to that adrenaline rush.
• Oxford Clinical Medicine for the MRCP PACES. 'Nuff said. I found volume 1 to be much more useful than volume 2. The handbook is GOLD. Grind it into dust and bring it to a boil. Drink it. Consume it. Digest it.
• Understand the exam format. There are things you do that gets your marks. Understanding the rules of the game and knowing what to expect will help you focus on your preparation.
• Apply what you learn in your daily practice. Let every clinical examination and every difficult encounter become a part of you so that it comes out naturally during the exam.
• Be sincere in your daily encounter with patients. Again, this will become a part of you and it won't seem like you are faking it during the exam.
• Pray. There's only so much you can do. The rest is really up to God. ie. You don't get to choose your examiners.

After you pass PACES, pat yourself on the back. It's not an easy feat and you deserve to reward yourself with a hearty meal. Bear in mind, one other requirement in Malaysia to gazette as a medical specialist is that you must have 4 years experience in the medical department, of which 1 year must be after you passed the exam. So take your time with the exam, there's no real hurry to binge through it like a Netflix series.

My journey through housemanship - Part II

Following General Surgery, my subsequent rotations were General Medicine, Obstetrics & Gynaecology, Orthopaedics, Paediatrics, and finally Anaesthesia & Intensive Care.

As tough as it is, housemanship continues to be a rite of passage medical graduates undergo. Suffering produces perseverence; perseverence, character; and character, hope. It is during these two years that interns are shaped and refined into independent and safe doctors. It is also during these two years that you form lasting bonds with like-minded people. It is very difficult to tough it out through housemanship alone. Housemen who work together produce better and safer outcomes for patients. There are some days when things just don't go your way, and only a fellow houseman who is going through the same journey as you would be able to empathize. Busy as we were, we tried to make time to hang out. By the end of housemanship, I'm grateful to have met and work with many great colleagues and I know that they will all be wonderful healers in their own fields.

If I were to choose my favorite rotation as a houseman, it would have to be anaesthesiology. I didn't ask for it and it was just given to me by the office. We worked in the operating theatre for the first month, and then we were placed in the ICU on the second month onwards. It was a good refresher as anaesthesia dealt with patients from all other postings. I learned how to perform intubation and how to assess the intrathecal space in a safe and controlled environment. In the operating theatre rooms, we were only dealing with one patient at a time and this allowed us to take our time to prepare everything needed prior to performing the procedures. There were some who said that being posted to anaesthesia meant missing out on learning how to treat emergencies but that was not the case. Patients in the ICU were critically ill, that meant that emergencies could happen at any time. The hours for housemen in anaesthesia were better compared to other postings, so I had the time to study for my exam. The superiors were awesome. Even when I did rounds with the head of department, I felt like a colleague rather than a subordinate. The working environment was just pleasant and I looked forward to go to work.

Before I knew it, two years finally passed. It was a bittersweet moment, thumbing out as an intern for the very last time. I was glad that I finally made it through housemanship. I lost fifteen kilograms and I'm probably healthier because of that. At the same time, it saddened me that I was leaving HTAR Klang. I loved the specialists and MOs that were so approachable and taught us so much. I loved the fact that housemanship brought different people into my life. We were sent to different parts of the country after our training, and I haven't seen a lot of them since. Some decided to pursue their career in another country. Some stopped working as doctors altogether and went on a different path.

After housemanship, both me and my wife were transferred to Jempol, Negeri Sembilan. We started living by ourselves as a family for the first time with our son. Not knowing what to expect, we moved to a rented single storey house in a quaint neighbourhood to begin our new adventure.

My housemanship journey - Part 1

Even before starting to work as a doctor, you'd hear rumors and horror stories of what it's like to be a houseman in Malaysia. When I was in medical school, I remember reading articles that were published in newspapers by parents and other relatives of then house officers of how they were being mistreated and bullied, etc. It can be demotivating to read and hear such news, especially before experiencing it first hand. Was is all true? Is housemanship really as bad as what people say it is?

To shed a bit of light to future doctors, I'd like to share my experience of housemanship and my hope is that the story will be able to help you in your own journey as you join our fraternity.

I did housemanship in Hospital Tengku Ampuan Rahimah, Klang. Back then during orientation, we were asked to list out 3 hospitals we wanted to go to, and HTAR Klang was definitely not in my choice. Excited to begin my career as a doctor (and not knowing any better), I decided to just go with it anyway. There were nine of us who were sent to HTAR on the 2nd of October, 2012. Following the administrative paperwork, I was given my first rotation, General Surgery.

Clinical work is very different from medical school. To succeed in medical school, all you had to do was know about your patient and talk arbitrarily to cook up some random management plan you don't even really know about. In the real world, you can't talk your patient back to life. Someone's actually gotta take the investigations, set up the cannula for intravenous medications, post the patient's case for surgery, and make things run. That someone is you, and boy was the learning curve steep. The analogy would be like putting a baby who has barely learned how to walk onto a 30 year old treadmill that's not stopped running since it was built.

Day three of life - I had a near miss incident and I was reprimanded by my surgeon and shouted at by my ward sister. The surgeon said these words and I remember it now as if he just said it yesterday, "You! If I had a knife with me now I would use it to cut you open!". I could feel my heart sink into my stomach. Following that the ward sister told me that I'd probably be extended for being the incident. Looking back now, I don't blame the surgeon and sister for saying those things. But I did feel like I was set up by the system to fail - who would ask a third day freshie to check blood products for transfusion? And is this the way the seniors guide the newcomers?

Welcome to the real world. That was the day I realized that no one owes it to you to teach you how the system works. No one is gonna coddle you the way your mum does when you screw up. No one is gonna say "Hey man, good job" even if you think you deserve it. If you want to learn something from somebody, it's up to you to convince the other person to share his insight with you. If you make a mistake, it is your responsibility to own up to it and rectify the situation.

I didn't bounce back from that incident immediately. I went back home that day and stared at the wall. I asked God if this was what He really wanted me to do, and if it was, why did He allow me to make such a stupid mistake. I contemplated quitting. (Retrospectively I just didn't want to take responsibility for my mistakes and be humiliated by others anymore). Then I realized I had a huge study loan to pay and quitting was out of the question so I sucked it up and went to bed.

As the days progressed, I found that I liked my job more and more. It was not always smooth sailing. I had patients scolding me for not getting the IV line in. One elderly gentleman almost punched me in the face when I attempted venepuncture on him. This other surgeon Mr. L was known for being salacious and I was not spared from his lewd comments. But I realized that what I did matter. Following ward rounds, the surgeons and MOs will leave the ward for other work and the only ones left behind were us HOs. We had to run whatever plans that were given for each of the patients and those plans made a difference. For instance, something as simple as tracing a blood investigation and correcting whatever minute abnormality meant that the patient could get his surgery done. We were the ones the staff nurses would call upon when there were new admissions or if a patient develops any problems, and they looked to us for plans and direction. That said, don't be a hero and know your limits. Anytime you've got something bigger than you, you should probably get a senior involved.

One of the things I learn as a fresh intern was that there are particular ways to conduct yourself in a particular rotation. In surgery, anyone above your pay grade was "Boss". Sometimes, even the PPK (or porter) was also called "Boss". Then, you refer a case to the medical team and call the doctor "Boss", and he says "I'm not your boss. You can call me Dr so and so". You end up scratching your head and wonder.. To boss or not to boss?"

Surgical housemen worked in 2 shifts, I think those posted to ED had another separate shift. I can't remember the exact hours. Say what you want, working anything longer than 12 hours straight is physically and mentally draining. Alternating between day and night shifts takes a toll on your circadian rhythm and sleep cycle. Night shifts were particularly challenging for me as you had much less manpower and the responsibility of the wards fell on your shoulders. While it may not be as crazy as working 36 hours every other day, it's still a challenging feat. I'm grateful that we do get better hours for rest and time to study in between.

Well, four months whizzed by without me realizing it. At the end of the rotation, I didn't get extended. I made good friends and I learned how to function as a house officer. Did I like the rotation? Yes, my surgeons and MOs were all good in what they did and very nice to us. It was a good introduction to the life of a doctor and it helped set up the momentum for the following 20 months to come. Also, I met the love of my life in this posting and we now have 4 beautiful children together. That's a story for another day.

Talking about quitting housemanship

There's a post going viral regarding a house officer quitting and how it was the best decision that she'd made. 7700 shares and 10000 likes go on to show that many people concur with the points made by the writer.

I'd be lying if I said the thought never crossed my mind. Being a house officer was physically and mentally exhausting. I was lucky (or unlucky) enough to be working in the shift system, but certain departments arranged the shifts in a way that you end up working everyday anyway. Take medical department for example, we worked long day shift, short day shift, night shift, and our post night was considered our off day; rinse and repeat. Most of the time, the post night would be spent on random work stuff anyway like venepuncture, settling discharges and summaries, attending CMEs to ensure you achieve the minimum required to pass the posting. etc. Night shifts were particularly scary because sometimes you'd have to work alone. You never know how many admissions there'd be and how many patients were gonna need resuscitation.

Most of the time, your work goes unnoticed. That means that it doesn't really matter if you did a good job or you made a huge blunder. It's not good either way because in one case it's demotivating, while in the other you won't know how bad things could be until the situation actually does spiral out of control.

Was it a toxic environment? It felt that way, and it still feels that way. There'll always be people who think that they're superior and better than you, and they talk down to you or talk at you rather than talk to you. Sometimes, it does feel like the superiors forgotten what it's like to be a house officer, or they choose not to care anymore. BUT, there'll also always be people who encourage you and inspire you to be a better doctor and more importantly a better person than you were yesterday. There will be superiors and colleagues who take the time to sit beside you, listen to you and offer sound practical advice, or even just be there.

(Of course, there are also those cartoons who are existing just because. You don't really understand what role they play in the hospital or in your life).

So what am I trying to say? If you're feeling burned out and you think you want to quit housemanship, I'd like to share what my thoughts and hopefully it would be able to help you come to a conclusion with the matter.

1) Housemanship will pass before you know it. Medical school took you six years of your time, what's another two? Not completing housemanship is like preparing all the gear you need for the run but calling it a day before even starting the marathon. If you're sure it's not your cup of tea after two years, it wouldn't be too late to consider something else then.

2) It is a thankless job and most people won't know or acknowledge the work that you do. And well, who cares? It doesn't really matter. At the end of the day, you're in this line of work because you wanna do some good and whether anyone else sees it or not is besides the point.

3) There will be good and bad days. Sometimes a string of the latter will happen before something good finally comes. That one rare moment a patient thanks you (Yes, you, a house officer) for taking good care of him and he gets to walk out of the ward alive? That is gold. I did say it doesn't matter (point 2), but it still feels pretty good to be appreciated. We're human after all.

4) There'll be toxic and malignant people everywhere, not just the medical fraternity. If you can't tolerate two years of internship whereby you're not directly responsible for your patient, will you be able to tolerate the other hardships anyway that come with a new job? Quitting housemanship shouldn't be about the external factors. It's about you realizing healing and comforting the sick is not what you want to do.

5) If you do want to quit though, be very sure of what your long term plan is. Hey, I'm not saying the salary's great but it pays the bills.

6) There were times I felt like quitting myself. I just wanted to share with whoever it is out there that feels like you can't carry on anymore, you are NOT alone in this. Everyone who has gone before you probably thought about it one time or the other, regardless of how strong or courageous they seem to be right now. There is absolutely nothing wrong with feeling stressed, defeated and discouraged - especially given the limitations of the system and workplace we're in. Get help. Talk to somebody. There's always someone who's willing to listen, and it gets better.

To the original author who penned about quitting and her points for it, kudos to her for speaking up and initiating discussions to the local healthcare working environment.