The SALAH Handbook

In a sudden moment of catharsis...

... rumours abound on the net how Dr Chee Soon Juan is actually a PAP plant to cause the opposition to own-self explode from the inside-out...

... well the TPL fiasco... maybe, just maybe... the opposition is... could it be? naah...

... but it all fits so well...

devious!

*****

randomthoughtsofamedstudent.blogspot.com is facing his imminent return to the welcoming arms of our local healthcare system with some trepidation, what with all the bad press the local inmates have given him.

Reading him brings me back to when I first came back, and reminds me how I'd wished there was some kind of handbook or manual for me to read, perhaps not to help me cope with what are ultimately very personal issues, but rather to let me know that I wasn't alone, and that someone else out there gave a damn, and really understood. It reminds me of the handfull of people who have asked me what working here is like, after already making the decision to come back and rendering any useful advice I could give (like "DON'T!!! NIET! NEIN! BU YAO!") invalid.

So here it is, the very first draft of the

Singaporean-medics Abroad Looking At returning Home (SALAH)

Handbook.

**************

Welcome to your new life as a houseperson in the world-renowned medical hub that is Singapore.

To successfully make your transition from normal human being to cockroach as seamless as possible, please peruse this entire document before disposing of it.

These are the Fundamental Tenets upon which your new and wonderful life as a physician or surgeon commences :

1. You are Beneath Contempt.
You are Houseman. Your sole purpose is to perform "Changes" (ie menial jobs like taking blood, ordering X rays, etc.)
From time to time you will hear nice words like "learning opportunities", and "protected teaching time", and "mandatory post-call rest hours".
These do not apply to you, since you are not Resident. Residency is reserved for those who have already been Assimilated. One day after your Assimilation you may be afforded Residency. For now, you are Probationary, coupled with Houseman and therefore beneath contempt. (Contempt is Houseman. Resident Houseman is ConteNt.)

As a subcitizen you must realize that you are expected to perform an unreasonable number of changes in a very short time, every day, and to not leave hospital until your changes have been done. In addition, you must complete your changes in time for the results to be ready by the exit round in the evening.

I was fortunate to return as a medical officer and didn't have to suffer the pain of Housemanship in Singapore.
I've watched my housemen coming to work... early... and leaving... late with some sadness, before letting the Medicine of it all wash over me as my housemen drone the results to me, and we go through the checklist of who is well and who isn't. It's just the way it is.

2. You must conform to working hour restrictions.
The ministry now mandates that you keep a log of the number of hours you work in hospital. This means that you must finish your changes in time, and ostensibly knock off work and be out of hospital before a certain time. Regardless of the realities of sheer volume of changes. A houseman who goes beyond their mandated working hours is judged to be inefficient and may be unofficially penalized. A department which has housemen going beyond their mandated hours is judged to be noncompliant, and penalized, officially.

Here are some short phrases to expand your vocabulary :
Everybody likes a team-player.
Truth is subjective.
"Performance Appraisals" are Very Important.

3. The nurses are not your friends
I remember the nurses from the UK who were peers, and interested in what they did.
Our nurses, for all practical purposes, are sentient machines. Much like you are, except you are a Change-making Machine, and they are Bed-Making, Patient-Turning, Report-Passing Machines.
They are a superior model to you, and you are beneath them. This is important to remember, because if ever you overstep your authority on an individual nurse, you will get away with it. She will act subservient to you to your face.
And then all hell will break loose, in a very subtle / not so subtle way, after her colleagues begin to discriminate against you, and after her Sisters get in on the gangbang.

You must remember that they are a separate community, and when push comes to shove it reverts to "Us versus Them" in this country.

I remember an OT nurse from the days when I was in Orthopedics. She was young, pretty, capable, and bright as a button. One of the Profs recognized this and used her to close all his wounds. I first discovered this when I was closing a knee, and she decided to lend me a hand. We smiled at each other and she started closing the opposite end. We shared a silent cameraderie. I marvelled in the privacy of my mind that a nurse could stitch, and so well at that. (OT nurses specialize in counting.) Our two strands met in the center and the result was Immaculate. It was almost a Movie Moment.

Unfortunately, her Sister walked in the door at that point. The result was a mess.
And Loud.

We are not here to work with each other. We are not working in tandem to improve patient welfare. We are working for our own Kind, exclusively. Patient welfare is an incidental byproduct of this union - sometimes.
Bear that in mind, when you are laughing and joking with them, or perhaps flirting lightly - they are not the same as the nurses from where you came.

Be advised to avoid flirting. One of the nursing subroutines is Gossip Making Machine, and Gossip can have unexpected consequences one day in the very, very distant future.

4. Your Role is Different.
The Patient-Doctor relationship is always unique to each consultation, but here in Singapore there is a strong bias towards a Client-Service Provider relationship. This is more frequently than not a more stressful relationship, with less satisfaction afforded to the physician, and more to the patient (or their families).

Young people (read : Me generation) here want to be in control, even if they don't have any fundamental grasp of the salient medical or administrative issues at hand.

They have an understandable perception that they are entitled to a lot, since they are paying a lot.

However many fail to realize that they aren't paying a lot at all, with the government subsidizing most of their healthcare. And that by the same argument that entitles them to be rude to their surgeon / physician, and/or barge in on someone else's consultation and demand to be seen because they have been waiting for too long outside the clinic, and/or complain when they see a doctor leaving clinic / eating food in the cafeteria prior to clinic / complain when they do not get the same doctor for all their visits / complain when they are seen by junior doctors or students -- by that very same argument - that money rules all - private patients who are paying more than them are entitled to more. The straits times forum over the last few days tells a different story though; double standards are sadly the norm and the system backpeddles to save face.

They also don't want to hear it - they don't want to hear that everyone else has been waiting just as long, that the patient you're barging in on now deserves as much time to be seen as you and you're eating into his time wasting time barging in on my room with the only possible outcome - of you being shown back out the door to await your turn - happening whether you vent your frustrations or not. That the doctor leaving clinic isn't even running the same subspecialty as the one you're consulting for / is going to attend to a ward emergency. That the doctors have just finished a long round seeing sick someones who aren't your Grandpa today, but might well be tomorrow... and are snatching a bite before going to run clinic for the next X hours at the very real risk of forgoing lunch, and food is one of those things that keeps people buoyant enough to face a long clinic with a sort-of smile. That junior doctors rotate in and out and even middle grades change teams or hospitals from time to time and that is why you can't see the same doctor through the years, unless you are consistently seen by a consultant - ie a private, paying patient. That big teaching hospitals are teeming with students who will one day be sitting across the table from you as your consultant, and they need to start somewhere too, or else wind up being shitty, incompetent half-trained doctors.

They don't want to hear it. They just want to be told that they are right, and they are king. They want to feel that they are in control, and the fact that they are called later after barging in to the room is proof positive that they made a difference in the grand scheme of things.

What can we do about it? Well, we can eat a hearty breakfast, then grin and bear it... We can be the face of the faceless organization and stonewall the patients politely. We have to - it's Us, or Them.

Speaking of which, I remember once upon a time firmly telling families requesting a "denial of service (information)" to the patients (mum won't be able to take the news that she has cancer. you musn't tell her!) that my patients were my priority, not their families, and that it sounded like they had communication issues and that lying wasn't going to achieve much, since frankly the patients would know eventually - it's their bodies. And that they would be even unhappier being kept in the dark. I would tell them that I'd be back in half an hour to break the news, and perhaps they could use that time positively.

Things are different here. Your role is different here. Your role is to write down in capital letters on the top of the case sheet PATIENT DOES NOT KNOW DIAGNOSIS, or else see to it that someone else does. Because the structures of the family units are different here. The heads of the families are the middle-aged childern, not the elderly. It's all rather confusing, and counter-intuitive. But eventually it strikes you - the old fogies really, really don't want to know. Most of them anyway. They just want to lie in bed and be doted on by their kids, and let the tides wash them whichever way they will. And for the select few who, years later find out after countless colonoscopies that the little operation they had to take out a small harmless lump was in fact a hemicolectomy for carcinoma of the colon, and are outraged... well... nobody really cares about how they feel. They only care that you betrayed the covenant of silence. Prepare for a complaint letter from the family. (Interestingly, the "betrayed" never think to write in and complain about being kept in the dark by their loved ones. Fascinating.)

4. The Patients are Different.

Language for one. It may be a relief to be able to speak in Singlish - for a while. Until that monolingual patient who only speaks Hokkien comes in. (Hua Yi Buay Heow) Or Cantonese. Or Tamil. Or Malay. Or...

Communication is often suboptimal because of this. We rely on family members to help us translate things. Things get lost in translation. Things like "you have cancer" turn into "don't worry there's nothing wrong, you just need a small operation." Things like "I'm sorry we did all we could" turn into "nothing lah."

Old fogies are more passive, as mentioned above.

Young punks are more aggressive.

Overall, people are less educated - not in terms of highest standard of education attained, but in terms of information. They are less informed, and more opinionated - they've read one or two dodgy articles online, or heard something from somebody's aunt, or their dad lived for five years with cancer of the lung before some doctor killed him off after he was admitted to hospital, or their TCM consultant has told them something different -- and suddenly they're the experts, and you're someone to be suspicious of.

These are of course the exceptions to the norm. Most of the time things will pass by smoothly enough. But when you hit a stumbling block like this, what will you do?

It was hard when I first came back, having to explain to a belligerent, inappropriately aggressive family member that novo-7 is not the standard of care for an intracranial haemorrhage, and that grandma might still be dying even with it. It was difficult to think with his face so close to mine that the spittle from his mouth as he shouted was landing on my glasses. I chose to be civil and attempt to explain it to him, with aid of the internet, over and over again until it became apparent that he was not here to hear, but to shout. At which point I told him as much, and left the ward, and hit a wall some distance out from the ward in frustration. (Hitting the wall, it's a turn of phrase, isn't it?)

Now that I've been Assimilated, I do what everyone else does. Talk until their time is up (approximately 5 min) then excuse myself and leave. If they didn't take anything on board in those 5 minutes, in clinic, on the ward... if they were too busy making themselves heard to hear in return - then nothing you say will make a difference. If there's a complaint letter hovering somewhere in the background, chances are it's already been written, and posted to the New Paper - even before Ms X showed up on the ward full of righteous fury.

Interestingly, sometimes Ms X shows up for the first time, after Ms Y and Mr Z, her sister and brother have spent the last month with dear old dad, and are completely informed and understanding. And Ms X will be the one to rain fire and brimstone upon the incompetent healthcare providers so obviously intent on killing dad, nevermind that she doesn't know why he's even been admitted. There's a simple reason for that, I think, and I think it's guilt. Ms X actually deserves more time; I usually give her about 15 to 20 minutes before packing it in.

People are different here.

5. The Other Doctors are Different.

Perhaps these are biased memories, but it seemed easier to be happy with Medicine while back in the UK.

You'd be hard-pressed to find someone here happy and fulfilled in their medical lives. The common grouses are excessive hours, incommensurately low pay and lack of public gratitude.

I think you'd be missing a fundamental truth if you chose to focus on any one single point of the above - or even on all of them combined. The truth of the matter is many doctors are depressed. Cast your net wider and you'll see it's not just doctors.

I remember how everyone used to go get pissed thursday (or was it wednesday?) nights at the pub, from the consultants to housemen. And how we'd all dance and generally make fools of ourselves.

I can't help but compare those memories to the present-day infrequent department parties, when professors and peons auto-segregate, and professors remain... professorial.

Yes, there is decorum and aplomb, and dignity befitting of royalty here. But maybe we've just... forgotten how to have fun.

How to cope? Just remember that fun here starts when you step out of hospital. Remember your family, your wife and your children are what make living worthwhile. I don't know if it works, but that's what everyone does.

7. Ethics are Different.
Be prepared to back down on those ethics your medical school ingrained into you. And prepare yourselves for the changes in your own ethical code which will invariably follow. It's a natural progression.

Perhaps the only real rule is to stay out of trouble, and don't offend anyone, be it your colleagues or your peers.

A few random names to google :
S***n Lim
Eu K*ng W*ng

Also, there is a "right" way and a "wrong" way to effect diplomacy. Again, see the above.

More random terms you need to know before you start:

"Do Not Resuscitate" - what is the difference between this and...
"Max Ward Care / Not for SICU / Not for intubation?"
Dangerously Ill (DIL) - what is the difference between this and...
Dangerously Dangerously Ill (DDIL) ?

Hypothetical question :
Is it ethically permissable to inform a family who lives far away that their father / mother is dangerously ill and they should hurry down as soon as they can to see him, if the patient is fading fast and their chances of making it in time are about as high as an opposition team winning a GRC? If not, perhaps it is kinder?
How about if the patient is already dead from say, a massive MI?

8. The Administration is Different.
This goes from the ministerial level, to the SMC, to the SMA, down to your local hospital administration.

There are notable differences between administrations of different countries.

Ours is a strong administration, that is efficient in achieving its aims.

Do not bemoan your "low starting pay" as a cockroach though. There have been recent revisions. Prior to them housemen were truly earning a pittance, at levels inappropriate for university graduates.
Pay revisions are not pegged to civil service. Medical professionals are servants, but apparently uncivil.
There is doubtlessly a reason for this. Perhaps there are just too many of us.
Do not stir the pot, or bite the hand that feeds you. Spectacular things have happened in the past.

The system is oddly dichotomous when analyzed from a financial perspective.

Either way you need to decide early on what your career path will be. Early on is now, when you have just graduated from medical school - because you are a graduate student and significantly older than the rest. There is an unhealthy obsession with age in this country. Life stops after 20, yet 27 year olds are too young for politics...

If your priority is to make money fast and have a comfortable lifestyle, become a GP. The net earnings over time will outstrip those of a government specialist.
The alternative is to give up medicine altogether and use your degree to seek another job. As ridiculous as this sounds now, it isn't. Senior Pilots for instance bring home $50k or more a month. Politicians need money to remain honest and uphold their integrity, so they earn... more than I can count in my head.

If your priority is to make ridiculous amounts of money to swim in, then specialize NOW. Choose your specialty NOW, even before you graduate. Join a residency programme NOW. It's what everyone else is doing, right now... and exit early, and go private. And become a very, very rich one trick horse. Just avoid $24 million bills.

If your heart is in it for your art (ie surgery) or the intellectual challenge (ie medicine) then tough luck. You're doomed to stick it out in government service and earn less than your peers in many of their lucrative business careers, and your lot is to whinge about it for the rest of your life, or else to just put it out of your head altogether and do what you enjoy most. If you fall in the latter category you are admirabe, but probably deluded or else dysfunctional in some way. Sadly, I am in that category.

9. Everything is Different.

Yet everything is the same.
Some things are better, some things are worse. It was the best of times, it was the worst of times and all that.

Standards of living here are good, possibly even high.
Costs of living are also high, if you seek the lifestyle of a young, executive professional, which although you kind-of are, you're not... (remember the cockroach) Decent sized condominiums cost in excess of a million dollars. Landed property cost about four to more times this. COEs are expensive. Annual road tax is about a month's salary.
If you are comfortable with a lower standard of living, you can achieve this comfortably, eg living in a HDB flat - which is fairly good and comfortable, functional living.

Things are clean here. Really clean. Sidewalks are clean, roads are clean, HDB landings are clean. Ministers are clean.
It's just the public toilets that are filthy... MRT toilets made the news today.
For some strange reason people here like to drape toilet paper into the bowl and trail it out, in the mens loos. Perhaps its to line the seats while they squat on the sitting toilets? Nobody ever lifts the seats. This makes for pee-water tracking out onto the floor thanks to inconsiderate laws of physics (capillary action).

This highlights something unspoken about our population.
It is a tiered population. Clean and dirty.

These should be sufficient for now.