Hi! My name is Daniel Lim Jhao Jian. Here is where I share my experience, knowledge and ideas. You are welcome to leave comments and follow my blog. You are free to copy anything from this blog. Please recommend this blog to your friends.

Monday 27 February 2023

The reality of clinical practice

If you are thinking of doing Medicine, you should read the whole of this post first.

Perhaps you had been observing general practitioners (GPs) working in private clinics, that they just had to sit in an air-conditioned room, wait for patients to come to them, do some checking on the patients and prescribe some medications, then they could earn a lot of money every month. Perhaps you had been watching some movies or TV series, where you see doctors working in nice hospitals and going around to save lives, which looked so great and interesting. Perhaps you are thinking that being interested in Medicine and being caring to your patients and having good knowledge, communication and clinical skills is all it takes to be a good doctor.

Let me tell you this: The reality of clinical practice is very different from that, and there's so much more required to be a doctor. Here, I will be explaining in detail about how working as a doctor is actually like, based on my own actual experience. 

Just in case you don't already know this, you cannot work as a doctor in any private clinic or private hospital in Malaysia straight away after you graduated with the medical degree. You must first undergo 2 years of House Officer training in a public hospital. After successfully completing House Officer training, you must then work as a Medical Officer in a public hospital for at least 1 year to serve your compulsory service with the Ministry of Health. After completing your compulsory service, only you will be allowed to work as a doctor in a private clinic or private hospital. 

Even then, you will be facing tough competition from many other doctors who are also seeking to work in private clinics or private hospitals, which makes it challenging for you to operate your own private clinic or to get a job offer in a private hospital. To stand out, you will have to become a specialist. The process of becoming a registered specialist is very long and complicated. You will need to complete a recognised Master's or Parallel Pathway Programme, which involves working as a Specialist Registrar in a public hospital for several years. The fact is that, working as a House Officer, Medical Officer or Specialist Registrar in Malaysia is extremely stressful and challenging.

First, there's long working hours. Although the standard work hours for House Officers isn't too bad, you have to undergo 2 weeks of tagging at the start of each of the 6 postings in House Officer training. During the tagging period, your work hours is significantly longer, which is from 7AM to 10PM every day, for 6 days each week with only 1 off day. Such long work hours is extremely tiring. At the end of the 2 weeks, you have to take the off-tag assessment, which is often difficult as it demands a lot of knowledge and skills. The long work hours means that you won't have much time to study for the assessment. If you don't pass it, you will have to continue tagging. As for Medical Officers and Specialist Registrars, they have to routinely work on-call shifts, about 4-6 times every month. Each on-call shift is 33-hour long, continuously from 8AM until 5PM on the next day. Just imagine how tiring and stressful that is! The long working hours means that you have to make sacrifices on your meals, sleep, personal time and your time with family and friends. Yet, doctors are always expected to put their patients above everything else, even above their own wellbeing.  You can't even help yourself first, yet you have to help others.

Often, there's a lot of patients and insufficient doctors in public hospitals, which results in a very high workload for doctors. When that happens, doctors have to work fast which is very exhausting. Doctors are expected to prioritise the more urgent tasks. It's often the case that the more urgent tasks are also the more difficult tasks. Some people may find it more efficient to do the easier but less urgent tasks first, but that's not allowed. You absolutely don't have the freedom in work in your preferred style. Doctors are also expected to multitask, even though it greatly increases the risk of medical errors which may cause harm to patients. Routinely, you will be asked to stop whatever you are doing to perform another new task that's more urgent. If you are the kind of person who doesn't like leaving unfinished work hanging around, you will find that very annoying. Doctors may get called to see new patients at the Emergency Department at any time, no matter how busy they are in the wards. Doctors are expected to answer their phone promptly at any time of the day, even when they are in the middle of doing a surgery. At the end of the day, you still have to complete all tasks regardless of urgency. If you haven't completed them by the time your shift ends, you have to work overtime.

You may be thinking that doctors don't face bullying at work, because after all, a core aspect of Medicine is mutual respect and collaboration. I hate to tell you this, but doctors actually do face bullying quite routinely. Some superiors will scold you if something doesn't go right, even if you made no mistakes at all or it's something where you have no control over. In addition to scolding, they may even bring up your mistake in front of all your colleagues or issue you with a warning letter, which will make you feel really bad. Your superiors will almost always expect you to join them when they conduct ward rounds and to assist them when they perform clinical procedures or surgeries, even when you are busy with other tasks. It's not just joining ward rounds, you are also expected to engage proactively during ward rounds, failing which you can be penalised for poor attitude. While some ward rounds can be fun, others are quite tedious especially if they go on for a long time. Occasionally, your superior may tell you to do something that's outside the job scope of doctors, and you are expected to comply with their instructions no matter what.

As a doctor, you are expected to know and remember the cases of all patients under your care by heart. While information on every case is recorded in the patient notes, your superiors may expect you to present the cases to them without flipping through the notes. Not only you have to know the diagnosis, you also have to know the whole progress of each patient from the beginning of admission until now. That's a lot of information to memorise which makes it very challenging. All doctors come from a scientific background, which emphasises more on understanding rather than memorising. You may not like memorising things, yet you cannot avoid that. Sometimes, you may even be asked to recall information about a patient from a previous admission if you saw the patient previously, even if that was a long time ago. In addition, there are all sorts of guidelines and protocols which doctors are expected to memorise.

A major part of clinical practice is history taking, not just from patients but sometimes also from their family members. History taking may look fun and easy, but it can actually be a very tedious task. Different patients may have very different ways of communicating their illness, and you are expected to tailor your communication for each patient as well as to accurately interpret what they tell you. It's particularly challenging to get a full history from patients who have reduced consciousness, dementia or a mental disorder, often requiring you to get a further history from multiple sources including from their family members, which can take a lot of time. In addition, doctors routinely have to get technical information from patients as part of history taking, such as their previous medications, surgeries and investigations. Getting technical information from a non-technical person can be really challenging, as you have to translate technical terms into non-technical terms that they can understand and vice versa.

A lot of unexpected can happen in clinical practice. Any patient in the ward may deteriorate quickly at any time. Whenever that happens, doctors have to attend to the patient immediately. You will then have to spend a long time managing the patient which can be very stressful. If your workload is already very high, that will worsen it. Moreover, doctors have to be able to perform all kinds of clinical procedures. There may be some procedures which you have never learnt before in medical school or in previous stages of your training or only have very little experience with, yet your superiors may expect you to be good at them from day 1 of your work. Not all of your superiors will be willing to properly teach you how to perform a procedure. Sometimes, you can only learn it through observation which may be inadequate for complex procedures. If you try to perform a procedure which you are not skilled at and end up not doing it right, you certainly will have to be responsible for that.

There's also complaints and medicolegal issues that doctors have to face. Some patients and their family members may make complaints for the tiniest issues which may or may not be the doctor's fault, yet doctors have to answer for every complaint made about them. Sometimes, a patient just won't survive or will develop a severe complication despite doctors having tried their best and not doing anything wrong. Yet, if you are unfortunate enough, the patient's family members may sue you in court for that. You may like to help others out of your goodwill. In actual clinical practice though, you cannot do things out of your goodwill, instead you are fully responsible for every single thing you do and you cannot avoid doing your job. If you do something for your patient with good intentions, but you unintentionally made a mistake in the process that causes harm to your patient, you still have to face all of the consequences for that. Nobody will bother about your intentions and efforts, everyone only cares about the outcome of the patient. The harsh reality is that clinical practice is not goodwill, it's an immense responsibility. That's what makes it so stressful.

Despite of all the stress and challenges of clinical practice, some doctors still enjoy their job a lot, while others don't. It really comes down to the individual. I have several friends who joined Medicine only to have to quit later because they realised that it's not for them.

If you are thinking about becoming a doctor, you most definitely should do comprehensive research on the job of doctors first. I hope you have read through and understood everything in this post. You should go a step further by doing a clinical attachment at a public hospital for at least a few weeks so that you can actually experience how doing clinical practice is like in reality. After that, ask yourself an honest question, are you ready to face all the challenges of clinical practice and is this really what you want to do for the rest of your life? If you can confidently say yes, then congratulations, you should go ahead with doing Medicine! Otherwise, please do yourself a favour by staying away from Medicine and exploring a different field instead.

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