A Learning Journey: Entering Housemanship

Foo Gen Lin, Anantham Devanand, Lee Pheng Soon, Ivan Low

Housemanship is a phase every medical doctor has to undergo, and its start marks the transition from student-hood to doctorhood. But how did the different batches of house officers (HOs) handle this transition? Have things changed over the years? We hear from four doctors, hailing from four different decades, their respective experiences as they first settled into their HO roles.

Dr Foo Gen Lin

Housemanship is a rite of passage into the medical world. There is no satisfactory way to describe the experience to another; those who truly understand would have had first-hand experience. It either makes you or breaks you.

It has been ten years (has it really been that long?) since I first stepped into my first job in Singapore as a HO in the Department of General Medicine, Tan Tock Seng Hospital. Starry-eyed as a new graduate and clueless about the local culture after almost a decade abroad, the first few weeks were harrowing.

The pride and confidence of feeling "wow, I am now a doctor" lasted for a few days before the immense responsibility, never-ending work and constant phone calls took over. Gone were the days of multiple-choice questions and objective structured clinical examinations; replacing them were real patients and dire consequences with any medical errors. The learning curve was very steep. I was fortunate to have very understanding and supportive mentors and colleagues during those times. Team breakfasts fed the stomach, mind and heart, as the seniors shared tips and helped us navigate the busy HO world. Having family members who were doctors helped immensely too. Joy shared is a joy doubled; sorrow shared is a sorrow halved.

The days were long, but there were daily reminders of why medicine is a true calling. There is no greater joy than seeing patients recover and walk out of the ward on their own. There is also no greater sadness than knowing that there is only so much that medicine can offer to patients with terminal or incurable illnesses. This is where we remind ourselves that our role is truly to cure sometimes, to treat often and to comfort always. William Osler sums it up best: "The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head."

The magnificent sunrise and the beautiful song of the birds mark the end of each call and with it the promise of another new day. Cherish the friendship and the memories of that year and do not forget that you are not alone!

Dr Anantham Devanand

August 1998
Tan Tock Seng Hospital
General surgery housemanship,
Vascular Team

Day 4: First on-call

5.11 pm: Chest pain for a Team 2 patient in Ward 11. That meant a circuitous walk from the "new" building to the pavilion wards at the end of Jalan Tan Tock Seng. They were affectionately called "cowsheds" and housed our Class C patients. I announced my perspiration- dripping arrival triumphantly, to which the nurse's reply, without even looking up, was, "He's the one groaning across the aisle." Two long rows of beds stretched out across the room, punctuated by the desks of the nursing station. All the patients looked like they were groaning.

The electrocardiogram had three clips for the limbs and six suction cups for the chest leads. Within minutes, both the patient and I were a tangled, sticky mess of wires, aquagel, chest hair and failing suction cups. I would eventually, with much practice, master the technique of requiring only one cup to stay on while precariously propping the remaining five in place with one hand and manipulating the machine with the other.

The elevated ST segments were obvious enough to prompt an immediate call to my supervising medical officer (MO). The MO continued to operate throughout the call and the relayed message from the scrub nurse was to initiate a reflexic cardiology "blue letter" consultation. Those guys had a fearsome reputation and my ears were still ringing long after I hung up the telephone receiver. Out of pity, the staff nurse pulled out a pair of scissors and a roll of scotch tape and placed them on the counter. My transient quizzical expression gave way rapidly to the realisation of the task at hand: the ECG trace was printed out on a long, single strip. The expectation was to cut out 12 representative segments and paste them on a blank sheet for the cardiology registrar to review.

While struggling with the bloods and initiating the aspirin/GTN/oxygen cocktail, I peered nervously at the ill-tempered blue letter consultation that seemed to involve much head-shaking and muttering. I was dispatched to the cardiac care unit to retrieve a beautifully packed Troponin kit and with an insulin syringe of blood, I obtained the "positive" result that bought the patient a transfer from the "cowshed". The journey was treacherous along the sloping corridor and my role seemed to serve solely as a human brake.

Any hope of following up on what would happen to the Team 2 patient from Ward 11 faded as I stared at the to-do list that had already accumulated. Five emergency admissions awaiting to be clerked, another five intravenous antibiotics to be administered and the pre-dinner capillary sugars to be checked at 6 pm. 14 more hours to go. Then at 8 am, Team 3 ward rounds.

Dr Lee Pheng Soon

I did my HO postings from 1982 to 1983, spending four months each in Toa Payoh Hospital's (TPH) Medical Unit, Kandang Kerbau Hospital's (KKH) University Unit, and Singapore General Hospital's (SGH) Orthopaedics O Unit. The stints at each hospital left many distinct memories that 35 years have failed to erase. Here are a few:

TPH's Medical Unit was led by Prof Lee Yong Kiat ("Prof"). The tone he set for the unit was: "together, we will do our best as individuals and as professional colleagues". I recall, on my unusually busy first call night, being guided by the MO through my first case of acute pulmonary oedema, being carefully observed while working on the second and managing my third alone (as by then everybody else was managing their own sick patients). On call nights, the HO's work was reviewed by the MO as soon as humanly possible, the complex cases reviewed once more by the registrar at 10 pm rounds, and finally by Prof and the rest of the Unit at 8 am rounds.

We learned swiftly on the job, did our best while limiting ourselves to what we safely knew, sought help once out of our depth, and were supervised by MOs and registrars who were intimately aware of our limits. We were trained to perform arterial blood gases, pleural taps, chest tubes for pneumothorax, and spinal punctures. Prof was determined we would gain enough experience to be safe MOs. Sometimes things went wrong, at any level. When there were external queries, Prof and his two consultants (Drs Chua Kit Leng and Fock Kwong Ming) replied, took responsibility for what had happened, and the buck stopped there.

KKH's University Unit had far too few HOs during my posting. Our call rosters, issued a few days before the start of each month, were either "good" or "bad". I remember two "good" months (13 and 14 nights on call) and one "bad" month (17 nights on call). We reported to the assigned call-ward straight from work at 5 pm for the handover round, and were sometimes so busy that we literally did not get even a minute of sleep the entire night till the 7.30 am hand-back round. We then trudged back to our "normal" ward where, more often than not, we worked till 6 pm. Three times during my "bad" month, I carried on to a second, then to a third consecutive night on call. For the remainder of that month I was able to go home to sleep on alternate nights. Conversely, on the two "good" months, I managed two, and another time three, consecutive nights "not on call". The HOs all worked hard, all shared the same load and all survived. Some returned as O&G trainees; I suppose they knew that things would get better as they got more senior.

In contrast, SGH Ortho O was pretty straightforward. There were about 12 calls a month; the surgical work was done by the specialists, and the HOs either assisted in theatre or cared for the post-op patients. My lasting memory was a lesson in patient autonomy. A 50-year-old diabetic refused amputation for a gangrenous large toe, stayed stubborn as the gangrene worked its way up his entire lower limb, and eventually succumbed to septicaemia three weeks later. By then, he had been transferred to the furthest of the single-bed rooms, and had the entire adjacent one-third of the ward to himself. I won't talk about the smell or his terminal medical care (delegated to me), except that he begged for euthanasia four times – the first when he realised it was too late to consent to a hind-quarter amputation. Since then, I would never hesitate to spare a patient the full details of the natural history of his/her disease, should he/she decline intervention early on.

Those were the early 1980s, when there was limited technology to help care for patients. (We started using disposable needles in the wards only two years earlier.) We paid attention to every symptom, learned to competently elicit clinical signs, and differentiated every sound we heard in the stethoscope - habits that stayed with me as a GP till now. We used what we had, cared for patients as a team, and were taught and guided well by supervisors who took responsibility for the actions of their juniors. Everybody worked impossibly long hours. The patients were resigned to seeing exhausted doctors and enduring inevitable mistakes.

I had a sense of déjà when I recently read an account of concerns about the National Health Service - from limited manpower and sub-optimal managers.1 In Singapore, patient care has moved on since. Both professional accountability and public expectations have changed from the 1980s (even at the houseman's level), and today's junior doctors walk in a different world. Thank goodness for change; I have many friends who still rely exclusively on subsidised healthcare.

Dr Ivan Low

Despite being a HO for only a couple of months, I have unfortunately built up quite a reputation for having "bad call luck". This, in addition to being fresh-faced and new to clinical medicine, made my first few months of work challenging. Looking back, there were three things that helped me keep my sanity, as illustrated in the vignettes below.

1. Good nurses

It was 2.30 am when my phone started buzzing with the annoyingly cheery default iPhone ringtone. It was a staff nurse in Ward 57 and she informed me that "the patient is acting really weird". Although it was an odd CTSP, I sensed the urgency in her voice and listened harder – the vital signs were stable but the gentleman had returned to the wrong bed after visiting the washroom. I headed down to assess him and found – rather horrifyingly – a guarded abdomen. His blood tests came back massively deranged and his CT scan revealed extensive bowel ischemia.

I learnt that night to trust the acumen of nurses. Hear them out on their concerns – they often know the patients better than we do.

2. Caring seniors and peers

It was Day 3 of work and I was informed of an acutely breathless patient. I ran down to initiate essential diagnostics but the patient stopped breathing in front of me. I pressed code blue and bagged the patient until the ICU team arrived. The patient died that afternoon. The family was in shock and I felt terrible. My fellow HOs jumped in to cover my team's changes for the morning without my knowledge, and my MO bought me a massive mocha frappe and talked me through the code situation. His feedback was constructive and he focused on what I could do better in future.

I learnt that afternoon that your fellow HOs and MOs can be real angels. Be thankful for your colleagues and lend a hand when you can.

3. ITD Help Desk

It was 7.25 am and rounds were starting soon. I set up the computer and ran through the list – ready for the daily grind. All of a sudden, the screen blacked out. When it came back on, I saw the dreaded message: "Your account has been temporarily locked." Without skipping a beat, I picked up the phone and dialled the ITD Help Desk. In less than 30 seconds, things were up and running again and – whew! – I made it just in time for rounds.

I learnt that morning that today's HOs face a different set of challenges, including technological ones. Take them in your stride.

Over the decades, some things have not changed – long working hours, unreasonable patients, difficult families and, occasionally, demanding bosses. But the spirit of medicine too remains - the compassion for patients, the collegiality among peers and the drive toward excellence. And I hope that counts for something.

  1. Knight S. Laughing, Crying, and Worrying About the N.H.S. 29 September 2018. Available at: http://bit.ly/2QwVkjU.

Foo Gen Lin is an orthopod with Woodlands Health Campus who has a special interest in sports. He is passionate about running - for himself and others.

Anantham Devanand is the deputy head of the SingHealth Lung Centre and is the director of interventional pulmonology. He leads the medical humanities office at the SingHealth Medicine Academic Clinical Programme and serves as deputy director of the SMA Centre of Medical Ethics and Professionalism.

Lee Pheng Soon is the Chairman of the Professional Indemnity Committee of SMA. Dr Lee has a Fellowship in Pharmaceutical Medicine from the UK Royal Colleges of Physicians and an MBA from Warwick University, UK. He works part-time as a consultant in industry and part-time as a GP.

Ivan Low is currently a house officer in Singapore General Hospital, General Surgery. He has a passion for public health, community outreach and medical education. In his spare time, he can be found relaxing at the park with his family and loved ones, his dog, and a cup of kopi peng (siew dai).


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