In order to become a practising doctor, every medical student has to go through the phase of being a house officer (HO) (better known as a houseman back in the days). These were not easy days for many, perhaps even fraught with worries and challenges for some. At the end of the journey though, there were always fond memories to be cherished.
In which year did you graduate from medical school/enter housemanship?
Charles Wong Sen Chow (CW): I graduated in 1972 – 47 years ago – from the then University of Singapore.
Jonathan Tan (JT): I graduated from NUS Yong Loo Lin School of Medicine in 2008.
Kenneth Mak (KM): I graduated in 1990 from the Faculty of Medicine at the National University of Singapore (NUS).
Tan Weng Jun (TWJ): I graduated from Monash University in 2016 and started housemanship in 2017.
What was the greatest challenge you and your cohort faced at that time?
CW: Back in the day, housemanships consisted of two six-month postings. My first posting was to the Department of Paediatrics, East Wing, Singapore General Hospital (SGH) and my second posting was to the Department of Surgery, Thomson Road General Hospital (later renamed Toa Payoh Hospital).
The housemanship days were really busy because there were fewer hospitals in Singapore then. After a long and tiring day on call (usually with only a few hours of sleep at best), a half day of rest the following day was only a privilege and not a right. If there were a lot of work to be done in the ward, we would have to forgo the half day off to complete the work. Often, on the way back from SGH, I had to swing by Mount Alvernia Hospital and park my small car in the carpark to take a short nap before resuming the drive back to Sembawang where I stayed with my parents.
JT: When I graduated, I thought that I had my future figured out – suffer through housemanship, apply for a Basic Specialist Training (BST) position, hopefully get it after trying a few times, then get into Advanced Specialist Training and become an orthopaedic surgeon one day. Little did I know that the biggest change in Singapore's postgraduate medical training was just around the corner – the residency system which was introduced a year later.
Needless to say, I was caught totally unprepared. Some in my cohort were ready for it and had either secured a BST position or were accepted into a residency programme as house officers. Most of my cohort however, had just re-entered national service and, as might be expected, the change was a source of great concern, especially for those of us who were unready for it. I was a prime example of someone not prepared for the new residency system; I had no publications or conference presentations and had not done any medical officer postings in the department I had hoped to work in. Things were certainly not looking good.
TWJ: The greatest challenge during our housemanship was familiarising ourselves with the various computer systems. I started my housemanship at Tan Tock Seng Hospital, where we were faced with a stampede of patients every day. We held on to our Computers On Wheels (also known as COWS) for dear life (as there were not enough to go around), only to find that they did not live for long. The computer system was a larger maze to navigate than the hospital itself, and just as I was able to proudly order the hepatitis panel in ten seconds, I found myself in KK Women's and Children's Hospital learning to decipher 16th-century secretary hand, wondering if the squiggly icon at the top of the screen had any significance when a new computer system was adopted.
What was the greatest worry/concern you and your cohort had about your future?
CW: Job uncertainties was worrisome in Singapore then. Some of our classmates migrated to Australia because they were offered good deals to work in surgeries (clinics) located in the outback, with minimum income guaranteed; any shortfall would be made up for by the authorities. After two years in the outback, they could move to the city to practice. I almost followed them there, but my application for surgical traineeship came through successfully. I had always wanted to be a surgeon, so I stayed put here.
After my promotion to registrar and senior registrar, my challenge and concern was in going into subspecialisation as general surgery was to be compartmentalised into the various subspecialties. I decided to go into colorectal surgery and in 1981, I was awarded the Health Manpower Development Programme fellowship to pursue this subspecialty in the UK from January to December 1981.
JT: Not being a resident and serving national service were certainly my biggest concerns and I am sure many in my cohort shared my feelings. We were out of sight and out of mind to the residency programme directors while the coveted residency spots in restructured hospitals were being snapped up by HOs and medical students. It didn't seem fair at all. Some of my contemporaries took it as a sign to strike out on their own to find their own paths, while others decided to explore this brave new world of residents and programme directors. I would like to think that we all found a path that suited us.
KM: Our class, at times, was more concerned about the quality of life in medical school than the quality of education. We played hard in the Medical Faculty Inter-Year games (Faculty of Medicine Shield), while a number of very creative people who were also passionate about music and the arts went on to produce music records. In those days, my class was considered big. Our cohort started with about 230 students but that pruned slightly over time until there were about 210 when we took our final exams. It was years later before class sizes expanded beyond that number to reach the current class size of more than 300 students.
With the big class size, the odds of us having a job post-housemanship and the opportunity to enter specialist training hung on some of our minds. A handful of us did sense that changes were afoot in our hospitals. Hospitals were being corporatized and new styles of management were being introduced. We didn't appreciate the importance of primary care as much as we do now, but there were great family physicians who were powerful role models for us, including Prof Goh Lee Gan. They taught us the importance of treating patients as people, not a set of interesting symptoms and signs. Many of us were inspired by our tutors to believe fervently that we could make a difference in the lives of our patients, and we continue to believe in this after nearly 30 years of clinical practice. Some of our then tutors have retired or passed on, and others have become our close friends and colleagues. This sentiment of wanting to benefit others, whether patients, students or fellow doctors, has become part of what bonds us together into a close fraternity.
TWJ: Our greatest concern was whether or not we would be able to pursue our desired specialist training programmes – a dream that we have had since we were in medical school. It was timely for those who wanted to pursue a career in family or general medicine as there was a push for generalists by the Ministry of Health in 2017. However, specialist training positions were very limited. Those who aspired to become specialists in popular fields were under pressure to outdo, outperform and outlast their peers.
Did things improve as you gained more experience?
TWJ: Yes, experience increased my efficiency and work quality. I was able to make decisions and perform procedures such as blood-taking more quickly and accurately the more I had to do them. The better the job done, the more satisfaction gained and the more enjoyable work became. Having experience also increased my confidence in my abilities, as well as my patients' and colleagues' confidence and trust in me.
How are the things different now, years later?
KM: Things in hospital practice have changed quite significantly. Nurses' uniforms have changed. We no longer have hospital matrons but Directors of Nursing. The ward sister used to be the most feared person for HOs in the ward but are now often their best friend.
The junior doctors' duties of responsibilities have also evolved. While most of the doctors no longer start the day taking blood samples from patients as part of their ward routine, they now seem more caught up with completing forms on electronic medical records and filling checklists. While this may be done with patient safety in mind, it does potentially detract from spending more time with patients at the bedside. There is a more collegial team-based care model in our hospitals and polyclinics, which is a great improvement from our times as HOs when a senior (who shall be unnamed) called us "slaves and minions..." The junior doctors may not believe it, but there is considerably more collegiality and mutual respect for each of the healthcare professions now, as compared to 30 years ago. It has become a key tenet in our work culture now that irrespective of background, all healthcare staff can practise to the apex of their potential and lead in multi-disciplinary care teams.
Presently, there is also a stronger emphasis on providing care that respects patient autonomy. This requires us to spend more time with our patients to explain to them their condition(s), as well as the treatment options available, the pros and cons of each option, and our recommended approach. We now better respect the preferences of our patients and only provide treatment with their informed consent. In the past, patients often adopted an attitude of dependency on their doctors to make the right decision and to treat them appropriately. They would also often delegate the decision-making responsibility to others in the family. We now believe more strongly in patient empowerment and that patients share in the responsibility for their own health.
What was the your greatest takeaway from your housemanship year(s)?
CW: Housemanship is about the hardest rookie period in any profession. We really should not complain about the hard work and lack of sleep. You learn a lot from the seniors and the patients you help look after. Although difficult, the training reminds you that you are in a noble profession – that's the greatest feeling I have had and will always have.
JT: My housemanship year was unremarkable but going back to the National University Hospital was certainly a rude awakening. It was disconcerting to be on the outside looking in while the vast majority of my juniors were residents. A quick look at some of their CVs made me realise that I had a lot of catching up to do. Objectively, they were much more qualified than I was. That helped me to stop blaming the system and start improving myself. It took two years of making full use of my unprotected time to catch up and even then, getting into residency was a close run. The memories of staying back on weekends and holidays to learn how to fix fractures, doing overnight data collection and waking up at 5 am to read up for the morning teaching session to impress the programme directors have become sweeter and less painful over time. My most important takeaway from those two years was the camaraderie and friendship I developed with my colleagues and teachers. Despite all my efforts, that coveted residency would have remained out of reach if not for their help and guidance, and I will always be grateful for their assistance. Certainly one of the motivations to become a resident and complete my residency was the chance to come back to the same place every day and work with the same people I had come to befriend and respect. It was certainly one of the turning points in my life and I am grateful that all things have turned out well.
KM: The greatest lesson I learnt during housemanship was time management. The transition now is better for medical students transiting into working life as a HO, with full-day student internship attachments in the final year of their medical school education.
Things were different for us then. We plunged head-on into housemanship and were entrusted with responsibilities for the well-being of our patients from day one, where we rapidly learnt to swim or sink. We had to manage our time by completing our ward routines and discharging admin quickly, attending to all other assigned tasks, assisting in surgery, making referrals, and more – all within the day.
We might start earlier than 7.30 am in some departments and not return home until past 8 pm on a post-call day. I remember that there were only four of us as housemen in Department X and this headcount dropped to three for a period of three months, as one of our colleagues was on a prolonged medical leave. This led to a mad routine for the remaining three of us as "the work just had to be done". Alternate day calls and sometimes even consecutive day calls over two days were not an exception to the rule but was inevitable to the extent that we would not complain about it. That wasn't ideal for patient care. Junior doctors now have a much better housemanship experience, thankfully.
TWJ: My greatest takeaway from housemanship year was that the most difficult of days can be overcome with resilience and support of friends and family. No matter how bad the call, morning will come. No matter how bad the scolding, there are plenty more opportunities to do better. No matter how tiring the days have been, housemanship will definitely come to a close.