Letters to the Editor
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"The Wonder Years - Housemanship 89/99"
It was the best of times, it was the worst of times. Our housemanship started on 3 May 1998 with a great deal of expectation. The excitement and anticipation of being a true doctor, was coupled with the trepidation and fear of killing someone, or doing something horribly wrong or gruesome. It is very difficult to recount all the events and emotions that transpired during this first of many journeys, but with apologies to some, I have attempted to write about the year, under a few headings which I felt are worth mentioning.
First Day: "Today is the first day of the rest of your life."
Medical practice is strange in that it is often assumed that you know exactly what to do, even on your first day. Other than dabbling with chemistry sets and lessons in our college days, we had never mixed chemicals or drugs, yet we had to prepare, deliver and expect to treat all complications that may arise from such an administration on the first day of work. The immense amount of paper work was somehow meant to be self-explanatory, despite the modest title of "DISCHARGE SUMMARY" and there other minor decisions that were somehow more difficult to make when you have so little confidence in your new found powers can a person go for "home leave"? Does a certain patient require accompaniment for scans? Can someone go "off hourly parameter"? It is quite amazing that we have become so nonchalant about making these decisions now, but on the first day, they required careful thought, consultation, confirmation then a decision. It was our introduction to the whole "deep-end" philosophy that was to follow us through the year, and perhaps even beyond.
First Call: "Its alright to be stupid, just dont be dangerous."
I think the real challenge that made men out of boys was the first call. Despite all our grouses about going on-call and wasting the night, I have come to believe that the closest thing to true doctoring for housemen took place at night. At night we were a vital and crucial member of the medical personnel. We were in the first line of defense in any battle. Romanticism aside, many of us remember our first call with the same fondness as our first obstacle course training in the army. It demanded that we made the transition from student to professional faster than we were prepared to. At night we were on our own _ fewer people to consult, and the added task of having to swallow your pride to ask for help. For many, it was our larger than life egos that pulled us through our first call. I can never forget running around the dark corridors of Alexandra Hospital seeing case after case, clerking, examining, taking blood, setting lines, giving IV medications, doing ECGs, speaking to relatives, seeing inpatients who are constipated at 3 am (even that was a challenge as I had not developed my constipation repertoire as yet!!!), and then dropping everything when called to run a resuscitation, then after 5 minutes of CPR, the first real-life, unsupervised intubation, defibrillation, drug administration, realising that I was alone because I hadnt instructed the nurse to call my MO!!!
The Rest of The Year "Work hard, play hard, die hard."
After a while, most of us settled down and adopted better planned routines. We started having our meals regularly, and spoke with much more authority over things we still never understood completely. Except for minor drifts that occurred when we changed teams or wards, and shifts when we changed postings, we adapted and evolved to the environment with greater skill. We slept more for night calls, became savvy at prioritising calls from irate nurses, and street smart at handling difficult patients, relatives, and nurses. Apart from mishaps that tend to occur from time to time, days and nights became more routine and we developed repertoires or our own protocols on handling different complaints chest pain, back pain, abdominal pain, leg pain, toe pain, vomiting, diarrhoea, constipation, insomnia, itch etc. They all had their own series of graded therapies, according to personal preferences and observations. Panaceas and placebos were used with more confidence than warranted or deserved. More importantly, we chanced upon a principle (at our own pace), that would carry us into our career from hereon clinical acumen. After 6 months some were even using phrases such as "in my experience", "this guy does not look good, come now" or even the foreboding "I dont think he will make it through the night."
Apprenticeship: "If it was so easy, anybody could do it."
Though medical education has come a long way with its own minor revolutions and resolutions, the principles of apprenticeship still remains one of the main institutions of clinical training. Housemanship is the first year of such an apprenticeship. Much of our decision making, modalities of investigations, thought processes, and the general approach to any clinical problem, is very much guided by all the clinicians we come across. The influences may be positive or negative, but we all find mentors and heroes whom we wish to emulate, and attempt to imitate. These persons include consultants, registrars, medical officers and nurses, but they all greatly influence our formative years. Of course, then there are others who are the subject of all our party conversations and derision. They exist to remind us what not to become and what to avoid!!!
One of the most important lessons we learnt during this year would have to be humility. No longer can we be the cocky, know-it-all medical student, nor the publication-quoting, mnemonic- wielding trainee if we wanted to better ourselves, we had to sponge off everyone consultants, registrars, medical officers, nurses, attendants, relatives, parents and even drug representatives. Reality has it that we had no practical experience 5 years of a theoretical education, which often emphasised on the exotic and aberrant, and some messing about with practical management meant a big black hole in our actual approach to any clinical problem. The experience of housemanship is meant to be a humbling experience, but it often requires one to set aside our false prides before we can set off to learn anything for some this takes longer than for others.
Unfortunately, many acquire this attitude at some point during the year. For most, it is a way of coping with the stress, problems and gravity of situations, but to others it becomes too deeply ingrained to escape notice, long after the housemanship. It is difficult to pin-point the exact root of the problem, but is often related to less-than-humane welfare and benefits from certain departments or individuals, or accusatory, finger-pointing approaches adopted by certain persons against the houseman. Not unwarranted, but it is often forgotten that our purpose is to learn, and if instructions and directions are nebulous or cursory, you cannot make rocket scientists from toddlers. Constructive criticism is always warranted, but public verbal caning has not worked, despite sadistic claims otherwise!! Another cause may also be related to less-than-scientific, fishing expedition approaches taken in practice often involving a barrage of investigations and procedures, not wholly justifiable.
Whenever we met socially or otherwise, there are always a lot of grousing and grumbling, but there are far fewer complaints pertaining to salaries, the hours of work, and the number of calls. Reality has it that we are not too far off from the average lawyer, accountant or other professional in their first year, and the financial crisis makes this statement easier to make. But there are and will always be some problems and issues that should be addressed and could be resolved for future generations.
As we approach the Twenty-First Century, we have to be more forward looking, and hence have to progress. Having a tough life in the past is insufficient reason to halt progress and efficiency, so the age-old phrases of "in my time" or "we had it much tougher, so stop complaining" could be used less.
Nursing is another aspect that deserves some consideration. It is not a matter of efficiency (howls of protests from housemen everywhere), but I tend to think it is a matter of giving them the powers and exposure of professionals, will true professionalism arise in the practice. Procedural liberties may be a step in the right direction, but I feel that the day when they are allowed to make decisions based on their personal training and observation, will nursing become truly professional.
This article was not written as one individuals opinion, nor as a collective outlet of all housemen, but perhaps as mere observation from a group of individuals encompassing almost all the hospitals. Whatever the year was to one and all, it is not an experience easily forgotten. It will eventually take its place among one of the most influential periods of our lives. We will always remember, reminisce, recount and romanticise, but most importantly remind ourselves that it is but the first year in our long lives ahead in the medical profession.
DR GOPALAKRISHNA IYER