Working in the District

I can’t stand waiting. I just don’t have the patience. 

Sometime last year, as I walked into work I noticed the front door wasn’t unlocked so the patients’ couldn’t come in. The clinic has a sliding door with a grill, and I noticed the staff were already behind the counter, while a few patients were already outside peering in. 

Despite the clinic opening at 730 for registration, the door was still unlocked when I arrived at 745. 

It wasn’t the first time this had happened. 

It turned out that the person who held the key to the grill was on leave, and the other staff member who held the key did not arrive until 8am. The last time that had happened, I had reminded my staff to ask our patients to come in through the backdoor so they could at least sit in the comfort of the clinic.

Working in a district environment keep you humble, but life is distinctly a lot more laidback. There’s nothing wrong with a relaxed environment, but principles need to be stood by – the principles of punctuality and professionalism were very important to me, and the fact that my staff could occasionally be so relaxed over the small things really annoyed me to no end.

It was the lackadaisical attitude that really got to me, the lack of proactive-ness; or perhaps it was just the fact that they couldn’t put themselves in the shoes of others to see how it would look life from an outsider – the closed clinic front door with the staff members casually sitting behind the counter – with no sign, no information, no anything at all – in a city setting the complaints would have already poured in. 

Work ethics shouldn’t be compromised, despite the setting. 

Needless to say, I had to give a stern warning to my staff. 

You can take the individual out of the principle, but you can’t take the principles out of the individual.

New Horizons

The impending thought of leaving a familiar workplace is a bit scary.

It's been two years since I moved to Muar to serve the district, full of expectations to serve a sleepy little town but to able to connect with a community that would have been very different from a hospital setting. 

I wasn't sure what to expect.

Coming from a big town and moving into a district setting, I had no idea what the daily working life would be, especially being so far removed from friends. I went with good intentions and the will to serve the people, and with the idea to 'do my time' and pay back to the community as a doctor.

I found myself enjoying work.

It was a vast different from having to battle traffic, and the experience became so much more enjoyable because the staff at Pejabat Kesihatan Muar were absolute class acts. It was a great team; the kind where everyone pulled their weight, and workplace politics were minimal, and people genuinely valued your work. Our bosses valued us and listened to our suggestions, and I had colleagues who were professional and looked out for each other.

It was busy, but as busy as we could be, with a team that worked together the whole process became so much better.

It was difficult to leave, but it wasn't quite home, and I needed to make my mark elsewhere before I became complacent to the life that was there. If I had friends who were nearby, or if I was planning to start a family there, I would have been very tempted to put down roots.

As it was, my journey was yet to begin, and it was with some trepidation that I viewed my leaving.

I am thankful for my time and the lessons I have learnt in Muar. 

I am thankful for being able to serve the people, the old pakciks and makciks in kampung; for reminding me of the bigger picture of the majority that we cater to outside out acute centres, for the stories and the lessons that I learnt during my short stay away from the city.

Where a door closes, another door opens - and mine was there, beckoning in the horizon; as obscure as that pathway still might be, but change was needed, and it was time for me to follow my dreams.

Ego

I am not naturally gentle or patient. 

It took years to train myself to not give in to anger. 

A patient came in today with her husband, who had refused to allow her the tetanus jab that we routinely give pregnant patients. I asked him why he refused. 

He shrugged. 

"My mother and her mother never had any jabs, and they’re perfectly fine. I stepped on a nail once and didn’t get the jab and nothing happened to me. Those back in the day were perfectly healthy, but today everyone is full of illnesses.” 

“Those back in the day used to die a lot earlier, and women would die from more complications in childbirth. Are you against it for any other reason? It won’t cause you or her any harm.” 

“Look doctor, I’m the type who once has made up his mind, my mind is made up. Nothing will change it.” 

“If you make this decision fully understanding the reasons behind why we give the jab and you understand, I can’t force you – but if you don’t even want to learn about it, you’re being unfair to your wife and your unborn child. Perhaps you should talk to your family members and get their input?” 

“I don’t care. Even if my mother tells me otherwise it won’t change my mind. If my wife wants to go ahead with the jab, she can – but I’ve told her, if she does it I’ll take her home to her parents and cut contact with her forever.”

…. 

Took me all the energy not to run him down with my car when I left for lunch.

Golden Love

The husband had brought his wife in for her hypertension follow up. 

“You’ll have to talk a bit louder doctor, she’s a bit deaf.” 

“I’m a bit deaf,” she smiled apologetically. They both exchanged smiles. 

I smiled at how they both essentially seemed to complete each other's sentences. “Your blood pressure looks good auntie. Everything in general looks good.” 

She had been a model patient, one who had always taken her medications and had a fantastic record of very well controlled hypertension. 

Her husband smiled happily, reminding me again how I had to talk louder so his wife could hear. 

"I have to remind her to take her medication."

"I always forget, but he reminds me to take my medication."

They had been married for over thirty years, and even now in their twilight years, with each other becoming a lot more frail, it was obvious how much they cared and depended on each other. It was in the gentle smiles, and the way her husband led her by the hand as she clutched precariously to her walking stick as they walked out the door together. 

In an age where divorce is common, and love seems exclusively for the young, I love meeting these couples who have survived many years together and grown into their relationship, who obviously still love and care for each other after so many years. 

Now that’s a relationship goal.

Beyond Blood

One of the medical assistants came in one day requesting a prescription for anti-hypertensive medications for a home patient. I'm normally very strict when it comes to giving out prescriptions, however he was a very senior stuff member and I didn't think he would be abusing medications per se. 

I noticed the prescription was asked to be made out to an elderly Chinese gentleman. My staff member was a middle aged Malay man. Out of curiosity I asked him who was this prescription was for, and who was the man that he was bringing these medications to. 

He shrugged it off initially but eventually admitted that this was a patient had known for many many years and was now elderly and limited movement. 

He would still go over to this patient's house and this patient had asked him to continue his medications as he could no longer go to the local clinic. I suggested he come over at least once in a while to monitor his blood pressure and to run routine tests for his blood investigations. 

My staff member smiled. "He's an old grumpy fellow but in all the years I've known him we've somehow ended up almost like family."

"That's dedication, to still care so much for the health of your patient. Doesn't he have children?"

He shrugged. "He does but he's somehow taken me on as an adopted son and I look on him almost like a father. The old man will get upset if I don't come over for Chinese New Year because he considers me family. He also insists on coming over every Hari Raya, even calls me son. I've somehow been adopted into the fold!"

 It's lovely to hear, a simple story about a Malay man with his own family, who had been adopted into this Chinese family, just by the continued good relationship between these two individuals. Somehow along the way, their hearts recognized something about the other, and they had built on that recognition.

Despite all the reporting about the seeming racial tensions, these conversations, these stories are what really make up the weave of our Malaysian society. Simple folk and their every day actions.

We are all humans first after all.

Don't Let Routine Break Me

Please God, keep me far, far away from apathy. 

Sometimes I wonder if a day will ever come where I become disillusioned with my work, and take it out on the patients I see. It is a daily process dealing with patients, but I wonder if my passion for health will ever fade away in the midst of the sea of patients. 

Most times I look forward to work. 

The variety of patients I see is a daily reminder that my role really is to serve the people and the community, and most times I do feel a lot of fulfillment in my role. 

There are times though, more often when I’m tired or stuck in a routine of sorts that I find my patience fraying. 

My normal ease with overanxious patients becomes a lot more businesslike. 

The chronic patients who have poor control over their sugar and their blood pressure, still refuse to change their diet or exercise, and grin foolishly when I catch them out on not taking their medications are the ones that usually grate on my nerves – especially after you invest so much time appointment after appointment counselling them on the harm and effects of their health, after you try and provide the most comprehensive breakdown of their disease and link them to all the available resources you have. 

On a bad day, I usually give them my sweetest smile and tell them, “Uncle/auntie, please be careful with your health. You might end up in a hospital and die.” Sometimes they look at me blankly, and think I'm joking - at times I think they probably get a bit offended or nervous.

That said, my worse fear is apathy – if I should ever get to a point where I become one of those doctors who stop caring entirely about the health of their patients. 

I’m sure we all know doctors like those. Ones who see their patients surprisingly fast, who casts a cursory eye over their markers and shrugs, and simply continues medications without counselling or any attempt to find out further or optimize the patient’s condition. 

If I ever find myself in that position, I will know that my heart is no longer with my patients, and I hope that day never comes.

Musing About the Government Health System

Sometimes I think we doctors continue working in the government because it keeps you grounded. 

You see patients who need you, not those who can afford your services. You see those from all walks of life, from the scared old lady who has no idea why she’s ended up in hospital, to the poor uncared-for gentleman whose children have abandoned him, to those individuals who feel entitled to certain services because of their class and rank. You really do see it all. 

You learn that patients are the same, regardless of who they are, or what they earn – all blood, muscle and tissue underneath our different skins. They’re the same uncertain individuals underneath that bluster, but it’s the way they deal with their illnesses that makes all the difference. 

There are times when working in the government sector is tough and disillusioning. There are times where you feel like you want to just see patients, but being a doctor is more than just patients, and as the administration work piles up, it is easy to become jaded with the system – until you remember your patients. It’s them that keep you there, like a life line that reminds you every day why you do what you do. 

Sometimes it feels like you haven’t done enough, or you cannot do enough, and there are days where you despair because humanity is much too harsh at times, and we have all had those moments where we’ve all become a bit too involved with our patients, only to realize we have to slowly pull ourselves back and find that balance between our professional selves and ourselves. 

You see your patients, day in, day out, and cross your fingers that you don’t burn out. It is the core challenge that lies with most clinicians these days.

The government system has its pros and cons, but what I would love most is a greater flexibility at work. A system of shared hours for those who wish to balance a personal and professional life, and a public/private clinic division – an incentive that I’m certain would help retain the number of specialists, and give them the opportunity to focus on their areas of interest.

It’s a pipe dream, but all dreams start from somewhere. In the meantime, I still look forward to work, and hope that every day I’m doing a little bit of good for the world.

A Resilience of Spirit

I met an 88 year old patient in clinic who had come in for knee pain, which would worsen when he was doing activity. He was skinny, with really deformed hands, the kind you see with really bad rheumatoid arthritis.  I've seen a lot of older people who suffer from really bad pain in their joints, and this sometimes leaves them unable to go about their daily tasts in life.

As part of my consultation, I enquired about his ability to do daily tasks, especially with the way his fingers were so crooked, but he smiled and waved me off.

It didn't seem to bother him, so I counselled him regarding his knee pain and the likelihood that he most likely had osteoarthritis. I offered him some pain medication, but told him that we had support for physiotherapy and occupational therapy if the pain didn't subside, and that we could always step up the pain medication if normal Paracetamol didn't work. 

He said he would take some for now, but told me that you couldn't 'manjakan' or give in to the pain, or it would gain control over you. He told me that his attitude towards pain was no to coddle it, but accept it and go on with every day life as it is. He didn't mind having a little bit of pain, but it would not be his master.

This man is 88 and still rides around on his motorcycle, does his usual activities of daily living normally and refuses to walk with a cane, just because he believes that the mind is stronger than the physical failings of his body. 

I find myself comparing him to the countless MC seeker that I see for a bit of cough and cold, or the patients who let their pains and aches get the better of them, and I admire the resilience of spirit this one old man has in order in facing his daily challenges.

God bless you old man. 

I'll remember you when I start feeling the aches.

Boundaries

A young girl walked into the clinic emergency entrance, shaking and bleeding from several abrasion wounds. I attended to her immediately, and she told me she had been involved in a motorcycle accident - a car had hit her from behind but thankfully she hadn't sustained any major injuries.

She was in a shocked state when she first came, scared and shaking and kept repeating how fearful she was at telling her mother - from the way she spoke it sounded like her mother was a real fire dragon. It turned out that she had lied to her mother about where she was going and had taken out the family motorcycle to meet friends in town.

“Take a deep breath, and focus first – there’s no point worrying about it. For the moment you’re well and that’s the most important thing,” I told her. 

Her mother finally arrived and I smiled as I let her into the clinic emergency section. Her daughter ran to her and I was about to smile, but it shocked me when she opened her mouth to speak to her mother – with disrespect, almost to the point of screaming at her mum. She really kept mouthing off, even accusing her mother of scolding her despite her being hurt. Her mother hadn’t even really scolded her at this point – it felt like her mother herself was shaking at the thought that her daughter might have been involved in a serious accident. 

I don’t know where the boundaries of respect were blurred between mother and child, but to me it is shocking to see a child mouth back at her mother so blatantly. While the child herself was definitely slightly traumatized by the accident, it was also obvious that she was trying to run away from her fault and shift the focus of the blame unto anything other than herself. 

I can only hope I've never treated my own mother like that or that any future child I have will ever speak to me that way.