Thursday, April 19, 2012

Do You Want to be a Doctor?

This is a letter written by my dear friend, Assoc. Prof. Wong from Monash University Malaysia in response to an inquiry by Daryl. It is reproduced here in full with his permission.

Dear Daryl,

Your aunt has asked that I share with you my thoughts on medicine and medical education today.

Let me start by saying that I am most blessed to have trained under your Aunt, Prof Florence Wang, and I recall my time in ward 12A at University hospital under her as a most formative part of my training. Thank you Prof!

It has been 3 decades since then and the world has changed. The world of Medicine and medical education has changed beyond even the most imaginative of us all had dared to dream. Some things are good and much detrimental.

I will have to ask you very honestly why you wish to pursue a career in Medicine for this is very important.

Most students simply have very little knowledge of the world of medicine and some very quickly become disillusioned in their clinical years. ALL my students come to me with FULL distinctions or stand at >97 percentile of their cohort; that they are brilliant is without a doubt but sadly many are NOT that motivated to serve humanity. They come into medical school because their results qualify them too, they sing the right well rehearsed song at the interview and because they think it is prestigious, they want to be a medical student!

But the real world of sick humans with all the smell and excrement and drains rapidly reverse all those good feelings, and harsh reality sets in. Osler a great Physician whom your aunt and I both greatly admire said that THE VERY FIRST QUALIFICATION is a Love for Humanity. I believe that that quality is far more important than all the 'A's in your result slip.

AS a GOOD doctor, You will be very important. We have plenty of doctors but not many GOOD ones. The future of many lives and families depend on what doctors do and SAY; imagine all the Good or Damage that can be done. But to be a good doctor is NOT easy. I just had a tutorial with my students and told them that the VOLUME of information that they need to read up is so MUCH that any serious student will honestly spent ALL his time doing very little but STUDY. I hope this realisation will help you understand the quality of life you will have as a medical student, or rather the lack of it.

Modern medical education has moved far beyond lecture based learning; here in the Clinical school the word 'LECTURE' is OBSCENE and students learn through SDL - Self directed learning. Its philosophy being that the advance of knowledge is so rapid that Students MUST learn to teach themselves rather than being taught formally in a Lecture Hall. This demands very matured and disciplined students for to the lazy student, SDL means Sleeping DeepLy. Are you prepared for years of being a nerd?

Please remember that Doctors are first and foremost Diagnosticians… those training under me MUST not only be skillful in diagnosis and management but also in social skills and leadership. When I was under your aunt, she demanded History taking so detailed and meticulous that 'War and Peace' looked like a short story in comparison. Today students speak in SMS like language, and do "Focused History Taking" instead of Detail History taking. Yes the Art of Clinical diagnosis is dying, and High Touch Medicine being replaced by High Tech Medicine.

In many Once Prestigious Universities which I will not name, Final Year students now teach 3rd year students Clinical Methods!!! Your aunt will tell you that 3 decades ago, only the senior consultants in UM were allowed to teach Clinical Methods as it was considered so very2 important. Osler is certainly turning in his urn!!

In your mind, do you envision yourself as a doctor spending hours talking, feeling, touching, examining the patients.... or a doctor ordering scans and more scans with nary a glance at the nameless poor sick man lying on the bed? Ask yourself that question now.

Yes, the practise of Medicine is in trouble.

Blatant commercialisation, rampant blood tests done without any doctors ordering or supervising, scans and probes of all kinds, are being conducted by laboratories and some doctors misguilded by wants rather than needs. When your aunt was holding the fort at Ward 12A, her ward rounds will start at 8am and the whole entourage of she the Professor, Dr HC Ting the lecturer, the Med Officer, The Houseman and the medical students will follow her from bed to bed. The Med Student or the Hseman will present the LONG DETAIL history and she will then TALK TO EVERY PATIENT WITHOUT EXCEPTION about aspects of the history and personally examine every patient to confirm or correct the juniors' findings. This of course was a Long tedious process and the rounds will stretch till 1pm. But it was the Art of Clinical Diagnosis at its finest. Today, I am sad to report that rounds are spent looking at scans and reports and its a RARE occasion that the Consultant lays his hands on the sick. Sadly I am not exaggerating. I wish I am.

Hope lies in every one of us doctors, present and you the future, for the sensible management of patients; YOU remain the hope for untold numbers of patients in the future. Sadly some doctors see patients not as patients but as a disease that needs treatment which provides our source of income. This is nothing new, physicians like Osler had repeatedly cautioned against not forgetting the man behind the disease, and medicine as a calling rather than a business.

“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. Often the best part of your work will have nothing to do with potions and powders, but with the exercise of an influence of the strong upon the weak, of the righteous upon the wicked, of the wise upon the foolish”.~ Sir William Osler

Many doctors are unhappy with their work or simply too busy to talk, console or listen. Yes thats life in the 21st century where we sms instead of talk. Many just treat the disease and completely ignore the person who has it. We hear endless tales carried by patients of doctors who grunt instead of talk, who are capable only of monosylable conversation and who zip patients in and out of the consultation room with a speed that will make Superman jealous. I try my very best to teach my students the Art of Clinical Diagnosis but even I fear that its a losing uphill battle. My colleagues and I here are led by Prof Khalid who is a old school clinician, and we refuse to belittle the Clinical Art despite the advancing machinery all around us. Students are amazed and impressed by all the wizardry and sometimes to my frustration fail to practise the Clinical Skills as much as I want them to.

Ask yourself Daryl, what do you want? I do not want you to come to medical school and be disillusioned by what you see in the REAL MEDICAL WORLD as compared to the idealised world that we had projected.

Doctors must never forget why we became doctors in the first place, and the wonder of caring for fellow humans. Some may be a bit burnt out. We had in our careers, seen and taken care of more pain and misery than most people. We saw prostitutes, drug addicts, criminals and the worst of humanity. Yes, this is another point that I must raise to you. AIDS today is the TB of your aunt's era, its everywhere! Most of my students come from very privileged families or they cannot afford the fees! Hence it is a shock to many when confronted with Vagabonds, homeless, addicts, pimps and Prostitutes. All the glamour flushes away when you realise that such folks are among the many that you will encounter daily unless you are in some Beverly Hills practise.

But of course we also treated decent human beings, doting grandmothers and innocent children. No doubt, the demands on our skills and the medical-legal complexities that accompany our practise would have made even the greatest of our medical ancestors shudder. And for this your training is NOT the 5 years of medical school BUT many2 years beyond. Are you prepared for such a LONG time spend in studies and training?

You had read Dr Pagal's blog and written to him, while he may be harsh and discouraging, much of what he wrote to you with regards to THE SYSTEM has some truth to it. The system is basically dictated by our political masters, a system undeniably sick, and Dr Pagal has written frankly of much of our woes that only drastic administrative tsunamis can repair.

Yes the system only makes it more painful. Long waits for post graduate training positions is the norm now. Regulations as thick as a medical text. Pharmacies selling controlled medicines like sweets. To change that will require one of us to be the next Prof Virchow, plunging head on into politics to make a difference.

In school we rose above the hoard, we were the cream de la cream, and yes I can testify to that in my students. Some are so brilliant they frighten me. We obtained results the envy of most and we strove with pride to enter medical school. Could the same students have done well in other fields? Of course they will shine too!!

In medical school you will work like ants on a long march. You will stare at slides till you see mitochondria in your dreams and memorised volumes of facts and figures. Some of my students are NOT prepared for this; they thought that it will be a smooth passage and when they hear this old Professor here telling them to read XYZ, they simply turn off and zone away. Are you ready for a student life that has NO LIFE??

I take them for tough postings in Internal Medicine, I am among the strictest examiners, I expect the students to flourish in the drudgery of crowded wards, to work till hypoglycaemic on medicine rounds, to perform every procedure required in the book, and of course to pass their exams reasonably well. I expect them to look at X-rays until their eyes turned red. And do I have such students? Yes, I am blessed that many such students have walked the wards with me. And I am proud of them. And I know they will overcome every obstacle invented by our political masters to excel in their fields because they have the fundamental quality to be a good doctor; their love of Humanity and of the Art of Medicine.

You will finally graduate and become a houseofficer. Yes the field is as packed as sardines from Msia to UK to Australia, Dr Pagal is NOT exaggerating when he says that jobs will be difficult to come by soon. But if you are GOOD, you will be wanted! Its TOUGH I do not deny and TOUGHER as the years pass by, BUT again I emphasize, if you are good, you will be wanted for the good doctor is a rare specimen.

A few years later, you will pick a specialty, from paediatrics to surgery, family medicine to cardiology, internal medicine to radiology, and shuffled off to more clinics, rounds grand or otherwise, work and studies. And MORE EXAMs. Girlfriend? Oh what Girlfriend!!!

In the 80s, new diseases appeared. I still recall with trepidation managing the very first patient admitted to our hospital with AIDS. We knew very little but feared a lot. As registrar, it was my duty to examine him. But again we survived. And learned. Now at almost every bedside teaching, I see patients with HIV. In your generation, you will see many2 more new ones, from Avian flu number something2 to any new thing that crosses species as humanity ravish the environment. Ready for that?

Your youthful enthusiasm and dedication will push you through the initial years. As young doctors, weren’t we incredible then, if only because we came back to the wards night after night, day after day for emergencies, calls, rounds or simply a ’tissued’ drip. “Bengkak” the nurse will phone and we leave our dinner to struggle with chemo wrecked veins for IV access.

Did you know that your aunt will reprimand the ladies for coming to the wards in pants? It is NOT acceptable then but now almost all my female students come in pants! OOPs sorry Prof for leaking such old tales!

We as doctors try to hold onto our commitment to heal, that wonderful calling. Then we see another world – the realm of the business of medicine, where every disease is a “case” to be investigated.

A very senior Professor tells me she had seen doctors ordering investigations before even taking a history! Here is also the world of the grunting and monosylable doctor, the superman of 2 minute consultations and management. True, the superb rare genius of a diagnostitian may well have obtained all the data that he needed sub- 2 minutes, but the poor human called ‘the patient’ needed at least 6 minutes of compassionate conversation. (By the way, that is why the OSCE exam is 6 minutes long, or SHORT from your examinee viewpoint.. now you know how the patient will feel when the consultation is even shorter than this!). Recall that the only reason the woman in labour remembered the attending medical student is because they held her hand while she screamed.

We are the descendents of Aescalapius, the inheritors of all that is noble in the Hippocratic oath. We may fail to change the ideas of many doctors however we may preach from some illusive high moral ground. But as individuals can YOU NOT lose that ideal? If you can, welcome to the world of medicine and modern medical education. You will thrive no matter what! If not, seriously reconsider another vocation.

If we tell our students that the learning of medicine is through their apprenticeship to us their seniors, then we better be sure that we are good role models. Your aunt was a superb clinician and diagnostician and had inspired many of us.

As a future doctor, you can be the hope of the febrile, the breathless and the pregnant.

Do not let what you see in the misadventures of some doctors discourage you. Instead let them be teachers to you for you now know what you do NOT want to be like.

When a doctor have taken medicine to be a business or trade, he will ask what are his achievements — material success, cars, wealth, etc..

When a doctor has taken medicine to be a calling, he will ask what has he become — his character.

I hope we doctors can discern and reflect on what we have become in the practice of medicine, and teach all our young charges, delivering them safely through the long 5 years of protracted labour into a reasonably sane medical world. Daryl, I hope I have helped you somehow. Your aunt, Prof Florence has taught me much, this is my little tribute in return, my Bunga Emas to her.

Thank you

Associate Professor Wong YO.

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Blogger Paul Long said...

This letter has applications to other professions as well ...

5:44 PM  

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