Are house-officers ready for an emergency?

House officers are newly qualified doctors, getting to grips with their new jobs as they transition from medical students to doctors. The new role is demanding, brings new responsibilities and greater expectations from everyone. House officers consider themselves to be at the lower end of the medical hierarchy and so, more often than not, end up doing menial work that does not completely do justice to their degree.

This, however, is unavoidable in most situations because the basis of medical training lies in the ability of the house officers to perform basic procedures. The house-officers training programme in Malaysia has evolved from a one-year programme to the current two years. The Medical, Surgical, Obs & Gynae, Orthopaedic and Paediatric departments are compulsory postings, whereas Primary care medicine, Emergency Medicine, Anaesthesia and Psychiatry postings are elective postings with the house-officers given the choice to choose anyone in order to complete their housemanship training in this country.

Given that choice, the majority of the house-officers will opt for any of the elective postings except Emergency Medicine for very obvious reasons. Doctors in the Emergency Department work in shifts, seven days a week and don't get to enjoy free weekends or public holidays like their counterparts. Who in their right mind would volunteer their services in such working conditions?

Many fail to see the beauty in the Emergency Department which lies in the fact that it sits at the fulcrum of the hospital, a gateway of sorts, guarded by an army of doctors whose primary function is in identifying ill patients and keeping them stable and alive long enough for other teams to intervene. A team of doctors who revert a patient's one-way ticket to a return ticket safely back to his home and family and whose initial care determines long-term outcomes. Such is the role of an emergency doctor. Such is the burden and responsibility of an emergency doctor.

The Emergency Department (ED) deals with a plethora of cases that exposes and prepares a junior doctor to meet the demands of practising acute medicine and master the essentials of acute patient care. Hospitals are deemed highly reliable in terms of safety and quality only with the existence of highly reliable EDs with highly reliable doctors, amongst others. As such, it makes sense to make it mandatory for all junior doctors to go through emergency medicine posting.

The ED posting trains the house officers in a myriad of cases, hones their history-taking and diagnostic abilities, allows them to experience interacting with patients and improving their communication skills. This is made possible due to the fact that ED doctors are front-liners and when house officers are posted to the Emergency Department, they too are propelled into the role of frontline "customer service representatives" operating in a variety of capacities. The role of an emergency doctor requires good people skills, good verbal communication skills, an ability to exercise courtesy with patients and colleagues, be patient, calm and accommodating, all in a highly charged and often volatile environment.

They go from mechanically performing "robots" acting on instructions from their seniors to interactive, analytical thinking doctors who are able to put into clinical practice what they learned in medical school. They learn to apply skills and plan the approach to each patient's situation in a supervised fashion. They learn to develop routines to streamline patient care with pattern recognition in a supervised fashion.

The ED teaches them the importance of teamwork and how to be an effective team player. The importance of effective teamwork in health-care delivery has an immediate and positive impact on patient care and safety. The challenge is not whether care is delivered in teams but rather how well the care is delivered by the teams. Training in emergency medicine addresses this issue and reiterates this fact throughout the posting of the house officer who otherwise has little understanding of how teams are constructed and operate effectively.

The ED teaches them about assigning specific roles or functions and how interacting dynamically, interdependently and adaptively together to achieve a common goal which is the gold standard and primary objective of the emergency services, helps to minimise early mortality and complications in patients. The ED teaches them to develop emotional stability and to quickly adapt to changing situations, especially when facing irate patients or family members or when overwhelmed with a multitude of tasks required to be carried out with utmost urgency. This enhances their abilities to prioritise, to strategise and to deliver efficiently.

The ED teaches them to defend their cases and fine tune their clinical acumen under the guidance of senior doctors who are always with them as opposed to in the wards where house officers are usually left on their own to deal with any emergency that arises.

Not knowing if what they are doing is right or not in that situation is generally how most house-officers feel and they are not incorrect in feeling so. Neither is it their seniors' or superiors' fault because they have a multitude of clinical tasks to complete in any given day. The Emergency Department is unique in that way because all the doctors work in shifts and they work together, therefore affording direct supervision with around-the-clock guidance, which is an ideal training ground for all house-officers.

With time, the acquisition of skills and practical experience increases and is further augmented with knowledge and guided training. According to the Miller pyramid, "knows, knows how, shows how and does" are the four cognitive and behavioural steps an individual progresses through, from acquiring knowledge to performing a task in practice. Simply "knowing and knowing how" does not always extrapolate to clinical performance or application of knowledge in the workplace. In the ED the "knows how, shows how and does" is performed under the strict supervision of senior doctors, thus identifying deficiencies, problems and gaps in knowledge and competency early on in the posting, is made possible.

The ED builds and strengthens their confidence and self-esteem of doctors as a whole by helping them to metamorphose from clinically illiterate MDs, incapable or fearful of making acute decisions in patient care to confident, proficient doctors contributing to patient management in a highly effective manner. As they contribute their two-cents worth in the clinical management of their patients, they develop their clinical expertise, gain faith in their own abilities, learn to troubleshoot problems and grow in confidence.

The ED teaches them to develop strong work ethics, to respect their colleagues and their time by emphasising on punctuality at work. As shift work requires every person to be on time for a smooth pass-over of duties, the ED trains doctors to be diligent, dependable, responsible and show respect for people and time. Teaching them to give themselves a buffer for potential unforeseen delays to work allows them to be more disciplined, relaxed and prepared for the shift and this instils integrity and invaluable character in the budding junior doctors.

Emergency medicine is a marriage of all specialities that arms and prepares the house-officers in a very holistic manner. By making it mandatory for all house-officers to be posted in the ED, we are laying the groundwork and assembling a battalion of future medical officers with the competency and proficiency, to not merely be able to function independently but also effectively. Expert cognition, good integrative abilities, relational abilities with good moral functions are the essence of a good and competent doctor.

By being posted to the ED, HOs learn how to deal with acute cases in emergency situations under the supervision of senior doctors. Many who skip ED and end up in district hospitals or government clinics have to deal with all sorts of emergencies with very limited or no supervision at all and this makes them unsafe, very vulnerable and liable to medico-legal suits. This is a harrowing experience for them, as well as for patients under their care, as they are forced to learn through trial and error at the expense of patients` lives, with many not learning from their mistakes thus repeating the cycle of doom.

As such the Ministry of Health should very seriously consider making Emergency Medicine a compulsory posting for all house-officers rather than an elective posting as it currently is. The training of house-officers in the ED "completes" them in more ways than can be mentioned here.

Honourable Health Minister, stretch your thinking beyond the current practice so that all house-officers are equipped with the will and the way to handle all emergency cases wherever they are. The more thoroughly equipped they are, the more skilled they are in identifying semi-critical and critical patients, the more confident they are in their management skills, the better the outcome for patients in the long run.

The current curriculum needs to be revised to keep with the times and the needs of the common man. Emergency medicine trains one to be Jack of all trades and in emergencies, one needs to be prepared to deal with anything and everything.

Predict and prepare. Not retreat and regret. - Mkini