House Officer Teaching

Dear House Officers,
There will be teaching on Tuesday the 18th of November, 2014 from 5.30 a.m. to 6.15 p.m. on the 9th floor. The subject will be about clerking. Your reference will be the clerking manual, management guide, procedure protocol and dosage guidelines. Please download and print it out. Thank you.

Reiterations

Due to some security reasons most of the Dropbox links are broken. Here now I will attempt to reshare some my manuals. All mistakes are mine and mine alone and they shouldn't be used as a replacement for seeing a trained physician. If you spot mistakes please inform me in the comments.

1. For the house officer who has no idea what to ask when clerking patients: CLERKING MANUAL
2. For the house officer who have no idea what are the basic managements: MANAGEMENT GUIDE
3. For the house officer who doesn't know what to do next when assisting the MO: PROCEDURE PROTOCOL 
4. For the house officer who can't seem to get in their heads the dosages of drugs: DOSAGE GUIDELINE
5. For the house officer having some language barrier in:
• Tamil
• Iban

Now there are no excuses. If you got any ideas for any more projects or if there are points of contention, please let me know in the comments. Thank you.

Review of Systems in the Iban language

The following work (Review of Systems in the Iban Language) is dedicated to all the house officers who will be sent to Sarawak for the district posting. I would like to thank Mr Morris for the Iban language translation of the review of systems. Any mistakes are all mine as it would mean that I have explained the term properly to Mr Morris is not a medical personnel. If there is anyone out there who can improve on the translation and the terms used and also provide for the missing translation please make mention of it in the comments section. Thank you very much.

Nephrology teaching 10 July, 2014

These are the slides for the introduction to nephrology. Dear readers I humbly request to inform me of any mistakes. Thank you.

Sorry for long time no post

Dear all,
My sincere apologies for not posting for a long while as I have been busy collecting new material and hopefully working on a review and new edition to the currently available notes. Please do continue to give you constructive comments and notify me of mistakes. As for downloading the notes. There seem to have been a problem with Dropbox so I am not able to share the Management Guide and Clerking Manual. Instead I am sharing using Google Drive. You can get them from the Resource Link List on the upper right hand corner. Thank you.

Systems review in transliterated Tamil

I would like to thank Father Eisu Das for providing the translation even through he has a very busy schedule. We hope that on a busy night when one can't find a Tamil-speaking medical officer or house officer, there will be place for the use of this translated and transliterated systems review. Having at least basic symptoms enables one to come to a diagnosis and start treatment. Please inform me in the comments if there are any mistakes. I will gladly correct them. All mistakes are mine and sincerely mine alone.

Systems review in Tamil

House Officer Teaching

Dear beloved House Officers,
There will be teaching tomorrow at 5.30pm, Thursday the 27th of March, 2014. We will be covering on some clerking and basic management of common problems in the ward. Thank you.

Know you generics

When a House Officer write a prescription he or she must follow the following format:
[dosage form] [generic name of drug] ([brand name]) [dosage] [frequency]
For example:
IV ceftriaxone (Rocephine) 2g bd
IV piperacillin-tazobactam (Tazocin) 4.5g qid
In order to do this one must know your generics and hopefully this document will help.

There is no one size fit all

Should we go back to the on-call system? The modified on-call system with pm off? With am off? 75-hours shift? 65-hours shift? 3 shifts per day ala Accident and Emergency? There are so many variations but at the end of the day there is no one-size-fit-all. Each hospital in the country has different staffing, facilities, training, equipment and circumstances. We have to make the best that we could with what we have and not what we hope or wish for. However there is one thing I am confident about that the best person to make such decisions is not some administrator sequestered in an air-conditioned office but the people on the ground reacting to changing situations by the minute. I believe that the best person is the people on the ground as represented by the head of department. Each department will have its own staffing needs in even the same hospital. I believe the Honourable Minister of Health and the Director-General should give the Heads of Departments the discretion to decide which system will be best suited for their department currently with the available resources. They should trust the Heads of Departments being the leaders in the field to be able to make the wisest and best decisions.

Probational release

Have you ever had a House Officer that was so terrible that you are in a dilemma? The said person is not good enough to be released and releasing him would be unfair to the next department and the public at large. However if you don't release said person but extend the person in your department it will rile up all the senior people, create havoc in the rostering and basically slow down the whole department. Since medical gets 80% of the first-posters, you can't really expect medical to keep and train all the weak ones. What should you do then? Either action is destructive. I believe we should be given a third option which I will call the probational release.
        With probational release, instead of immediately serving the extension the House Officer is given an opportunity to go to other departments to pick up more skills and experience before coming back to medical to serve his extension. Thus the other departments share in the training of weaker ones.
         For the House Officer they are given the opportunity to pass with their friends thus avoiding stigmatisation, they are also given release from the current batch of senior doctors so that by the time they return they are less likely to be with senior people who are victimising them (if that be the case) and thus with additional skills and experience, they will be able to give a better impression to a different batch of senior doctors.
        For the senior doctors in medical this will be a breather and given time we will have forgiven and forgotten the crazy things that got the House Officer extended in the first place thus making it easier to give said person a chance to prove his or herself. And of course all the other departments will have an opportunity to have input into this person's training. Looks like a win-win-win situation for me.

History-taking, summarising and presenting

History taking:

1. Pre-morbids (D2FMC3):
1. Duration
2. Diagnosis
3. follow-up
4. Medication
5. Compliance
6. Control
7. Complications
2. Presenting complaints:
1. Open questioning
2. Closed questioning: relevant negatives

Summarising:

1. How was the diagnosis made?
2. What was done and why.
3. What you doing and why.
4. What you will be doing and why.

Presenting:

1. History:
1. Presenting symptoms improving or not?
2. Side-effects of your treatment.
3. Basic functions:
1. Eat
2. Drink
3. Sleep
4. Pass motion
5. Pass water
2. Vital signs and observations.
3. Examination.
4. Investigations results.
5. Plan.

Management guide

This is the draft version of the management guide for House Officers. In the old days we used to produce our own management guide but nowadays House Officers rarely do this so I produced this PDF file as a guide to them.

In addition to that it is time to bump up the older stuff I did. These will be the nucleus of Hospital Klang House Officer guide:

The clerking manual

The procedure guide

The medication guide

All these are still in draft version but I hope it still will be helpful. Do contact me regarding mistakes in the comments section so I can correct them.

Teaching tomorrow

Dear beloved house officers,
Tomorrow, Wednesday at 5.30pm the 19th of March, 2014 there will be teaching for house officers. I will compering some basic things to do in the ward. Such as the basics of clerking, how to summarise and present a case.

Today's house officer teaching slides

The teaching slides for the house officer teaching on the 27th of February, 2014. The subject was the first part of an overview of neurology.

House Officer Teaching on 27 February, 2014

Ladies and gentlemen,
There will be an overview of neurological diseases tomorrow Thursday at 5.30pm, 27th February, 2014 at the 9th floor of the hospital.

To control the current outbreak we must look to the past and learn its lessons.

With the current dengue outbreak, many have asked what can be done? The question has actually been answered more than 100 years ago albeit in a fashion considered crude today.  What happened was that we have failed to integrate the lessons learnt from the building of the Panama Canal as taught by Dr William Gorgas.
   The Panama Canal took 34 years to build. During that time almost 37 thousand people died (this works out to 1100 persons a year) while building the canal mainly from vector-borne diseases such as malaria and yellow fever (which is a cousin of dengue, both being flaviviruses). While John Frank Stevens was the gentleman who decided on the lock-based canal that enabled the canal to be built, it was Dr William Gorgas' efforts to control malaria and yellow fever that enabled the workers to fulfil their tasks. Till today more than 100 years later the Panama Canal area is still an area free from malaria and yellow fever.
   What is there left to do for us but to learn the lessons of the past.

The Art of Presenting

The house officer is required to present the case he or she has reviewed in the morning to either the medical officer or the clinical specialist. Only by doing this does the house officer learn the pertinent and important points of the case. He or she will also learn what is to be discarded and what must be included. When a senior doctor ask a house officer if he or she knows a case, what is meant is not whether he or she can rattle off the problem list brainlessly but to know a case one must not only be able list out the problems but he or she must be able to tell:

1. How the diagnosis is reached
2. What was done
3. What you are doing
4. What you are planning to do

   When presenting for the first time more information is presented for the pre-morbids, presenting complaints and history of presenting complaint.
   To start a presentation mention:

1. Age and sex
2. Pre-morbids including duration, follow-up and treatment
3. Presenting complaint
4. Relevant negatives if this is a presentation for the first time
5. The examination and investigations leading to the main diagnosis
6. What was done, what you are doing
7. Other diagnosis in the same format
8. Patient's current condition: asking how are the presenting symptoms now, any adverse effects of treatment, and the basic functions which are eat, drink, sleep, bowel motion and passing urine.
9. Latest vital signs
10. Latest examination findings
11. Latest investigation results with comments on whether they are improving or not.
12. What you will be doing

Example:
" This is a 74 Chinese gentleman. He has diabetes mellitus for 7 years on OHA, hypertension for 2 years on treatment; both under MOPD, gastritis for 5 years no OGDS done, and IHD for 3 years under IJN; angiogram done in 2011 showing 3 vessel disease,"
" He presented to us with a 3 day history of cough, fever and greenish sputum. Chest examination revealed bibasal crepitations, CXR showed bihilar haziness with total white count of 13, CRP of 100 temperature of 38 degrees,"
"He was treated for community-acquired pneumonia. He was started of IV ceftriaxone 2g OD and tab azithromycin 500mg OD on 19 February. Currently day 2. On admission it was noted that he was hypotensive. He was started on IVI noradrenaline on the 19th until today the 20th which we just taken off because the BP has stabilised. Blood culture and sensitivity taken on 19th for which results are still pending,"
" It was also noted that his creatinine has jumped to 300 from a baseline of 180 3 months ago. We are treating for AKI secondary to sepsis and dehydration with 2 pints of normal saline over 24 hours. Glucose was persistently more than 15 but there was no acidosis, ketones was negative and serum osmolarity was normal. He was treated for uncontrolled DM for which we started IVI insulin on the 19th also,"
" Currently, the fever has resolved, cough has reduced and the sputum has turn from green to white. He had no symptoms of hypoglycaemia. He is able to tolerate orally, sleep well and have no problems with either bowel motion or passing urine,"
" His blood pressure is 130/80 without inotrope, heart 70, temperature afebrile, glucometer showed sugar of 8.0"
" Lungs are much clearer but still some residual left basal crepitations,"
" TWC has reduced to 8, creatinine improved from 285 to 230"
" I am planning to continue the current antibiotics, trace the blood culture and sensitivity, his appetite has also improved so I am planning to take off the drip."
  I don't know about you but this is how I like it presented so house officers please take note if you are in my ward. Anyone would care to share how they present and can it top this for completeness?

Teaching on Endocrinological Diseases done on 19th February, 2014

These are the slides for the House Officer Teaching done on 19th February, 2014. It was an introduction to endocrinological diseases.

Powerpoint slides for the teaching on 28th January, 2014

These are the slides for the teaching on diabetes mellitus and hypertension that was done on 28th January, 2014. Your kind constructive comments are appreciated.

House Officer Teaching on 22nd January 2014

This was the overview of respiratory diseases that I did on the 22nd of January, 2014. It is still a work in progress and will probably go through many editions. Constructive comments are appreciated.

Systems Review in Mandarin

Sorry for the hiatus. I was celebrating Chinese New Year. Anyway I would like to thank my medical officer, Dr Chua Ping Lik for helping with this translation. I hope that this would be helpful. Systems review in Mandarin. Please comment and send in corrections. This is still a work in progress but we hope it will benefit many and serves as a reference.

Helminths

This is a short note on helminthic infection and its treatment.

House Officer Teaching

To all the House Officers,
I will be doing my hopefully regular weekly teaching on Tuesday 21st January, 2014 at 5.30pm. Our topic will be an overview of respiratory diseases and if I have time how write down a proper diagnosis so that it will codeable base on ICD-10.

An overview of cardiovascular diseases

This is the start of series where I hope to provide an overview of diseases affecting different systems in order to provide the house officers with a view of the grand scheme of things instead of a great amount of scattered details everywhere. One illustration I used today is just as we can't eat all three meals in one go but over the course of one day, we also can't be eating one months worth of food in a few days. I use this to illustrate the fact the human brain like the human stomach cannot accommodate so much information within short period of time. So studying last minute is mostly futile unless you are a known genius. Anyway today i gave a brief overview of cardiovascular diseases. Hopefully this easily digestible for one meal.

Of languages without a dictionary

While I was researching about the 3 most widely-spoken languages of Sarawak and the 3 most widely-spoken languages of Sabah. Only Iban and Kadazan have their own dictionaries according to Ethnologue and both of their dictionaries are out-of-print. Melanau, Bidayuh, Murut , and Bajau do not have their own dictionaries.
The language statuses for them are a follows: Iban is 3(Wider communication), Bidayuh 5(Developing), Melanau 3(Wider communication), Kadazandusun 5(Developing), Bajau 6B(threatened) and Murut 6B(threatened). The smaller the number the greater the usage. For example English would be 0.
This is the scale as explained in Ethnologue.
If this is the status of the major languages one shudders to think of the other smaller language groups. However one can also look at it on a positive note and treat this as a call to arms for people who use it as a first language to develop their mother tongue. In order to do so one need not look any further than the history of English.
In a nutshell English was a language that even the ruling and intellectual elites of England did not use. Latin and French was much preferred. How did it become so dominant? One can say it was an accident of luck and history but then it wouldn't be instructive and denigrate the diligence of the English in developing their language. Though all the steps were more or less concurrent but for simplicity sake I have spread them out.
The first step actually involves the compiling of a dictionary. This enables the standardisation of the language and spelling. Second involves the translation of important foreign works into the language. This not only enriches the vocabulary of the language through borrowing but also the minds of the speakers with new ideas, concepts, creations and inventions. This paved the way for the indigenous production and creation of not only works of literature but also scientific discoveries. The works of literature incentivised mass literacy and the scientific advancement enabled it to conquer other nations as well as forcing the intellectual elite of other nations to learn English in order to catch up. Currently the United States of America is holding the baton upholding the place of English in the world with it dominance of scientific advancement and mass media. This is a simplification but if we are to learn anything the lesson would be a need for lexicographers in Sabah and Sarawak to start compiling.

D2FMC3

This is the mnemonic that I teach my house officers to remember questions that they need to ask when they going through the past medical history. It stands for duration, diagnosis, follow-up, medications, compliance, control and complications.

DURATION: It is important to know the durations as the longer that once has the illness the more likely that the person has already developed complications from it. It is better to state the year that the diagnosis was made than a vague number such as 7 years.

DIAGNOSIS: A lot of the times the patient may claim to have a certain condition for an x number of years however we must be aware that they are not healthcare professionals and sometimes even healthcare professionals may have misdiagnosed the patient. In this section the house officer is encouraged to ask for the characteristic of the disease, by whom and where was the patient diagnosed. A diagnosis in a pharmacy is less credible than in UMMC. For example, in the case of bronchial asthma the house officer is encouraged to ask about childhood onset, family history, allergic rhinitis, atopic dermatitis and allergies.

FOLLOW-UP: Unfortunately where you are followed-up does make a difference and knowing this is useful when discharging the patient because we need to know where to send them back to.

MEDICATIONS: Please list the medications the patient is on.

COMPLIANCE: Whether the patient is taking his or her medications regularly? And if not why? Is it due to side effects? Are there any other problems that the patient faces when taking medications?

CONTROL: If you bother to ask you will surprised how well the patient knows his or her sugar level. They may not know what is good control but they do know the levels. For asthma one use the GINA classification.

COMPLICATIONS: This is self-explanatory but some conditions have more of it than others. For example intubation and pneumothorax will be the complications for bronchial asthma. Whereas for diabetes mellitus they include diabetic ketoacidosis, hypoglycaemia, diabetic retinopathy, myopathy, peripheral neuropathy, nephropathy, gastropathy, cataracts and so on.

D2FMC3

Medication guide

In paediatrics they have Frank Shann. I am not claiming to be anywhere near as good but for the purpose of our Hospital Klang what I did was took the pharmaceutical master list, took out all the drugs not commonly used in medical, put in their dosage form, starting dose, maximum dose, renal dose and some notes. I ale made a separate list for generic names. This is no way medical advise and you should always always consult your regular doctor.
House officer dosage guideline
Know your generics

Husband-friendly labour room

A husband-friendly labour room is one that allows the husband to accompany the wife while she is in labour. But for the life of me I do not know why they translate is as rakan suami instead of mesra suami. Mesra suami will connote that the labour room is friendly to husbands while I feel that rakan suami is better translated as husband's friend. So I would interpret a 'wad bersalin rakan suami' as a labour room that allows the husband's friend to enter but not the husband. 'Mesra suami' sounds much better.

Old uncles and aunties in the interior.

Sometimes they speak only there own mother tongue. We can't blame them because they are from an era where education was not so accessible. As doctors we are suppose to be one reaching out to people and not expect them reaching up to us. I have been preparing a translation of the terms used in the systems review so even though we can't get a full and perfect history at least we can get some basic symptoms that can reasonably lead to a diagnosis. I now planning to do translations into Mandarin, Tamil, Iban, Melanau, Kadazandusun, Murut and Bajau. So far the only I have is down by a staff nurse in my ward Pn Cressida Cristy. I would like to publicly thank her for doing the Bahasa Bidayuh Bukar-Sadong translation. I hope this can also be used as primer for the doctor sent to the interior to learn the local language.
Systems review in Bahasa Bidayuh Bukar-Sadong
If anyone wants to help in the effort I would appreciate if we can get it in other languages and together we help out fellow doctors in the interior.
Systems review template

Are there more than enough doctors in Malaysia?

The answer will depend on who you ask: if you ask a certain cardiologist and rheaumatologist then we have more than enough. If however you ask the director general of the Ministry of Health in Malaysia then the answer is no. But let me posit to you that both are the wrong answers to the wrong question. Both are merely playing with the numbers game.

Malaysia will be hitting the target of 1 doctor to 400 persons in few years time and some say we have already reached that target but what does that mean? Germany has 1 doctor to 300 persons but do they claim that they have enough doctors? On there contrary they are still complaining about the lack of manpower. You see this is what happens when you ask the wrong questions; nobody is any wiser. Everyone is arguing among themselves, getting all worked up and hurt, and thinking that they are right when in actual fact both are right and wrong at the same time. Lets get to the fundamental facts:

1. There are more than enough doctors of dubious quality and work attitude.
2. There are more than enough house officers in the big popular hospitals.
3. There are not enough house officers in the so-called 'unpopular' ones.
4. There are not enough senior doctors to train and supervise the junior ones. 
5. There are not enough sub-specialists to train more sub-specialists hence the long waiting period for even subspecialties that are experiencing acute shortages.
6. There are more than enough specialists and sub-specialists in the private sector and you can see the action of some to protect their rice bowl.
7. There are not enough specialists and sub-specialists in the government sector leading to overwork, burn-out and finally them quitting government service.

As you can see both parties are asking the wrong questions and giving the wrong answers. This is why both parties seem to think they are right when both are wrong at the same time because half of the facts support their position but the truth is the other half don't. To improve our health system we have to stop reinventing the wheel and look at more advance nations such as France, Germany, Switzerland, the Netherlands, and Denmark to learn from their mistakes and successes. These are not just any countries. These are countries with high satisfaction ratings from the people and also highly rated by the WHO. I address some of the things we can learn from there countries in a future posts but suffice to say we should stop asking the wrong questions and start asking the following:

1. Do we have enough doctors that we can give patients an appointment within three months fro their follow-up?
2. Do we have enough specialists so that everyone is seen by a specialist at least once a year?
3. Do we have enough cardiologists so that EVERYONE including those who cannot pay is at most one hour away from a catheter lab?
4. Do we have enough endoscopists so that everyone who needs a scope for a suspected bleed gets it on the day itself and not some unspecified time in the future?

There are more questions but I think you get what I am trying to get at. It is idealistic and maybe a tad unachievable but if we don't set high standards how are we going to achieve progress. Remember the best students don't compare themselves with the the ones from the bottom of the class like what our political elite do, they aim to be number one or close to it. They don't aim for a pass or compare themselves to Zimbabwe; they aim for 90%, they aim for A1, they aim for a gold medal and even if they don't achieve it in one semester, they persevere and aim to move up the rankings every year until they are near the top in the end. That is progress.

Migrant workers

We have many foreign workers in our hospitals but yet many times we tend to forget that they also bleed red and are also the Children of God. Does one think they really wanted to leave their homes, families and friend in order to gain a better life for those left behind? Beware one day the tables may turn and lest we regret mistreating our guest workers.
Since they most commonly are admitted to the dengue ward for fever I have prepared some translated questions so we can at least get some basic history. They include:
Fever clerking in Bengali
Fever clerking in Burmese
Fever clerking in Nepali
If anyone knows of any other languages of the migrant workers and wish to contribute, the template is here:
Fever clerking template

How to write a formal letter.

Dear House Officers,
I don't know if they still teach you all how to write a formal letter but from what I gather most don't know how to or they use the wrong template. So below I am providing you all with a template which I think will serve you well. In addition to that I think it actually looks better.
Model IJN formal referral letter.
As you can see in the letter other than the format I included the premorbids, presenting complaint, everything that was done for the patient, latest investigation results, and latest medications. I have also included the reason I am sending the patient there. This is framework for radiological and blood requests forms, referral letters and other documentations.

Paradigm shift in training procedures.

It is unfortunate that nowadays that house officers do not do as much procedures as we used to. I think there is good and bad. In the bad old days we were barely supervised and it was through trial and error that we perfect out technique much to the detriment of patients. Nowadays there is better supervision and house officers are better rested but with so many of them many will never have the chance to do a procedure. So when it comes to their turn to assist many house officers are blur. What I attempt to do with the protocol is to provide a step-by-step guide to doing some basic procedures so even if the house officers have never seen the procedure before he or she will have a vague idea of the items needed and the basic steps and thus if they read and understand they will more likely to know what are the next steps so making them much more efficient assistants and soon operators themselves.
Unfortunately the paradigm has changed no longer can one solely depend on learning by accumulating experience as there are now so many house officers that there are not enough procedures to go round. We cannot expect the house officers to learn as we do instead we must shift our paradigm. Times have changed and in order to alleviate this problem there must be a combination of spoon-feeding and with the modern technology multimedia such as through blogs, Youtube and so on as well some good old-fashioned initiative and interest.
House officer procedure protocol
Nota bene: This blogpost and the procedure protocol do not constitute medical advice implicitly or explicitly. It is only for educational purposes.

Clerking

One of the primary roles of the house officer is clerking. Most times the person with best opportunity to get a full and complete history will be the house officers first attending to the patient. Therefore they must be trained and equipped to take a full and proper history which not only tease out the positive symptoms but also the relevant negatives. If they fail to do so a golden opportunity would have passed for the patient's stroke may worsen and render him or her aphasic, or respirator distress intervene and cause the intubation of the patient.
The following clerking manual is based on my old MRCP PACES notes on history-taking. I have taken the liberty of arranging the symptoms in the form of differential diagnosis. This manual as I often repeat is bicycle training wheel. When the house officer is new he or she is encouraged to strictly adhere and ask all the differential diagnosis so as not to miss something that may kill the patient. However once they have reach a certain level of competence and confidence then they may start to develop their own styles. Even then they must still cover all the relevant negatives.
The clerking manual
Nota bene: This blogpost and the manual in no way constitutes any medical advice implicit or explicit. It is only for educations purposes.

Why am I starting this blog?

Over the past year I have been making my small insignificant contributions to improving house officers' training in the ward and department. I have noticed shortfalls in their training and the following materials are my attempt to address then. These are not perfect and I would most welcome constructive feedback and criticism to improve the material. Please feel free to share if you have materials of your own. It is not a one-man-show together we can make housemanship more enjoyable and educational.