The Coffee-stained Pages: Singapore Houseman Guide (HO Guide)

Disclaimer: The views expressed in this post are mine and do not reflect the views of the Hospital/MOH.

Dear incoming HOs from overseas universities,

Before coming to Singapore, we were 'warned' multiple times regarding how hard life will be for a houseman/PGY1 (post-graduate year one) in Singapore, especially for those graduated from the overseas universities, a.k.a. the international medical graduates (IMG). During an orientation session, we were told that it will take 4-6 months for an IMG to be adapted to the local system, and an even longer period to be as good as the local graduates. Coming from the NHS, which is as multi-national as a healthcare system could be, I couldn't believe it - I mean, we managed to work with people from so many countries around the world, how would a more homogenous system (one that is much closer to my own culture) be an issue?

Well, for the first few months as an HO, I cried almost on a daily/weekly basis due to work-related matters. My fellow IMG HO and I almost started a counter on 'I-wanna-quit-my-job' to chart the frequency of us saying that phrase throughout the day as we were busy fighting fire on the wards, while the local graduates HO, who also demonstrated signs of struggle at times, had an incredulous look their face as they watched how we were struggling all the time. Eg. The panics we had while managing a simple hyperkalaemia, while the local grads went 'What? Just give the HyperK kit lah...!' but what is a hyperK kit?!

Honestly, the MOHH staffs and the hospitals' HR were really good and efficient in easing the IMGs into the system. There were barely any issues with the admin matters (the SMC registration, the Employment pass etc). They even organised orientation days (with really good food) and shadowing days for us. Our seniors were very understanding and caring towards us, though understandably frustrated at our incompetence at times. And of course, our fellow HOs (who were in their 2nd posting when the UK IMGs started), who are the most important unsung heroes of the year, who saved our lives and our patients' lives as we survived housemanship together. We also received a copy of the CTSP handbook (call-to-see-patient) and HO survival Guide from the local grads to help us during calls. However, there still seems to be a gap, esp for a non-Singaporean like me, that took me months to fill up, to function properly as a PGY1. Now that I completed PGY1 (with all the bittersweet memories and struggles still fresh in my mind), I hope that this post, alongside all the existing materials, would be in any way helpful to you, as you navigate this complex healthcare system.

NB: This is an attempt to fill in the gaps for IMGs, on top the existing guides, please read the guides before starting!

The Public Healthcare System

There are 3 healthcare groups, aka 'clusters', that manage the 10 public hospitals in Singapore. They are Singhealth, National University Health System (NUHS) and National Health Group (NHG). The hospitals are:
- 7 general hospitals (Singhealth - SGH, CGH, SKH; NUHS - NUH, NTFGH; NHG - TTSH, KTPH)
- 1 integrated hospital (NUHS - Alexandra Hospital)
- 1 women's and children's hospital (Singhealth - KKH)
- 1 psychiatric hospital (IMH)

At PGY1 level, these clusters may not affect our daily life, but as one progresses up the ladder, each cluster has its own residency programme for different specialties, which may differ, but that is a topic for another day.

To learn more about the structure:
- https://www.moh.gov.sg/our-healthcare-system/healthcare-services-and-facilities
- Wikipedia - Healthcare in Singapore - has a good summary

Who is in your team? (aka 'Firm' in the UK)

Depending on the hospital and the specialty you are posted to, the team structure may defer.

A usual medical team consists of:
- 1x senior consultant (SC)/Consultant (C)/ Associate consultant (AC)
- 1x registrar
- 1-2 Medical Officers (MO)
- 1-4 House Officers (HO)
- +/- Nurse clinician (if you're lucky to have one, will talk more about it below)

A usual surgical team consists of:
- 2-6 consultants
- 1 registrar
- 1 MO
- 1-2 HOs
- +/- Nurse clinician

While the hierarchy in the UK is generally quite flat, there is generally a steeper sense of hierarchy in the SG system, esp in the surgical teams. Before asking your boss out of coffee or commenting on his/her outfit, it would be good to gauge how your bosses are like and ask them what is expected of you.

Aside from your team, you will work with many other healthcare professionals, who will try their best to make your daily life better. Briefly, they are:

Nurses: Ward sister, staff nurse (SN), registered nurse (RN), nurse assistants
Nurse clinicians - Usually a senior and specialised nurse. They are able to deal with nursing matters + are able to do most of the things you are able to do (except doing prescriptions, MCs etc...things that require your MCR number).
Physiotherapist (PT) - manages your patient's rehab, focusing mainly on the strengthening of the body. Commonly referred for therapeutic exercises and chest physio. Able to prescribe walking aids/incentive spirometry and recommend when CH is needed for further recovery.
Occupational therapist (OT) - manages your patient's rehab, focusing mainly on improving patient's ability for independent living (transfer from chair-bed, carrying of oxygen cylinder), able to prescribe splints/mobility aids (eg scooters) and recommend when CH is needed for further recovery.
Medical Social Workers (MSW) - for psychosocial support of the patient and family, financial support, discharge planning (application for a helper at home) (Click here to learn more)
Dietitians - for optimising your patient's diet (soft diet, normal diet) and also part of the parenteral nutrition team
Speech Therapist (aka SALT) - for swallowing and speech assessment and therapy. Important for them to assess first if you think your patient is at risk of choking when eating/drinking!
Pharmacists - Call them for any prescription related matters/doubts. They will usually look through your prescription and call you if any amendments/clarifications needed. During the night, there is usually a pharmacist on-call to save you through your calls too.
Porters, podiatrists, radiographers, respiratory therapists etc

This list is not exhaustive!

What are the working hours like and what do you do on a daily basis?

Firstly, please bid farewell to an-8am-start. (Sorry mate!)
Depending on the specialty you are in and the workload, the working hours differ but are generally longer than the ones in the UK. Also, surgical postings tend to have very long hours (the longest I had was 4am to 9.30pm).

Eg. A typical day in a medical team
6.30 am - Arrive at work. Discuss with HO/MOs in your team to allocate patients you need to take care of for the day. Start pre-rounding on the computer. For each patient, read through the overnight events, vitals, investigation results and put in a 'DRAFT ' morning entry. (Though a draft entry is not necessary, I like to put it before the ward round starts to allow more time for 'changes' (i.e. 'jobs') later on. To make a ward round more efficient, I would also see as many patients as I could and examine them before the round starts so my consultants may not need to go through all the steps again during the round.

8 am - Start of ward round. Present your patients and note down the changes. Clarify with your boss for anything that you don't understand (or you may find it difficult to do the changes later on).
Eg.
- Referral: What exactly is the question/purpose for this referral?
- Radiology: What are we looking for in this scan? How soon should it be done? CT - with or without contrast?
- PT/OT - Weight-bearing status of the patient after the surgery (esp relevant for ortho)?

10 am - Coffee round. When your boss hands you money after the ward round to order drinks, please do not say 'Oh, I already had my drink this morning.' Take the money and as the most junior member of the team, this is your unofficial job - take the drink orders from all members of the team and order (Good chance to grab something to eat too!) Usually, we will sit down with the boss and go through our list of changes, clarify any further doubts and have a short teaching session.

10.30 am - Time to get cracking on the changes. Your ability to prioritise is the key here! This is how I like to prioritise:
- Anything the sickies urgently need: scans, referral, drugs, take blood
- Referrals a.k.a. Blue Letters. Please get the referrals out ideally before 11am. (More on how to refer below)
- Discharge patients - order the discharge medications ('TTOs') to allow the pharmacist sufficient time to look through your prescriptions and dispense them > complete discharge summary > MC > any memos for outpatient follow up
- Order any investigations needed
- Update patient and family
- Review any CTSPs or clerk new patients (sometimes this is done by the MO)

1 pm - Lunch/Teaching sessions. Depending on the posting you do, the department will usually arrange some teaching (often with food).

2 pm - Complete your changes and trace investigation results (aka 'chase results' in UK lingo). Put up a draft PM entry.

3.30 pm - Exit round. Usually the bosses will do a paper round for the stable patients. For the sickies/new admits, bring the boss to see physically if they want to.

4 pm - Do exit round changes.

5 pm - Hopefully....you're done with the changes. Handover properly and go home! If you're on call, this is when your phone will start ringing non-stop.

Surgical postings will differ slightly by having an earlier ward round as your bosses need to go to the OT (the earliest I started putting morning entry was 4am) and having a later exit round (wait the OT list of the day to end).

How to write a morning entry?

I personally find the entries in the UK and SG differ quite a bit. So this is just an example of the format of a morning entry:

<The team you're in > AM WR
s/b <insert the consultant/reg name after round>
Overnight events in brief
Subjective
Objective/On examination (O/E)
Investigation results
Issues list/Impression
Plan - Nursing, Allied health, Investigations (Ix), Management (Mx), Discharge plan

It may be difficult to make a plan when you first started off, but as time goes by, you will learn to make a comprehensive plan and you just need to confirm with your boss re the plan before executing them.

One thing I find very different as compared to a UK entry - the Nursing plans.
The nurses usually are very good at coming up with their own plan, however, for clarity sake, certains points are better written down in your entries, or the nurses may call you up to clarify with you:
1. Para - how often to take the vitals. eg Q4hrly para + SpO2 - to take vitals 4 hourly.
2. H/C - Hypocount. How often to measure the blood glucose. eg H/C TDS + 10 - to take hypocount 3 times a day and at 10pm.
3. Diet - Nil by mouth (NBM), clear feeds, full feeds, soft diet, full diet, diet of choice (DOC)
4. IO chart - intake-output chart
5. Regular turning, regular orientation
6. Weight bearing status (WB) - eg FWBAT (full weight bear as tolerated)
7. Anything else you would like the nursing staff to take note of

The style of an AM entry differs from person to person. You will find your own format/style soon enough. I find writing a clear, well-formatted entry really helpful for everyone involved in the patient's care, and it will also reduce the need for the nursing staffs to call you up to clarify what was wrote in the entry. So, take some time to refine this art.

How to write an exit entry?

No need to be as comprehensive as the morning entry.
Just key in any updates/results traced, and any changes in plan as compared to the morning ones.

What is a Blue Letter?

Please read the HO Survival Guide on Blue Letter.

This is basically a referral letter, from your team, to your senior colleagues, seeking their expertise. I find it helpful for your seniors to start your blue letter by explicitly stating the question you have. For example,

Dear Colleague,
Thank you for seeing this XXyo lady who has been admitted for XX.
Question: How do you ______________?
SBAR
Thank you once again.

Discharge planning

This is what takes up the most time in an HO's day - how to get the patient home. You should start thinking about this as soon as the patient is admitted under your team. As the community services available in the UK are very different from the ones in Singapore, I took quite some time to learn about this. The common avenues for discharge are
1. Home
2. Home with a caregiver. May require caregiver training from the nursing staffs/PT/OT before home. It is common for the elderly in SG to have a dedicated helper.
3. The Community Hospitals, aka 'Com Hos'/ CH, where patients can receive step-down care when acute care in the general hospital is no longer needed, i.e. when your patient is well and stable on the ward, but not exactly well enough to go home yet, then your boss (consultant/reg) will ask you to discharge plan. You may need to apply for the CH via the Agency for Integrated Care (AIC). Common indications for going to a CH are rehabilitation after surgery and wound care.
The CHs available are: Outram CH, Jurong CH, Yishun CH, Sengkang CH, Bright Vision CH, St Andrew CH, Renci CH, St Luke CH and AMK CH.
4. Nursing Home

Tip: If patient is ready for discharge but is unable to take care of him/herself at home and has no caregiver available, you will need to discuss with the family re the options. Get the MSW onboard earlier if you foresee any discharge issue. There is a service called Interim Care Service (ICS), where an interval helper takes care of the patient at home until a more permanent caregiver is available.
For more community-based services - https://www.aic.sg/

Common brand names

'Please order Nexium.' 'Nex what?'
Unlike UK which uses the generic name for most drugs, there are certain medications of a particular brand that are so widely used that everyone just uses their brand name instead.

Plavix - Clopidogrel
Lasix - Furosemide
Nexium - Esomeprazole
Losec - Omeprazole
Clexane - Enoxaparin
Dulcolax - Bisacodyl

Piriton - chlorpheramine

Telfast - fexofenadine

Ketotop - ketoprofen plaster

Maxolon - metoclopramide

Fluimucil - acetylcysteine

Anarex - Orphenadrine Citrate and Paracetamol

Arcoxia - Etoricoxib

Epilim - sodium valproate

Keppra - levetiracetam

Augmentin - Amoxicillin/Clavulanic acid
Rocephin - Ceftriaxone
Flagyl - Metronidazole
Tazocin - Piperacillin/Tazobactam
Fortum - Ceftazidime
Klacid - Clarithromycin
Bactrim - Co-trimoxazole

Please don't stress over this. You will remember them as they get repeated multiple times throughout the day. And if you really don't know, just ask!

Common abbreviations

'Please CRIB the patient.'
I think abbreviations are not just a product of the fast-paced Singapore healthcare system, rather the Singaporean culture as a whole. Some abbreviations make sense, some are just downright absurd. It took me at least 4 months to learn most of the abbreviations I see on the daily entries from various parties. Again, if you don't know, just ask your colleague sitting next to you. It's completely acceptable to ask!

s/b - seen by
H/C - hypocount, blood glucose measurement
Para - parameters ie vitals
I/O - input-output
CRIB - complete rest in bed
FWBAT - full weight bear as tolerated
NWB - non weight bear
DOC - diet of choice
Nx- nursing
Ix - investigations
Mx - management
VS Afeb - vitals stable, afebrile
PEARL - pupils equal and reactive to light
FROM - full range of motion (joints, ocular movement)
L LL/UL - Left lower limb, upper limb
TOC - Take out the catheter
STO - Stitch take out
BO - Bowel open / BNO - Bowel not open
PU - pass urine / NPU - did not pass urine

cm - Latin: Cras Mane, meaning tomorrow morning; coming morning

SOOB - sit out of bed

SOBOE - shortness of breath on exertion

CAP/HAP - Community-acquired pneumonia, hospital acquired pneumonia

CGT - caregiver training

WS - walking stick

WF - walking frame

QS - quad stick

CAD - Coronary artery disease

PVD - peripheral vessel disease

HTN/HLD/DM - Hypertension, hyperlipidaemia, diabetes mellitus

TTE - transthoracic echo

TEE - transoesophageal echo

MCHC Anaemia - microcytic, hypochromic anaemia

NAGMA/HAGMA - normal anion gap metabolic acidosis, high anion gap metabolic acidosis

Tw - total white

RP - renal panel

C/M/P - calcium, magnesium, phosphate

c/s - culture and sensitivity

PVRU - post-void residual urine volume

ARU - acute retention of urine

NOF# - neck of femur fracture

AKA/BKA/TMA - above knee amputation/below knee amputation/transmetatarsal amputation

POD - Post-op day

PORV - Post-op review

s/p - status post (eg s/p lap appendicectomy)

DKD - diabetic kidney disease

RRT - renal replacement therapy

SLED - Sustained low efficiency dialysis (SLED)

VI - virgin

NVD - Normal vaginal delivery

DIL - dangerously ill

CCOD - certificate of cause of death

NEHR - National Electronic Health Record (where you can get information from other clusters)

Careform/Maxward - DNACPR + not for escalation to .... (to specify)

TCU - 'To see you' - follow up
TCU .... FBC OA - To see you with full blood count done on arrival
NFU - not for follow up

Abbreviations of a few specialties that are harder to guess (not all hospitals uses these..but just in case they pop up)

ANA- Anaesthesia
AIM - advanced internal medicine
CVM - Cardiovascular medicine
RES/RCCM - Respiratory Medicine
REN - Renal Medicine
GAS - Gastroenterology
DER - Dermatology
RHI - Rheumatology
END- Endocrine
INF - Infectious disease
GER/GRM - Geriatric medicine
PLM - Palliative Medicine
CTVS - Cardiothoracic and Vascular Surgery
NES - Neurosurgery
PRAS/PLS - Plastic surgery
CLR/CRS - Colorectal surgery
UGI - Upper Gastrointestinal surgery
OTO - Orthopaedic surgery
DVIR - Interventional radiology
DDI - Department of Diagnostic Imaging/Radiology

On-call

Yes, you work 30 hours straight.
I dread calls the most, but it is always also the time when I learn the most. When a HO is oncall, you usually work 30 hours straight. How is that possible? I could not imagine doing it too until I did it.
It starts with your usual day job, then at 5pm, your call duty starts and it continues until 8am the next day. you At 8am the next day, you continue on with your usual morning ward round and hopefully, you get to go home by lunchtime when you are done with your morning changes. It's common to turn half-zombie by the next morning, but people understand. It is not a safe working environment for both you and your patients, but this is how it is for decades. There is some effort to move away from this, especially in the NUHS, but generally, it is still a 30-hour shift.

5pm is a busy time as this is the time when everything floods in.
- Handover. Different hospitals have different systems for handover. Some do it electronically and some call up the oncall team. Ask your predecessors how this is usually done.
- Admissions. For any admits that come in after 5pm, it is your responsibility to clerk them in, unless stated otherwise in your hospital
- CTSPs (call to see patient) start to come in. The nurses may call you (your mobile phone; we don't have pagers as in the UK), or in some hospitals there is a messaging system. There is usually a CTSP guidebook for HO, specific to each hospital. It will guide you on the common CTSPs and the management plan. Please ask your predecessor/seniors for it and read through before starting work! (You won't have time to read it when you are actually CTSP for it)

Pro tips:
Before call starts
- Have a meal and a drink. If you can, have a nap too.
- Make sure the on-call roster on the system shows your name
- Contact your MO before the call starts. Please let them know you are new and ask for help whenever you feel you are out of your depth.

During call
- Have a system of keeping tracking of your changes when you're on call so you don't miss out things!
- Have a shower/nap if you can, and a snack/drink as often as you can
- Remember - the sun will rise!

Practical procedures

Setting IV Cannula aka 'IV Plug', taking bloods and doing an ECG are usually done by the FY1 in the UK. In SG, these are usually done by our very dedicated nurses, unless they have difficulty doing it. (some places may have an unspoken rule that the admission blood must be done by the HO). The nurses in SG do a LOT more to help us, so please be nice to them.

Common procedures that must be done by a doctor, i.e. you:
1. Group cross-match 'GXM'/Blood culture
2. ABG / Femoral stab
3. Male urinary catheter
4. Drain removal
5. IV medications - D50/HyperK kit/Lorazepam
6. Manual evacuation

You can technically do any procedures as long as you have sufficient supervision. (Eg IA line setting, VAC dressing change, Lumbar puncture, knee tap, PICC line culture, suturing, backslab) If you're not comfortable, don't do it or ask your MO to show you how to do it.

Also, note that: Death certification and Consent taking can only be done by the MO. The only consent you are allowed to counsel as an HO is the Blood Transfusion consent.

Symptomatic medications

This is another topic which I found myself dealing with very often, during the day and while on-call, which was not taught in the UK, mainly due to the NHS and its funding system. Patients here love love love the symptomatic medications. Yes, it doesn't cure their diseases, but if it makes our dear patients feel much better (and thus can sleep at night) and it doesn't harm them/interact with other medications, why not make them feel more at home?

Some common medications which are generally safe for HOs to prescribe while on-call:
Acetylcysteine - mucolytic 'thick phlegm'
Bromhexidine/Dextromeorphan - antitussives (avoid in elderly population)
Guaifenesin - expectorant
MMT/Buscopan - stomach cramp
Lactulose/Senna/Dulcolax - constipation
ORS/Kaolin/Probiotics/Lacteoforte - Diarrhoea
Melatonin/Chlorpheramine - insomnia
QV cream - dry skin
Ketoprofen plaster/gel - joint pain

Caution: Please be careful when using these medications. Please assess/review the patient before prescribing them!

For a list of common medications: http://www.geraldtan.com/doctors/druglist-130505.pdf

What to learn during your shadowing period:

- Structure of the hospital (toilet, food, water, lab, ED, OT, ICU/HD)
- How to put in entries, look for investigation results
- How to make referrals
- How to write a proper discharge summary
- How to order medications (inpatient and discharge)
- How to refer a patient to a community hospital

What to obtain from your predecessors before you start

- List of useful phone numbers of the hospital
- Add you into the existing communication group of the team (eg WhatsApp)
- Handover of the patients
- Tips for surviving the posting
- Ask them nicely to update the discharge summary before they end their last day

What to do before you leave a team

Usually, we change teams on a monthly basis. Before you leave the team, please:
- Update the discharge summary (a basic courtesy for the incoming HO)
- Make memos for your successor (if you're nice) just in case the patient gets discharged on day 1 of handover

Wednesday, October 23, 2019

Singapore Houseman Guide (HO Guide) - From an IMG's perspective