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Housemanship (or house officer training as we know it today) is a phase every doctor past and present has undergone. It is a time of transition, of overcoming challenges, and of forming lifelong friendships. Here, SMA News invites doctors to share a glimpse of how their respective housemanship in the different decades were. We hope that readers of all ages can take this chance to recollect your own fond memories, and appreciate the many similar and also vastly different conditions that fellow practitioners experienced.
Low Lip Ping
I started my housemanship in 1965, which at that time consisted of two postings lasting six months each.
I was first posted to Paediatrics East in Singapore General Hospital (SGH). I enjoyed the experience looking after children and would have gone on to train in paediatrics, but then those like me who had received government scholarships did not get to choose.
With three house officers (HOs) in the whole department and only two on duty on admission days, night duty was hectic, though not as much as in my next posting in surgery. Learning to insert tiny needles into scalp veins in infants for intravenous therapy was one skill I learnt. Another was performing exchange blood transfusion in infants with neonatal jaundice, to reduce jaundice and prevent kernicterus. My saddest experience was an unsuccessful resuscitation of a child who was brought in choking on some peanuts. This was a time before training in CPR was established.
I was next sent to the most feared posting - Surgery B, headed by Mr Yahya Cohen who had a reputation of chewing off the heads of all those whose performance did not satisfy him.
With only three HOs in Surgery B and the two surgical units taking turns to admit new patients, work was extremely heavy. There were so many patients that temporary beds had to be set up in the walkways on the ground floor, and we had to work nonstop with only brief breaks for a meal. There were no rooms or beds for us to take a nap, so we sometimes slept on trolleys.
Because of the limited number of HOs, we often had to work continuously for 48 hours with only one night off after. The most memorable experience there was the first time I performed a tracheostomy on a man who was choking because of head and neck injuries. With the medical officer (MO) and registrar busy in the OT, I had no choice but to proceed alone, guided only by a very experienced nursing officer, Ananda. When the registrar, Dr Diana Yip, did her rounds at midnight, she asked who did the tracheostomy and I sheepishly admitted that it was me. She commented that it was the biggest tracheostomy she had ever seen but complimented me on saving the man's life!
On another occasion, a man came in with a pneumothorax. With Ananda's help, I inserted a chest tube. At one point, the man took a deep breath suddenly during the procedure, resulting in an increase in the pneumothorax. I panicked but Ananda quickly and calmly connected the tube to the underwater seal and stabilised the situation.
On 9 August 1965, I was in the operating theatre lounge when the late Lee Kuan Yew came on TV to announce Singapore's separation from Malaysia. That, I think, was the most memorable moment during my period of housemanship in 1965.
Yeoh Swee Choo
I presented myself for my first day of paid employment at 8 am on 1 April 1979, at Ward 43, Medical Unit 1, SGH. The ward MO Dr Aw Tar Choon had been there since 7 am, and he had already completed half the ward round. I trailed him in a blur, scribbling his orders as best as I could. First day on the ward - orders, forms, more forms to fill, blue letters to write (To whom? About what? Just do it!) and a huge pile of summaries left over by the last HO. Perform chest tap – look at the X-ray, percuss and give some local anaesthesia (thankfully supervised for my first). Spinal tap – check ocular fundus , palpate, locate, skin preparation, local anaesthesia, tap (whew, clear cerebrospinal fluid). Manometer reading okay.
First night call on the first day of duty. No lunch, no dinner, no breakfast; only something on the go. The ward was on take and was filled to the rafters with two rows of fold-out beds in the middle corridor. Prof Rajasoorya and colleagues were in their final year then, and they helped me clerk cases throughout the night. An “A” class patient developed a dry cough at the stroke of midnight and had to be attended to immediately. No one in medical school had bothered to teach us about cough mixtures. “Just prescribe this”, instructed the senior staff nurse, and I escaped back to the pandemonium of Ward 43. A whole row of chronic obstructive lung disease or bronchopneumonia cases, a second row of acute pulmonary oedema, congestive cardiac failure and acute hypertensive emergencies, and then the rest made up of cerebrovascular accidents, diabetic comas (Alberti had recently described his regimen), the down-and-outs, and the “I don’t know what he has”. Three resuscitation cases did not make it that night. The skinny, resigned and sullen opium addicts with occipital calluses were memorable.
Prof Wong Poi Kwong was asked to see a young man with lobar pneumonia who could not seem to do up his buttons. He looked, smiled, tapped the thenar eminence and walked out of the ward, to everyone’s consternation. “Myotonia dystrophica” , he whispered to the medical students. The apple dropped and all the missed classical signs became glaringly evident. A 45-year-old with haemoptysis and right apical fluffy lesion – tuberculosis, of course! “Err – take the X-ray to the radiologist”, and I sullenly obeyed sometime later in the afternoon. Dr Lenny Tan demonstrated bony metastases and explained the other not-so-subtle changes of malignancy.
Next up was KK Women's and Children's Hospital (KKH) "U" unit. HOs 1, 2 and 3 were assigned to the delivery suite. HO 4 ran the rest of the hospital at night. High-risk patients in the air-conditioned wards on Level 2 and low-risk patients on Level 3. One midwife to four low-risk patients. "Clerk all patients on admission" was the instruction -a breeze compared to the long, complicated histories of the medical wards. The quickest patients to clerk were those who had no antenatal care and no history to speak of.
"U" unit had brought in cardiotocography (CTG) machines, mounted on heavy wooden carts with wheels that got entangled with whatnot on the floor. Try pushing these around. Use of a CTG machine was deemed a research project, so the HO or, if you were lucky, the helpful trainee would have to set it up and monitor it. There was no such thing as a central monitor -we had to walk up to the trace and look at it every 20 or 30 minutes. Intravenous catheters were an absent luxury - we set drips with pink needles which tissued in four hours. Deliveries took place with the birth attendant standing to the side of the bed. Black looks if you dared to ask for lithotomy. Blood-stained personal footwear was a badge of honour.
At 0400 hrs, the nurse opened the door and harsh corridor light flooded the tiny mouldy restroom when I had just put my head down. “Wake up! You have two patients to stitch and two new patients to clerk.” Need a stitching set and a standing light? Get it yourself. Positioning the patient, setting up the light, and stitching? All by yourself. We called ourselves sewing machines. Nurses were often too busy with other duties to assist, but they could be angels when you got to know them better.
There was a dark room with attempts at soundproofing where eclamptic patients were nursed. Medical students would help to check the blood pressure every 30 minutes and, as a HO, I had to stand by to titrate the Librium and Neprosol intravenous drip. Another postpartum haemorrhage in the OT – I was told to run to the lab to collect blood and run back up to the operating theatre. A few potentially difficult forceps deliveries were conducted in the OT. There were two theatres within the delivery suite. It was my duty to guard the perineum as the MO pulled and, of course, to write up the notes. On my first night call, I assisted in several forceps deliveries and three emergency caesarean sections.
Nonetheless, there was order in this frenetic work. Prof RL Tambyraja was the ward consultant and did one round in the morning and one in the afternoon. Prof SS Ratnam would do a grand round once a week. I would see him puffing on his pipe, palpating the breech presentation. Under supervision, I was allowed to do some outlet forceps deliveries and one elective caesarean delivery. The pace and pulse were invigorating and, frankly, rather exciting and inspiring. I loved the urgency and immediacy, the blood and thunder of it all. This was where I wanted to be.
The last four months of my posting were spent back in SGH, surgery "B" Unit. The surgeons were all men, with egos to match. No physician smoked, but surgeons had different ideas. And, between operations, they had time to eat and play gin rummy. Surgeons were fun – they planned lunches, dinners and holidays, and always paid for the HO.
If clerking patients in KKH was a comparative breeze, then clerking surgical admissions was a dawdle – most of the time. Acute pain one day, with fever. Nothing much else to write about. An average admission day would include about six acute appendices, two or three perforated gastric ulcers, several acute urinary retentions and renal colics, and other acute abdomens. The terrible Sengstaken-Blakemore tube, before the days of gastroscopy and kinder methods of dealing with bleeding oesophageal varices. The prolapsed thrombosed piles were, well, memorable.
Evelyn Lee and I were persuaded to assist in theatre. Our male colleagues preferred to work harder running the wards - the language was more civil when women were pulling on the retractors. One surgeon refused to use electrocautery for any operation - knot-tying skills from KKH were honed at many a partial gastrectomy. Passive night calls were run by one HO, who covers the entire unit. Open prostatectomies were common practice then and I could expect to spend the night washing blood clots out the bladder. 50 ml syringes were in short supply, imagine flushing the bladder with litres of saline using 20 ml syringes. For some inexplicable reason, it always occurred at 3 am.
I recall a little boy brought over by sampan from the Riau Islands. He skipped into the ward clutching his skull X-ray. A large three-pronged fork (the type they use to grab 100 kg rice sacks) was firmly impaled on the top of his head. Rather ignorantly, I determined that his head should be shaved and sent in a chit to the OT for its removal. An astounded MO showed me just why he would have to be transferred to neurosurgery.
What I write of must be taken in the context of the times. SGH wards comprised just Bowyer Block, Norris Block and Mistri Wing for paediatrics. A&E was housed in a new building. There were three main blocks in KKH: delivery, obstetrics and gynaecology. The babies were here and there, with a small number of neonatal high dependency cases.
Funds were limited and those were times of economy and economisation. We washed, dried and powdered gloves, and boiled and reused needles. Disposable chest tubes and other tubes were practically unheard of. Yet, the facilities and standards of practice of medicine were sound and equitably distributed to all, regardless of ability to pay. Well-ventilated open “C” class wards were the standard hospital bed. One administrative office with just a handful of administrators for the entire hospital. I think that you will think very carefully about what you write and what you ask, when all you have is a manual typewriter.
Healthcare costs were also simpler. We did not, for instance, have to contend with the enormous costs and complexities of chemotherapy, simply because such treatments did not exist. There were, of course, shortcomings but these were rapidly addressed in the next decade, such as coronary artery bypass surgery.
As a HO, I was worked to the bone in medicine and in O&G, with no half days after a night call. That meant 24 hours plus eight to ten hours of nearly continuous work, doing calls at least every three to four days. The surgeons, for all their bluster, gave us a half day's rest. So, it was 24 hours plus five to six hours and calls rostered about every four to five days. Notwithstanding the hours, I loved working in every department that I was posted to and have made many lifelong friends. By and large, we learnt medicine and surgery from those just one step senior to us, who had little time to teach but taught by example. Then again, training in medicine is very much an apprenticeship. Happily, training programmes are today much better structured and administered.
It has been oft repeated that the experience of hard work and long hours are crucial to the training and development of a doctor. The mantras of “If I survived it, so should you” and “If I did that, so must you also” are common. The newer generations of medical students and doctors are no less resilient than we were. But the hardships of the past should not dictate current practices. Training should be planned to allow for time to learn, reflect and rest. Inasmuch as other healthcare workers work shifts, so should doctors also work reasonable hours. The division of duties could be more equitable. For example, simple tasks and procedures should not be delegated to junior doctors only. It is really no shame to pull one's weight, regardless of seniority.
Lee Pheng Soon
40 years ago, there were not enough doctors to man the hospitals. We knew because when we were students (19771978), we noticed the construction of the new SGH had paused while efforts were made to find the necessary doctors. Our class of 1982 was the first to be bonded for five years' service post-graduation, in order to plug that staffing gap. HO year was the only time we had to learn to be safe MOs.
What was it like being a HO in 1982?
Long hours, night calls, old technology. But there was clear purpose: we were trained at every opportunity to become competent (or at least "safe") MOs in that discipline, by the end of the four-month posting. We could never embarrass our boss when we started in the next unit as fresh MOs.
Call rosters were full
"Good months" and "bad months" were simply those with fewer or more than 15 calls a month respectively. I recall that my best month was 12 calls, and my worst was 18 nights. The most notorious was KKH "U" Unit, where maybe half the calls had us literally on our feet the whole night. Fellow housemen in the "A" and "B" units mysteriously fared better.
Very little orientation and time to find our feet
One classmate recalls how on his first night on call at paediatrics, he was paged to go to the delivery suite to attend to a 18-weeks pregnant woman, originally scheduled for an abortion but whose child had come out breathing. He recalls that the resuscitation mask offered was larger than the baby’s head.
The second night I was on call at Toa Payoh Hospital's Medical Unit, there were so many admissions that I had to start urgent treatment and stabilise three cases of acute pulmonary oedema by myself. I was guided only by the succinct and clear instructions in the trusty red HO's Handbook of Acute Medicine, published by the Medical Society of the University of Singapore, each succeeding edition incorporating the wisdom from exiting HOs. This book, first published in 1974, has been the life-preserver of every houseman when their MOs were busy attending to more urgent matters.
Another classmate recalls: “First day of my housemanship, I was on call: worked through the night. Three wards on three floors. One septicaemic shock, two acute asthmatics, one congestive heart failure who we had to bleed…”
The following morning, it would be back to routine work in the ward we were assigned. Some units would allow the post-call HO to leave after lunch “provided he had finished his work by then”. It would often be more than 30 hours on one’s feet. A good call roster meant that one would get uninterrupted sleep every alternate night that month.
Our typical workday
Ward rounds, then ward procedures, discharges (with another discharge round if it were admitting day), then post-discharge case summaries. A ward of about 50 patients may have just two or three HOs caring for them, and woe betide the HO who did not know the medical status and the management plan for his assigned patient during ward rounds.
Technology was primitive
We relied heavily on history-taking, clinical signs and first principles. For example, the ultrasound facility at KK Hospital did not work after office hours, and I recall one very sad incident of a case of ectopic pregnancy that the night A&E MO assumed to be acute appendicitis and failed to do a pregnancy test.
Additionally, I recall settling an argument of whether a new admission, already in labour, had twins or not - to the amusement of the specialists on duty - by simultaneously detecting two different heart rates with two bedside CTGs of different brands, thus for the first time successfully overcoming electronic interference in the two sensors. For some years after, this was referred to as "the HO test".
The pros and cons of such training
Essentially, we had to master anything that a MO was expected to be able to do independently on his first day on call. As HOs, we therefore welcomed every opportunity to learn something new. The idiom was, "See one, do one, teach one -but harm no one." Each HO in my cohort learnt to do several of these: insertion of chest tubes, lumbar puncture, urinary catheterisation and bladder washout, removal of post-surgical drains, manual removal of placenta, forceps delivery, breech delivery, lower segment caesarean section under supervision, bone marrow aspiration, blind chest and peritoneal taps, among others.
As we were single-mindedly trained to be safe MOs in an acute hospital setting, we ended up with almost no clue about how to conduct competent primary care. However, at the end of our HO year, many of the guys would go into National Service, where they would function as GPs (thankfully to generally healthy young men).
I also recall that HOs were paid about $1,000 and MOs about $2,000 per month then. I guess we were too tired to wonder if this was fair.
What lasting impressions do I have?
First, we did the best we could with what we had. For example, in venepunctures, we used sterilised needles that had been resharpened so often that some were reduced to half the original length. We would first test the tip by running it through a ball of cotton wool. If any fibres caught on the tip, it meant that the tip was barbed, and the needle had to be thrown away. The few disposable needles we ever saw were locked away by the ward sister and were sparingly brought out for difficult veins when a drip had to be set.
We made everything count. I remember the rule for requesting a blood test: you first had to be clear on "what you were going to do with the result" - ie, you had to be clear on how your treatment plan would be guided by what might be found.
Last, everybody chipped in. I recall busy admitting days when Consultants and "The Prof" would be seen squatting beside patients on their stretchers, each clerking the patients' history. Everybody checked the work of other team members, helping to detect inevitable mistakes born from tired minds.
How did we survive those 12 months?
I suppose youth has a certain special inexhaustible energy. Moreover, we were driven by a certainty - we would be in this system for at least five years because of the bond, so we had "better learn as much as we can" for fear of being incompetent MOs. Each week, there was something new to learn. Work made us too tired to care about passing months, and before we knew it, the twelve months were over.
Acknowledgement
The author thanks his classmates from the Class of '82 for helping his fading memory. Special thanks to Dr Celena Tay for finding her copy of The Handbook of Acute Medicine.
Ee Tat Xin
My first housemanship posting fresh out of medical school was in Changi General Hospital general surgery and of course I had to undergo trial by fire, with the vascular team no less. Nothing could prepare us for that intensity of work. This was almost pre-residency, hence restrictive working hours were never a bother. My fellow HOs and I stayed till 10 pm almost every night and started work at 5 am.The medical officers were kings and registrars were gods. Everybody was confident and assertive in order to keep the well-oiled machine running at full speed at all times.
I remember the first time I met my two vascular consultants in my first week. A 68-year-old obese lady with all sorts of comorbidities and an almost non-existent vascular access had been admitted for cellulitis and to rule out necrotising fasciitis. By the time I got to clerk her, she had collapsed due to acute necrotising fasciitis. Both my fellow HO and I struggled to even get a blue intravenous (IV) cannula in to resuscitate her. Suddenly, two vascular consultants appeared out of nowhere. Each took an arm and a green IV cannula, and inserted them successfully on their first try purely based on their knowledge of the vasculature. Needless to say, the patient survived with timely surgical intervention. Till this day, I remain in awe of these two superhero consultants who treated every patient with respect and dignity.
Life in the past might have been tough but I never once remembered being unhappy or disgruntled. Every day was about trying to live up to the teams' impeccable standards so that one would feel proud to be a functioning part of the team. It may be overly cliched, but when you enjoy your work, you win never have to work a day of your life.
Medicine is one of the few professions where you can experience instant gratification from your actions, such as an acute rehabilitation patient feeling instant relief from your insertion of the indwelling urinary catheter.The landscape of medicine now may have changed, but the basis of why we do what we do will never change.To cure sometimes, to treat often, and to comfort always.
Chie Zhi Ying
Housemanship is the rite of passage that all medical graduates will invariably go through to become a fully registered doctor, and,for better or worse, an experience unforgettable. My housemanship took place almost a decade ago in 2013 but the memories are still rather fresh in my mind. Although we were trained under the Student Internship Programme in our final year of school to provide a smoother transition to our housemanship year, nothing would have prepared us for the daunting and onerous year ahead.
My first posting was a gynaecology posting where house officers were rotated to take care of the gynaecology wards (both private and subsidised) and labour suites. From learning how to clerk a labouring would-be mother and delivering the first newborn as a doctor with the help of midwives and seniors, to doing the first episiotomy and scrubbing up to help in myomectomy, it was really a good posting to ease myself into the system.
I enjoyed my surgical postings very much (though I was not surgically inclined), especially the neurosurgery posting, as the team of HOs worked really closely together to take care of the many patients on our list.The team had great camaraderie as we supported each other for daily ward work and survived calls together.The only downside about surgical posting was that we had to wake up very early to begin preparing the ward list and rounding our patients in the morning, but our great team spirit eased away all the fatigue and aches.
To survive well, one needed to multitask well and soldier on, come what may. I remember once attending to an ill patient in a general medicine ward when I was on call.The patient's blood pressure suddenly crashed in the middle of the night, and he faded into unconsciousness right before my eyes. A wave of panic swept through me as I quickly told the nurses to activate code blue while starting CPR on the patient. The patient was eventually transferred to the ICU after his pulse came back, but unfortunately passed on later from a massive stroke. It was heartbreaking.
As the days passed and postings went by, we grew in maturity, efficiency, confidence and resilience. From making succinct ward presentations and As the days passed and postings went by, we grew in maturity, efficiency, confidence and resilience. From making succinct ward presentations and being able to do discharge summaries efficiently, to doing changes fast (hopefully as we do the rounds) to being able to come up with a good management plan for each patient, nothing brought a brighter smile to my face than patients and caregivers thanking me upon discharge. And nothing made me sadder than when I went for morning rounds and found that the terminally ill patient had passed on the night before. And I couldn't have been prouder when seniors beamed with approval and gave me a pat on the shoulder for the hard work I have put in.
A toast to the HO year and to all who are about to embark on it or are in the midst of it!