On call Versus Shift System

12:02 AM

There is a never ending debate on which system is the best. Before I discuss any further, let's go through some terms and definition:

On Call:
Despite "on" & "call" combined to make a word, it does not mean "turning on your phone and wait for calls from the hospital from the comfort of your home". It is common for people to get confused. Some fresh housemen seem to assume this is the actual definition.
On call-ers will be in the hospital through out the day, even after office hours. They are part of the team that keeps the hospital running at night. Usually there is a small room for doctors to rest at night. If you are lucky, HOs can get some amount of sleep. The job scope of HOs at night (at least back in those days) is take blood, attend to sick patients before help arrives, insert branula, clerk new patients and perform procedures. Usually its one HO per ward but it is the norm to have 1 HO covering the whole wing (5 floors of male medical ward)....back in those days.

Pre Call:
Pre call is the day before the on call day. On this day you get the sinking feeling of uneasiness. Simply said "malas". On this day, you try to get everything at home done. Munch on anything you can get & pack on the calories. Its the day you prepare for war!

Just stuff everything in!

Post Call:
The symptoms of post call are:
1. Disheveled look
She most likely had a bad on call

2. Able to sleep while standing and clerk patients
3. Red eyes
4. Able to fast the whole day....food does not matter when you are sleep deprived
Basically, you just feel SUPER tired. There was no such thing as post call off. You just continue working until 5 p.m. (if you're lucky). That's 7 a.m to 5 p.m. the next day i.e. more that 36 hours non stop!

EOD Call
This means on call every other day. This can last through the whole month if there are not enough staff. For example, on call on Monday, get home on Tuesday afternoon, then on call again on Wednesday. Just 12 hours of rest at home. EOD calls are horrible. It takes a toll on your health and your circadian rhythm goes haywire. You can't even tell what day it is and can't differentiate day and night.

The typical shift system for other staff in the hospital are; 7 a.m to 2 p.m, 2 p.m to 9 p.m and 9 p.m to 7 a.m. These 3 shifts keep the hospital running. In 2011, Ministry of Health started the shift system to cater for the increasing number of housemen in hospitals. This was their response to the constant complaints by housemen that they are overworked. I was fortunate to experience both on call and shift system. The shift system has been through so much changes and adjustments. I am not really sure how it works now but the main point is housemen can work up to 36 hours a week only. I am unable to elaborate on the exact working hours.

Back in those days (dan sebagainya).
This sentence is always used when MOs & specialists talk about their history.

"Back in those days, I cover the whole hospital alone tau"
"Back in those days, HO pakai kapcai tau, bukan Golf GTi"

I used to hate hearing these old grandpa stories. But now that I am an MO, I have the "licence" to use it! :)

The Comparisons
1. Work hours
On call: on a good month housemen will need to do between 8 - 10 on calls. This will depend on the number of housemen available in each department. When there are not enough, its EOD calls.

As mentioned in my previous post on Being A Doctor, working on normal days will see HOs work for 224 hours per month. Assuming 10 calls per month with 2 being on weekends,

9 hours x 8 + 14 hours* x 2 = 100 hours

So its 324 hours per month

*On calls on weekends are longer as other HOs are working for only half a day

Shift: The captain (HO leader in the department) will arrange the schedule to ensure that each HO works for 65 hours a week.

65 hours x 4 weeks = 260 hours per month

In terms of work hours, it SEEMS to be better but it is not always what it seems. Some hospitals just can't follow this ruling as there are not enough housemen.

2. During work
On call:
During office hours, there are quiet a lot of housemen working together. Work gets done appropriately. Some will get radiology appointments, some will do discharges and some will handle the clinic. Most of the job gets done during office hours. However, some HOs will abuse this luxury. In a ward there will always be special groups of HO:

This guy will dress smartly without their white coats and pretend to know everything. They will go around telling junior housemen to do their part of the job. These people will come to work late, go back early. Be punctual for lunch and even go out for solat Jumaat even though they are not Muslim. During HO teaching they will only blurt out other smarter HO's answer to show that they know things....tapi show je la, kepala kosong gak.(To my colleagues who remember this guy, please NO NAMES here. Nak gossip PM ye :p)

Whine, whine, whine. That's all they do.
"Penat la nak masuk operation theater, MO tu garang"
These people will also datang lambat, balik awal.

Its nice working with these guys. They will try to do everything. They will be around the hospital even when not on call. However, other HOs will have to compete to complete their logbooks.

Always MC la, EL la for stupid reasons. I was once a HO captain in Medical Department and had one HO under my care.

HO X:      "MOfrust, I EL la harini. I stuck kat KL ni. Semalam ada family issues nak resolve"
Me:          "Eh, try la get back earlier. Its still 7 am. We are short of HO to cover your ward. If you EL                  I have to cancel your leave request this weekend"

At 730 a.m. I was informed by the staff nurse that he came to work. Sometimes, you have to deal with a lot of rubbish with doctors as well. For the record, my training hospital was THREE HOURS from KL.

HOs come to work according to the shift required. This would work fine in big hospitals where at any one time, there can be up to 40 HOs in a department. But at my training hospital we only had 20 HOs at one time. Imagine the trouble to distribute 20 HOs into 3 shifts and distribute them in charge of 5 wards and the specialist clinics. In the end only ONE HO to cover one ward of 30 patients. It might be OK at night but imagine the work that a single houseman has to do during their shift. Taking blood, discharge summary, procedures, cover clinics and so on.

I was particular disappointed during my term as captain because the administration called for a meeting to discuss about implementing shift in my small hospital but never considered anything from the HO point. Yes, the working hours should reduce and benefit HO but not without the number of HO that we had. The typical answer would be "pihak atasan dah bagi keputusan". 
They shouldn't have wasted resources on surveys and meetings if that was the answer. (This kind of actions really put me off and contributed to my FRUSTness (frustration)...pardon my English.

3. Quality of work
With the shift system, there is less responsibility towards patients. It will depend a lot on the attitude of the individual though. Most of the time, when asked by MOs or specialists regarding the condition of a patient, the answer would be "I don't know boss, the previous shift HO didn't passover to me".

It is not entirely a HO's fault. When working in shifts, it is difficult to follow up on patients especially when the turnover rate in the ward is high. When you just come to work at 2 p.m., you can't be expected to know what happened in the morning in detail. During the oncall system, I was able to recall patient's condition from the previous day. Their blood result trend and progress was easy to recall mainly because we review the same patients at least twice a day. It becomes easier and faster to write reviews as well as I didn't have to keep on flipping the pages so often.

4. Pay
Rate of claims for oncalls on weekdays was RM 100 and RM 120 on weekends. That was the old rate.

Flat rate of RM 600 as additional allowance.

Is the extra money really worth it?Most HO would rather sleep and rest than getting RM 100 for on call.

Which one is better?
In terms of training and experience, the on call system is still relevant. You are able to learn more in the ward. See more weird things in the ward. On top of that, there won't be too much of a culture shock. Most HOs will get transferred to a hospital as an MO and will have to have on calls. They will have to find a way to adapt to 36 hours of non stop work. As I see it, the people at administration always fail to see what is going on on the ground. They will always say there are too many HOs. There are too many but not distributed equally. They always come out with some ad hoc decision. At the moment, I see too many of my ex HO being sent to ONE hospital in KL although other hospitals are in need of MOs. What is the point of sending 4 juniors over there? Who is going to teach them? Who will guide them?

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  1. You can still know your patients well before your shift starts, by coming early to look through the case notes before your shift starts. everyone does it, the nurses come early/stay late for hand over rounds, the secretaries, the accountants, the IT people, the police, whoever who is doing any shift work does it. So why can't you as a doctor.

  2. I agree with you regarding the come early part. But it still doesn't have the same effect as seeing the patients everyday. Taking their blood and tracing and reviewing their results daily

  3. The issue with shift system is that there is very few HO's at a time, esp in the morning. 2 HO covering 40 patients for morning rounds can be rather cumbersome, esp when you just came back from a vacation or work from a different ward prior. That being said, you have to review the patient from the day of admission till the latest progress to come up with a proper management, which is rather time consuming. Most of the time, the clinical plan was not carried out by the HO the day before as he/she may "push" the job to the next morning for the next HO to do. In this sense, there is no sense of responsibility from certain HO's while the responsible ones like me slogged it out the whole day.

    Even in Temerloh, the place where the shift system started, it was a total mess while the director pushed for the system telling other states that it was a success. On papers, we worked not more than 60 hours a week, but the actual system can be minimum 72 hours a week (12 hours x 6 days)with none of the promised off days. Plus coming early one hour earlier and back home 2 hours later makes is close to 90 hours a week, because of the sense of responsibility. That made it around 280-360 working hours a month...

    I remember the days where the 12 hours shift flew quickly as you have 12 hours to complete all the tasks, since there are few HO's. Back then during the nice on call days, there are 10-15 HO's taking care of the 40 patients, so each HO gets 3-4 patients and carry out the needed management before going back at 5pm. For the shift system, you get 2 HO's during the day, and 1 at night. Not to count the days when there's a collapsed patient which means there's only one HO(or none at night) left in the ward to carry out the remainder tasks throughout the day(Provided if no other patient collapse elsewhere in the ward). I remember resuscitating + CPR a patient at night on one bed and carrying out auscultation and endorsing meds and taking blood for the new patient with COPD next to him. Both survived, and there were also 12 more patients who came in at night and 40 patients for blood taking throughout the night in a hosp with computerised system which requires immediate documentation as possible. All stabilization was done alone as the MO's were hiding under their bed with their on-call phones. Fortunately, those MO's had mostly left the hospital and replaced by more responsible MO's.

    That being said, the shift system is not necessarily the best one as being mentioned by MO frust, it is up to the initiative of the HO's. The early ones like us ended up knowing all the patients in the wards despite the high turnover rate as we want to avoid screwing up, but the new batches of HO acted like a dumbshit. They'd only review 1-2 patients in the morning and let the MO's do the rest because they can't finish in time. Mind you, there are also grads from local uni's such as UM, UKM, UPM etc! With more HO's now, there could be 4-5 HO's in the morning and 3 at night but still could not perform up to par. Unbelievable!

    Btw, I have completed my 2 years of HO-ship without fail, so I hereby also claim my "license" of grandpa stories. :P

    1. I heard about the issues in Temerloh and tried to convince my pengarah that it wont work and instead be an added burden to the departments...but they still proceeded. Im glad "grandpas" like us don't have to go through it


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