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S E M S O n l i n e N e w s l e t t e r |
I s s u e A u g u s t 2 0 0 6 |
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Reflections of a HOD
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[HOD: acronym for Head of Department; but could also mean a hod, which is ‘a container for carrying bricks made of an open box on a pole that is held against the shoulder’]. There are certainly times when a HOD feels like a hod when bearing the burdens of the department on his or her shoulders.
As I approach the end of my tenure as Chief of Emergency Medicine at NUH I look back with a mixture of emotions. My decision to emigrate for the third time was, surprisingly, not that difficult. I had been working in a busy ED in Toledo, Ohio USA for seventeen years under the guidance of one Bruce Janiak, a fellow with one and a half brains, who had been President at one time or another of everything and anything to do with American College of Emergency Physicians or American Board of Emergency Medicine. Bruce was a brilliant administrator and all of us in the ED absorbed some of his skills just by being around him. However, he was only a few years older than me [yes, Sock Koon, there are practicing emergency physicians in this world older than me!] This made advancement in to the world of ED administration difficult.
Over a seventeen-year period, from 1977 to 1994, I had been exposed to the daily hurly-burly of a typical American ED with the gamut of pathophysiology ranging from the usual P4 conditions to the critical. As you may know, EDs in the USA provide a safety net for the whole population [more than 39 million have no form of third party coverage], and you saw everything there was to see – no postman philosophy in Toledo. So, I felt pretty confident in the area of clinical care, as well as teaching, since I was the Director of Medical Education for my hospital’s half of a residency-training programme shared with another hospital. However, administration remained an area of weakness of mine. Simply put, I wanted to see if I could run an ED.
After several visits to Singapore from 1988 to 1993 for the purpose of holiday plus some ad hoc teaching, I finally took up the suggestion of moving full time to Singapore, arriving in June 1994.
Perhaps as a warning of things to come, the quarters provided by NUH in Chip Bee Gardens were far from adequate. I certainly did not expect anything up-scale but on the other hand did not expect the dilapidated house offered us - rusted pipes all over, bare windows, absent internal door knobs and no ventilation of any sort. Needless to say we moved out next day, made appropriate protestations to NUH Administration and moved temporarily to the Mandarin on Orchard Road - and, yes, NUH actually paid the bill! After twelve days we moved in to Gillman Heights where we have stayed to this day.
My first day of work was 27th June 1994 and for the next two weeks I recall going home to my wife and saying…’Well, it’s different!’ It was a massive culture shock coming from the ED organization of the USA. My arrival gave the department 2.5 senior full time equivalents [FTEs - forget protected time at that stage of our development]; Shirley Ooi was the one registrar with Ng Yuen Yen a part-time senior registrar. Many shifts were covered solely by MOs, more senior than they tend to be today, but still MOs nonetheless. I can still recall the looks of apprehension and downright fear in their eyes when the senior went home in the evening.
To show how disorganized things were at that time, administratively, we were under Nursing! That was the result of some political trading in the early years of NUH when nobody wanted administrative responsibility for the “A&E”, as it was known. The physical plant was severely lacking, comprising a number of ill-suited rooms leading off of a main corridor. The original plan for NUH, as I understand it, was for it to be a small cottage hospital for NUS. It was never intended to be a large tertiary care hospital and certainly was never meant to have an emergency department to serve the population of the western half of the island.
So, our small team of similarly minded souls worked hard under difficult conditions to slowly build the department from scratch. Our priority was, and still is, quality care aligned with excellent teaching. This has been difficult to maintain in the face of the demands from the public and administrators alike for service in the form of short consultation waiting times. Because of that pressure, I am very proud of our record of one sentinel event in the last five years, though I am probable tempting fate by quoting that statistic!
I believe it is only by paying attention to the basics of good quality care that we can gain the respect of the public and our professional colleagues in Medicine. I am especially sensitive to the peer-respect aspect of our work. When I got here in 1994, the attitude within NUH to the EMD was downright non-collegial, unprofessional and disrespectful. It was nothing for a ward-based medical officer, or the occasional house officer, to call the EMD and scold our medical officer [or even registrar] over a particular admission. For those of you who have not worked outside Singapore, it is only in this country, it seems, that the verb ‘to scold’ has retained acceptability. Needless to say, my colleagues and me have reversed that undesirable trend by a combination of standing up for ourselves but, more importantly, by paying attention to quality clinical care and by providing an environment of learning. In addition, this has been helped over the years by collaborative initiatives with departments that were previously hostile to us.
Over the years I have been blessed with the fact that good people continue to want to join us, with our ultimate target being a specialist on every shift. And, I believe that “a specialist on every shift” must include the HOD. I can think of no better way of losing the respect of one’s peers than by not being there ‘in the trenches’ with them during the difficult times. Unfortunately, that brings difficulties since ED rosters are generated generally a month ahead. Administrators either do not know that, or they do not care, when they arrange meetings, invariably at short notice, then expressing surprise and irritation when the HOD cannot attend the meeting due to clinical work commitment. I have lost countless chunks of days off over the last decade as the result of administrators failing to understand the way ED physicians work.
Another unique area that sets us apart from the more traditional disciplines is that of protected time for non-clinical activities. All registrars and specialists require time to develop in areas other than clinical. Sacrificing one’s own time for such activities is not a current societal trend; rather, one is encouraged to spend one’s off time in family-centric pursuits [the government itself says so, damn it!]. This provides a clash point between the traditionalists in Medicine and the younger generation of clinician who wants to do ‘hospital work on hospital time.’ My personal feeling is that if Emergency Medicine is to develop as a speciality, then its exponents – us- need to be given the time to develop along appropriate lines to become the very best medical experts, communicators, collaborators, managers, health advocates, scholars, and professionals i.e., what it takes to truly become a holistic specialist. To achieve this end and knowing that traineeship is now a mere five years, I think protected time is an essential component of modern day training. However, be aware that to administrators, protected time is a charge to the hospital and takes you away from the patient.
In many ways, my situation in Singapore has been unique since I came to an underdeveloped ED. Many of you will join departments that are already established. A few of you will reach that level where you are eligible to become HOD. An even smaller number of you will become HODs and to this group I offer the following advice:
During the last twelve years I have been through the stages of de facto Chief for four years, Acting Chief for one year, and Chief for seven years. I think I will have trouble knowing how to behave when I leave my position at the end of June. Assuming I have sufficient time to give my successor a reasonable handover before then, I think I will go to my favourite regional escape [Philippines] and spend two weeks unwinding with the help of 1881 cigars and Tanduay rum, while contemplating my next career as a pimp! Cheers! Hic!
[Dedicated to the efforts of my colleagues Shirley, Suresh, Chong Meng, Malcolm, Li Lee, Q, Irwani, Ben, Tiong Beng, Sock Koon, Amila, and Joelle, Gaik Bee, Erlinda, Uma, Ruhana, Colin, with the back room help of Joyce, Ke yoon, Norlin and Kasey plus a supporting cast of God knows how many medical officers and staff nurses.]
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Prof Peter Manning |
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Copyright © 2005 The Society for Emergency Medicine in Singapore |
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The Society for Emergency Medicine in Singapore c/o Department of Emergency Medicine Singapore General Hospital, Outram Road, S169608 Phone +65 63213558 Fax +65 63214873 |