Excerpt #10: Fixing The Out-Patient Clinic Circus

Excerpt #10:  Fixing The Out-Patient Clinic Circus

M. Bakri Musa (www.bakrimusa.com)

With my re-organized inpatient service now running smooth, it was time to focus on the pasar rabucircus that was our outpatient surgical clinic. Well, not just ours, the entire hospital’s. No one had paid any attention to those clinics. The elite, meaning the top civil-servant patients, were insulated; they bypassed the clinics with their direct access to the specialists.

            We had twice-weekly outpatient clinics from 2-4 PM, Mondays and Wednesdays, seeing in excess of 200 patients per session. They all came early with their assorted relatives tagging along and plugging up the waiting room and adjoining hallways. You get tired before you even start your clinic just by seeing the crowd.

            After the first few sessions, I could no longer tolerate the circus. I gathered all my doctors, nurses and ancillary staff to discuss on how best to handle the situation. One nurse suggested that I did not have to see those patients; they were the responsibilities of the trainees and junior doctors. She mistook my seeking a solution as making life easy for me. I also presumed that she did not want me to see all those patients as that would also increase her work load! The others did not even see the problem. Outpatient clinics everywhere in the country were crowded. Get used to that! They were free; what do you expect? Besides, we could not dictate to the other clinics what time to send their patients to ours.

            I had expected some suggestions from them seeing that they had been at it for years. Instead, they saw no problem. You cannot begin to solve a problem until you know that you have one.

            While it was true that we did not have any control over the other clinics (like the Casualty Department, Pediatrics, and Medicine) that referred to us, why not let only those patients come at   2 PM, our scheduled opening time. For those whom we had control, as with our follow-ups, have them come later at 3 PM. That would immediately reduce the crowd at opening time by half–substantial! As there was no opposition (at least no one voiced any) to my suggestion, that was the change I implemented right away.

            At our next outpatient clinic when the change became effective, it was a great relief! The throngs were gone or at least reduced substantially just as I had anticipated, to be replaced instead by a steady but manageable stream instead of the usual unruly mob that greeted us at 2 PM as with past sessions. Absent the mob, the associated mentality and behaviors–pushing, shoving and screaming–were also gone. The patients were now polite and well behaved. While it did not quite yet feel like my private clinic in Canada, the crowd was at least manageable.

            Like a well-manicured garden in the tropics, the beauty and orderliness did not last long. Soon, the overgrowth of unruly shoots and branches began appearing and took over. Within weeks the unruly crowds were back, at first a trickle and then as if nothing had changed.

            I could not figure out what had gone wrong. So one day I stationed myself in an unobtrusive corner of the waiting room. One of my follow-up patients came in at 3 PM, as per her appointment card. She had followed the instructions given to her.

            The receptionist however, berated her for being late. My patient protested and showed her the appointment card. The receptionist responded that while it was true the patient’s appointment was at 3 PM, it would be better for her to come early, as at 2 PM. The doctor was a busy man, she told her. As such it would be better for us to wait for the doctor and not the other way around.

            I had to control my laughter! My own staff had undermined my reform, and did it in a very soft and subtle manner–the Malay way. There was no way my patients could rebut her.

            That day after the clinic I gathered my staff again and asked why we were back to the bad old days of a mob at our clinic. No one volunteered an answer or offered suggestions as to why the changes that had worked so well for the first few weeks earlier had now failed us.

            I hinted that perhaps a few might not have understood the rationale for those changes and thus were not following them. We were undermining our own efforts. I sought out ideas on reducing or managing the crowd. Again, none was forthcoming. After much prompting on my part, the record keeper finally admitted that the old system made his work much easier. He had to go to the chartroom only once–at the beginning of the clinic–instead of back and forth with every arrival of a patient.

            I acknowledged his extra workload and then added that we should first think of our patients. We should lighten their work as they were the sick ones, not us. Seeing that my response had embarrassed him, I said that I would reconsider reverting to the old routine of making all patients come at 2 PM if that would make his work easier. Then with the spare time he could help in the clinic.

That solution did not enthrall him at all. What he had in mind was to have all the charts ready at the beginning of the clinic so he could retreat to the backroom to resume his siesta and not be disturbed until the clinic was over and he had to stack those charts away.

            Going back and forth for the records was a valid complaint. To alleviate the problem, I suggested we have a list of all our follow-ups beforehand and pick those charts up regardless whether those patients would show up or not.

            With that, my changes were back on track and the pasar rabucrowd outside our clinic was now gone again.

            However, this was Malaysia; what may look desirable may not be so. To me the lack of a crowd meant a smooth, well-organized operation; not so to locals. My nurse hinted that people were now avoiding our clinic because they thought the lack of a crowd reflected on the quality and reputation of our doctors. She suggested reverting to the old system with its unruly pasar miggumob, and with that, the façade of a “popular” clinic.

            I responded that I was less interested in how others view us rather more on how our patients regarded us. I was not into peraga(showy acts) like having a big crowd outside our clinic.

Our new routine remained, and with that our outpatient clinic continued to be orderly!

Next: Excerpt #11:  A Much-Needed Break!

From the author’s second memoir, The Son has Not Returned.  A Surgeon In His Native Malaysia(2018).