Excerpt #9: A Leaner, Flatter Organization

Excerpt #9:  A Leaner, Flatter Organization

M. Bakri Musa (www.bakrimusa.com)

I reorganized GHKL’s Surgical Unit III by dividing the large male ward into two, keeping the smaller female ward as one, and combining the first and second class wards as the fourth division. It turned out that each had about the same number of patients; that helped even out the load. I further divided each division into two and assigned an intern to each, with a medical officer over the two interns.

            I streamlined the organization and clarified the lines of authority. Whereas before there were the senior and junior house officers, the medical officers with their own myriad titles of registrars–ordinary, junior, and senior–and the consultant, now there would be only the interns, medical officers, and me.

            There was immediate dissatisfaction, not expressed openly but quietly as per the oriental style. I had two senior registrars and they did not take kindly to what they viewed as an apparent demotion to being mere medical officers. One was Freda Meah. A full-fledged surgeon before she left her native Myanmar, she was with the university so I could dispense with putting her into my scheme. I told her to find her own level, supervise the rest, and report directly to me. She had no problem with that.

            The other was also a lady trainee who by now had a reputation as a perpetual surgical test-taker. She had taken her FRCS examination umpteen times but never made it. As she was much older than me, she figured that she was just as qualified if not more experienced a surgeon than I was except for those silly string of alphabets behind my name.

            As she would need some time to study for her next examination, I put her in charge of the much lighter first and second class units. She was ecstatic not because of the reduced load, rather the chance to hobnob with the hospitalized senior civil servants and other elite of Malaysian society.

            I told Mahmud privately that he could take any case he wanted and then supervise the intern and medical officer assigned to that patient. I made it clear to everyone that he and I shared the clinical leadership. With his training in pediatric surgery, I had Mahmud take charge of that small unit with Zul who had shown an interest in that field as the designated medical officer.

            There was one other stipulation I introduced. No case should go into the operating room no matter what time of day unless Mahmud or I were present and scrubbed. Since Mahmud was busy on campus, that effectively meant me. “Even for a simple appendix?” one medical officer asked, less for clarification, more for sarcasm. “Yes!”

            As a surgical resident back in Canada, I used to chafe when the attending would not scrub with me and instead waste his time in the lounge discussing local politics or recounting his latest exotic vacation. I reckoned that the day I operated on my own would be the day I collect the full fees. Most residents felt otherwise however. They felt that the presence of the attending reflected on their competence, or lack thereof.

            My attitude was shaped by a “simple” appendectomy I was forced to do. Dr. Frank Turner was the attending. Such a case was not for the chief resident but all the other residents were busy. Sensing my displeasure at having to do the case with him, he went out of his way to show me that he still had a thing or two to teach me.

            As I inserted my index finger through the incision to retrieve the appendix, he stopped me. He asked me to describe the pathology just through the feeling of the tip of my finger. I did, and he then asked about the ovaries, liver and the rest of the bowels. Everything was normal I assured him except for the liver and the rest of the bowel. I could not reach them. Then he took over and inserted his finger and started rattling off. “Cirrhosis, gallstones….” I repeated my exploration but could not tell anything as those organs were beyond my finger’s reach. I wanted to enlarge the incision but he would not let me.

            Suitably humbled, I finished the case in silence. He had made his point. I should find out as much as possible through digital exploration. After the case, sensing my dejection, he said that he did not actually feel the gallstones rather those had been the incidental preoperative ultrasound findings.

            I wasn’t mad at him. Instead I took his lesson that day to heart. You could always learn something even from a simple routine case. I would often pull that old trick on my arrogant residents and medical officers just to humble them.

            Since that episode, I had picked up innumerable unexpected pathologies, like colon cancers during routine hernia repairs, ovarian abnormalities during appendectomies, and stomach cancers during simple umbilical hernia repairs, just by digital exploration through the incision, even in these days of exhaustive and expensive preoperative scans.

            As for my insistence on being in the operating room (OR) at every case, decades later the United States Medicare Agency would require surgeons to attest as to their presence in the OR, scrubbed, on allcases they billed.

            I implemented all those changes in Unit III the Thursday of my first week. That way they would get a two-day trial and have the weekend to recover. I apprised Mahmud of the changes, being careful to present them only as proposals. With Sister Fong reminding him of the problems with the current system, I had no trouble convincing him. He added that it was similar to what he had at the University of Malaya Hospital.

            I was surprised at the smoothness of the change. The nurses were pleased as they now knew exactly who to call and were spared the usual “call the other intern” response. With everybody knowing their responsibilities, things were smooth with little wasted motion. My earlier stipulation that I be scrubbed on every case was not as onerous as I had expected. I tried to restrain myself to be only the first assistant and let my trainees do the actual surgery. The junior doctors enjoyed my direct supervision. Up till then, the practice was for the more senior trainees mentoring their less-experienced juniors. This old “see one, do one, and teach one” was also the standard practice then at many major medical centers in North America. That was one reason I left McGill’s program to return to Edmonton where the tradition was for a resident, no matter how junior, to work directly with an attending.

            The new arrangement worked so well that everyone thought this had been the case all along forgetting the earlier chaotic system which we had abandoned only a few weeks earlier! As we were now efficient, we had ample time for coffee breaks after our rounds. The house officers in the other units were now envious that my staff were getting time off for coffee! The chaos in the other units reminded my staff how bad those not-so-long-ago days had been.

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

Next: Excerpt #10:  Revamping The Out-Patient Clinic Mess