TAN KAI TING

1. Executive summary/Abstract

Our group spent 3 weeks at Tan Tock Seng Hospital (TTSH) shadowing Dr Endean Tan, Head of the Acute Internal Medicine Service (AIMS) at Tan Tock Seng Hospital. During our attachment, we started writing a report about influenza A and how different wards handle influenza A patients (specifically a comparison between General Ward and AIMS). We provided some background information regarding Influenza A and how doctors decide whether to ward patients. We reviewed the possibilities of creating a future screening tool that could aid doctors in deciding if patients should be warded.

During our attachment, we attended many medical lectures conducted by Dr Endean Tan and other TTSH doctors. In particular, we learnt in depth about sepsis (a life-threatening illness) and gait analysis (a study of human motion to identify gait abnormalities). Additionally, we sat in on the comprehensive case analysis of new and existing patients in the AIMS ward every morning. Hence, in our wiki, we included a section on how doctors format their case analysis to present to the senior consultant in the ward, detailing the doctors’ thought process regarding patient management.

There were many interesting aspects of this job. As we were shadowing a consultant, we had access to places in the hospital where the public is not allowed. However, our attachment was cut off early due to the 2019-nCov virus (Wuhan virus). Despite that, I have learnt a lot of life lessons from Dr Endean - especially the importance of having passion for one’s job. I picked passion as my main takeaway as I greatly admired his passion for medicine.

2. Background information of the projects / tasks which I was involved in.

I was involved in various tasks [including a presentation on Influenza A and a few smaller tasks like research on asthma, May-Thurner syndrome, etc].

Our project examined the issue of unnecessary hospitalization among Influenza A patients. In addition, we aimed to develop a screening tool based on a scoring system to determine if Influenza A patients should be hospitalised.

Singapore hospitals currently face the issue of overcrowding with an average daily bed occupancy rate for public hospitals at 85% in 2018. In particular, Tan Tock Seng Hospital had the longest waiting time at around 4.5 hours during the time of study and had the second highest bed occupancy rate of 95% among 6 public hospitals surveyed. This is especially concerning considering the increasing healthcare demands due to Singapore’s ageing population and the possibility of a huge spike in demand should epidemics occur.

Influenza, commonly known as "the flu,'' is an infectious disease caused by an influenza virus and is mainly transmitted through respiratory droplets. Symptoms of Influenza range greatly in severity, from sore throat to possible pneumonia. There are 4 main strains of Influenza, namely Influenza A, B, C and D. We chose to focus on Influenza A as it is the most common form of influenza that humans are infected with.

Through this project, we hope to create a standardised medical scoring system, which can be utilised by all Singapore hospitals to reduce the number of unnecessary hospitalisations. With the guidance of our mentor, Dr Endean Tan, we analyzed the data of the patients admitted to TTSH with Influenza A in a 3 month period. From this, we determined the symptoms that could act as indicators for patients who required hospitalisation. In addition, we compared differences in the threshold of discharge of Influenza A patients between the General wards and Acute Internal Medicine Service (AIMS) at Tan Tock Seng Hospital to prove that there are significant differences between how patients with similar background and similar severity of influenza were managed.

With this knowledge, we then developed a scoring system to act as a screening tool that determines when patients can be discharged. There has been increasing reliance on medical scoring systems as these scoring systems are more objective and can be used to gauge the severity of the condition. The utilisation of this tool would standardize the threshold for discharge, thus reducing unnecessary hospitalisations.

3. Elaboration / record of the activities done

Firstly, we conducted a literature review to gain some background information on Influenza and the issue of unnecessary hospitalisations.

Secondly, we obtained data from TTSH regarding Influenza A patients admitted to TTSH. We then performed analysis on this data by categorising the patients into those that were hospitalised for a day and those who were hospitalised for more than a day. For patients that were hospitalised for one day, we assumed that these were unnecessary hospitalisations. We analysed their demographics, pre-morbids and identified symptoms that are prevalent among these groups of patients. For patients who had a longer period of hospitalisation, we analysed their demographics, pre-morbids and symptoms as well. We also compared the standards for hospitalisation and discharge between AIMS and the General Ward at TTSH by comparing similar patient cases for AIMS and General Ward and identifying differences in the duration of treatment between the 2 groups.

Thirdly, we compared our findings for the 2 categories of patients (those who were hospitalised for a day and those who were hospitalised for more than a day). From this, we determined some indicators that showed the need of hospitalisation. Using these indicators, we designed a medical scoring tool that will aid doctors in deciding if a patient should be hospitalised.

The rationale for creating this scoring system is that currently there exists no standardised tool for this purpose - whether a patient should be hospitalised or discharged is based on the doctor’s judgment. This can result in unnecessary hospitalisations or excessively long hospitalisations. To make the decision-making process more objective, we decided to propose a medical scoring system. We assumed that patients which were only hospitalised for a day were unnecessarily hospitalised since their cases are likely to be less severe and could be treated in an out-patient setting. We chose to compare patients in AIMS and the General Ward with similar background and similar severity of influenza as we wanted to prove that there are significant differences between how they are managed.

4. Elaboration / record of results / deliverables / impact of work done

As findings are confidential, they will not be published here.

5. 3 content knowledge and 1 skill learnt

Sepsis

Sepsis is the body's response to an infection, which involves releasing chemicals into the bloodstream to fight an infection. When these chemicals are out of balance, the patient is septic and may have damaged organ systems. This can progress to septic shock (a life-threatening condition in which blood pressure drops dramatically).

Q-SOFA score can be used to calculate the risk of sepsis. Early treatment for sepsis includes antibiotics and large amounts of intravenous fluids. To be diagnosed with sepsis, one must have a probable or confirmed infection and all of the following signs: (i) Change in mental status (ii) Systolic pressure less than or equal to 100mm Hg (iii) Respiratory rate higher than or equal to 22 breaths a minute. If the patient experiences septic shock, he/she will have unrecovered hypotension despite adequate fluid replacement, thus requiring medication required to maintain blood pressure greater than or equal to 65 mm Hg.

Risk factors for sepsis include: Young or old age, people with compromised immune system, patients with chronic illnesses of invasive diseases and people with open wounds or injuries, patients who have previously received antibiotics or corticosteroids.

Gait Analysis

Gait is a translatory progression of the body as a whole produced by coordinated, rotatory movements of body segments. Clinical gait analysis is the process by which, through the use of technology (e.g. specialized video cameras), quantitative information is collected to aid in the understanding of gait abnormalities and in treatment decision-making.

Normal gait is a rhythmic and characterized by alternating propulsive and retropulsive motions of the lower extremities. Gait has 2 main phases: the stance phase (comprising of the heel strike phase, foot flat, mid-stance, push-off) and the swing phase (comprising of acceleration phase, mid-swing, deceleration).

Gait abnormality rating scale (GARS) is used as a screening tool to evaluate a patient’s risk of injury from falling. Patients are assessed on 16 different aspects and patients with a score above 9 are at risk for falling. Conditions associated with gait abnormality may include foot drop, ataxia and limp.

Case Presentation

When meeting a new patient, a doctor should classify the breadth (medical, function and social issues) and depth (justifications for the differentials and for the decisions made) of case.

The doctor should then write the Comprehensive Case Analysis (CCA). This is written in the SOAP format (subjective, objective, active issues and passive issues). Active issues refer to issues that are receiving or have received treatment, have new evaluation and management. Active issues are anchored to presenting complaints with corresponding plan(s). Passive issues refer to issues that have no new evaluations and are receiving ongoing treatment. Passive issues are presented after active issues with single-line entry and no plan(s).

Before going on ward rounds, the doctor would refresh himself/herself on the patient’s case by reading the detailed version of the CCA. The doctor would also review overnight events and results and check the parameters. Afterwards, the doctor would speak to the patient and conduct a focused physical evaluation. The information obtained should be documented in the SOAP format and the active medical problems would be listed concisely and justified if appropriate.

During the ward round, cases would be presented in the following format:

Testing for speech abilities in patients

When testing for speech abilities, one needs to test 2 aspects, namely cortical and non-cortical. Cortical abnormalities affect the content of speech and is linked to motor/reception problems. On the other hand, non-cortical abnormalities affect the type of sounds one can make in speech. This is linked to lower motor neuron problems, muscular problems, etc.

Tests would include the following components:

• Test if patient can obey 3 step commands 🡪 e.g. When given the command, please raise your right hand, use your left hand to touch your nose and wriggle your toes. (If the patient is unable to obey, it is highly likely that the patient will fail subsequent tests.)
• Test the patient’s motor skills, which affects the components of speech production. The doctor will ask patients general questions like what they did yesterday or about their family to see if they can produce a coherent response.
• Conduct a test to identify sub-cortical abnormalities by seeing if the patient can repeat a sentence.
• Conduct a nominal test, where the doctor points at objects to see if patients can name 3 objects. The 3 objects are usually named in order of increasing detail (e.g. watch, watch face, watch hands). If the patient is unable to do so, simplify the task by asking the patient to name 3 distinct objects around the room.
• Lastly, the doctor will conduct an idiomatic test. An example of this would include asking the patient to explain what “no ifs, ands, or buts” means.

2 interesting aspects of MY learning

Ethics

The 4 principles that form the foundation of medical ethics are beneficence, non-maleficence, respect for autonomy and justice. The priority of each of these 4 values varies according to the situation.

Beneficence: how the actions of doctors should provide medical benefits and the decisions made should be in the best interests of patients and their families. A prerequisite to this is that they must be competent in their field and should constantly improve their medical competency through keeping up with recent medical advancements.

Non-maleficence: ensures that no harm is done to the patient due to the medical treatment or that treatment should maximise medical benefit and minimize harm. The treatment of patients ought to be based on a combination of reliable and established medical knowledge together with the experience and wisdom of the medical profession.

Respect for autonomy: how patients have a right to decide for themselves what treatment to accept. Doctors have the duty to aid patients in making informed decisions by informing them of all relevant information. The ability to do so also indicates a healthy mind and body of the patient. This goes against the “paternalistic” tradition within healthcare.

Justice: treating patients fairly and equitably, according to their medical needs. Doctors need to fairly distribute scarce health resources (distributive justice), with respect for people’s rights (rights-based justice) and for the laws of the country (legal justice).

I found Singapore’s medical ethics interesting because Singapore is a very diverse country. Therefore, although our medical ethics are mostly based on Western values, Asian values still have an impact. For example, one of the major differences between Asian values and Western values is that Asian values prioritize the community, while Western values place more emphasis on the individual. The influence of Asian values can be seen in our medical ethics when it comes to respecting a patient’s autonomy. There is a note in the Singapore Medical Council Handbook on Medical Ethics that patient autonomy is not absolute because respect for autonomy includes respecting the autonomy of those who may be potentially affected, such as other healthcare professionals or other members of the community. This corresponds to how Asian values consider the collective well-being of the community.

Personality Disorders

Personality disorders (PD) are a type of mental disorder in which the person has a rigid and unhealthy pattern of thinking, functioning and behaving. A person with a personality disorder may face challenges in social situations. This can affect both the individual’s life and those around him / her and may result in social isolation or alcohol or drug abuse. Personality disorders usually begin in the teenage years or early adulthood. Since personality is affected by both genetic factors and one’s environment, risk factors for such disorders include family history of PDs, chaotic family life during childhood, diagnosis of childhood conduct disorder, variations in brain chemistry and structure.

There are 3 clusters of Personality Disorders (Clusters A, B and C). Cluster A involves thinking and behaviour that are considered by others to be odd, bizarre, or eccentric. Cluster A disorders include Paranoid PD, schizoid PD and schizotypal PD. Cluster B refers to thinking and behaviour that is dramatic or erratic. This includes antisocial PD, borderline PD, histrionic PD and narcissistic PD. Cluster C refers to PD that makes one anxious or fearful. This includes Avoidant PD, dependent PD and obsessive-compulsive PD.

Other than PDs, a particularly interesting mental disorder would be the Munchausen Syndrome. Patients with this syndrome repeatedly and deliberately act as though they have a physical or mental illness despite them being perfectly healthy. This may be related to severe emotional difficulties.

Such conditions should be taken into consideration when a doctor meets a patient. For example, during our time at TTSH, we encountered a patient with borderline personality disorder and Munchausen Syndrome. I think that this is a particularly interesting aspect of the job as the doctor must be able to effectively differentiate what statements from the patient can be trusted. Typically, patients will want to get better and thus would not intentionally worsen their symptoms. They should also know their symptoms the best and doctors can rely on their description of their symptoms to come up with possible diagnoses. However, with this syndrome, doctors must trust their own sense of judgement and rely on more factual data as they might not be able to rely on what these patients say regarding their symptoms. In such cases, if the doctor fully trusts the patient and accedes to all the patient’s requests, it can harm both the patient and those around them. For example, some medical treatments prescribed for a physically healthy patient may result in adverse health effects on the patient. Morever, even if it does not harm the patient, it is a waste of the doctor’s time and medical resources to treat a physically healthy person.

1 takeaway for life

One takeaway for life would be that passion for one’s job is essential. Passion enables one to enjoy what they do and gives one the motivation to push on when the going gets tough. This is especially since jobs may not be as glamorous as they seem. For doctors, their job involves extremely long working hours. I distinctly remember Dr Endean telling us about his increased workload for that week. Instead of complaining about it, he seemed rather enthusiastic about it and said that since he was extremely interested in his job, he will report to work the next day with the same level of enthusiasm regardless how tired he is.

Being passionate drives one to persevere and allows one to be intrinsically motivated to perform his/her duties to the best of his/her ability. I think this is important since being a doctor can be a relatively thankless job. For example, since patients may not be able to see how busy doctors are, they may not be appreciative of their doctors’ efforts - especially if the waiting time is long. In addition, many would think that another patient has already shown their appreciation to the doctor or that the high cost required to consult doctors is sufficient, thus rendering verbal appreciations unnecessary.

Beyond just personal motivation, the passion one has for the job can be infectious. Due to his enthusiasm, Dr Endean checks in with the patients about their current condition far earlier than required. Thus, he can conduct ward rounds with other doctors and students earlier. This enables his department to send patients down for tests ahead of schedule. This improves their efficiency since patients can be tested before the patients from the other departments or wards are sent for those tests.

As Simon Sinek once famously mentioned:

“Working hard for something we don’t care about is called stress. Working hard for something we love is called passion.”

Doing what one loves and is passionate about will enable them to enjoy every moment of their work.

Pictures taken with Dr Endean and the medical students