Monthly Archives: September 2013

Prescriptions & Prejudice

rxpad

kindly include prayers as needed..

Part of what I do as an In-House physician in the hemodialysis center where I work is to review the patient’s list of medications and if needed, refill prescriptions for the said medicines, as we often limit them to a month’s worth as they may have to be changed later based on their response to the said medications. One time, the husband of a patient came to me asking if I could make three identical copies of his wife’s prescription. When I asked why, he reasoned that he was going to ask three different entities, namely, the City Health Service of the City of Angeles, the Philippine Charity Sweepstakes Office and the Office of the Governor, for the said medicines. Further reasoning that if all three gave him, he would have at least been assured of 3 months worth of meds, if not, he will just buy them instead. I pause and give a short sigh, but remember having read this letter from a woman who experienced prejudice firsthand, I would think twice before passing judgment.

Going back to the said letter, I was drawn to another website where it was also featured not to the article itself but the commentaries of the people who have read it. Some of them pointed out that true, there may be people who are actually in need of this kind of aid from the government, there are still those who abuse these kinds of things as well. Government aid, they argued, can be a bane or a boon depending on how we look at it and from whose perspective. Given the ongoing talks about misused funds and taxpayers money, I heave yet another sigh.

I remember when I was still a Junior Intern (or Clinical Clerk as they are known in some other institutions) during my rotation at the Out Patient Services, Charity Division of the hospital my then OPD resident told me to assist a patient to the Social Services office prior to their admission. The patient was a male in his early 20’s and with him was his father. Based on the planned surgery, he would be needing titanium plates and these would cost money of course. The question would be: will the hospital shoulder some or all of the medical expenses, given that this was a charity case. At the Social Service office he was asked routine questions about their family and the patient: Where they lived, source of income, etc. I was there so I know for a fact that the father claimed that he had no stable source of income, when lucky he would ply the streets as a tricycle driver. That they were living with relatives in Manila just for the time until the surgery can be done. He presented some documents for scrutiny, and after several minutes had his admission stamped with “class D” – meaning he was from the lower income bracket and was indeed qualified to avail of the hospital’s charity services.

So what has the above story connect with the first? It was only later when I went to see how the patient was doing when I accidentally overheard the father of the patient talking to another relative in the ward. He said, or rather boasting, that he wasn’t really poor at all, that they had just been from Hong Kong the month before, and that he just wanted to save the money he would have otherwise spent on the titanium plates had they known his real status in life. We have to be wise about these things he said with a laugh. I cringed. We all have been fooled, the people who just wanted to help, by some people who deliberately choose to deceive and get the upper hand.

What is disheartening most about this is not the fact that part of what was used to pay this particular patient’s hospital expenses came from our tuition fee as medical students, but that the same treatment could have been given to someone who actually did deserve and needed it. This happened several years ago, but with today’s current issues at hand foremost the circus that is the pork barrel scam still to find a resolution, I choose to abide by the oath that I have taken as a physician, and rather than be a critic, to just do what it is we hope to do best: to be a healer to the sick and afflicted no matter their race, creed or stature in life and hopefully in our own little way, be a catalyst for the change that we yearn for.

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Old Methods, New Learnings

[NB: The following appeared on the opinions pages of the Philippine Daily Inquirer  the online version can be found here. The article was written by Dr. Leonardo L. Leonidas who retired in 2008 as assistant clinical professor in pediatrics from Boston’s Tufts University School of Medicine, where he was recognized with a Distinguished Career Teaching Award in 2009. He is a 1986 graduate of the UP College of Medicine. All copyrights remain with their respective authors and the Philippine Daily Inquirer]

med_school_591

medicine.. lifelong learning

About 17 years ago, Bethany, a former patient of mine, asked if she could shadow me for three months at my office. She had just finished her premed course at the University of Maine. She wanted to apply to a medical school.

In the first couple of weeks, she just observed what I was doing. Then I let her listen to the chest and heart of my patients and, in time, to use the otoscope to look at the eardrum. Soon she was palpating the abdomen of babies and checking the hips for dislocation.

After about a month of Bethany’s observing and listening to how I took the clinical history of children with ear and throat infections, I would leave her to interview the parents and write the history herself. When I would return to the examination room, I would find the history and details of the physical exam already done in the computer.

Near the end of her three-month “training,” Bethany was writing prescriptions for the most common antibiotics for ear and throat infections as well as pneumonia.

A couple of years later, my son, Len, completed his course in biology at the same university that Bethany went to. He wanted to take a year off before applying to medical schools, and he volunteered to help at my office. Like Bethany, he shadowed me and learned how to take a patient’s clinical history and conduct a physical examination.

Neither Bethany nor Len attended formal lectures in basic medical subjects like anatomy and physiology. Because my office was busy, I just told them the main features of a disease to make a diagnosis. I advised them to read about pneumonia, asthma, ear infections, strep throat, appendicitis, migraine, etc. after office hours.

Len shadowed me for about 11 months, and I treated him like a third year med student. And during that time, aside from diagnosing the most common illnesses in children, he was able to suspect appendicitis in two cases—and the surgical reports confirmed it. Just after about three months, I left Len alone with my patients and their parents, and he independently wrote the histories and physical examinations, made diagnoses, and wrote prescriptions. I reviewed what he had done and signed the Rx. In the vast majority of patients, his diagnoses were on target.

Now why am I telling you about Bethany and Len? With the advent of the iPad, tablets, smartphones, and laptops, I think we can drastically change how we educate our medical students, in a better and faster way, with less of the stress that may lead them to depression or suicide.

The only lecture-based topics that medical students need are: how to take a history, to do a physical examination, to make a differential diagnosis, and to request the most common lab and imaging procedures. These can be done in the first six months of med school. Then they should be exposed to patients as early as the second half of the first year. The “basic sciences” standard lectures should be reduced by 80 percent; they should be allowed to study independently outside the lecture room using video lectures by the best teachers, which are available 24/7.

During the bedside interview with the patient, using an iPad or tablet, students can easily look for the common signs and symptoms, pertinent physical exam, and patho-physiology procedure needed to figure out the diagnosis. With a resident guiding or demonstrating to them the steps in making a diagnosis, students will learn clinical medicine faster than in the traditional lecture-based education which, from my experience, was stressful because of tons of memorization.

Armed with an iPad, tablet, or laptop, students can make an electronic patient portfolio file (EPPF) that they have to keep from first to fourth year. Their graduation will be based on this EPPF. However, they will have to see a minimum number of patients afflicted with asthma, migraine, diabetes, pneumonia, heart failure, meningitis, depression, head injury, fracture, appendicitis, etc. The EPPF will carry complete histories, physical exams, differential diagnoses, work-ups, discussions, and evidence-based medicine references (if available).

The EPPF will be designed to include a self-assessment test after each case; a student should be expected to answer and pass this test by at least 90 percent. The questions will be almost the same as what are being asked in the national board exams.

Students’ EPPFs can be easily reviewed by senior residents, mentors, or consultants without them leaving the comfort of their office or living room. A patient may also access an EPPF if he/she desires to do so, and correct or add new information. If the patient has an e-mail or Facebook account, a student can do follow-up work and an outcome study. Those who are interested in teaching, even if not part of the faculty, may volunteer to be e-mentors. With this pool of talent and experience, learning can be more personal and global.

About 10 years ago, I hosted an e-learning case-based problem-solving session with third year students of the University of the Philippines College of Medicine. It was fun, and one of my e-students commented that he learned from my e-mails much more than in the six-week rotation at the Department of Pediatrics. This student has just completed his gastrointestinal fellowship at Mayo Clinic.

Bethany is now a cardiovascular surgeon, and Len an internist-pediatrician.

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We would like to acknowledge the author for giving us permission to repost his article in this blog and saying that he might contribute here as well.


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