Author Archives: allen mallari

About allen mallari

physician by profession, writing is his other passion. irregularly updates his blogs spread precariously over the web. he also has a penchant for the absurd, the sublime and everything in between.

Medicine Maxims

THE MAXIMS OF MEDICINE

Before you examine the body of a patient,
Be patient to learn his story.
For once you learn his story,
You will also come to know
His body.
Before you diagnose any sickness,
Make sure there is no sickness in the mind or heart.
For the emotions in a man’s moon or sun,
Can point to the sickness in
Any one of his other parts.
Before you treat a man with a condition,
Know that not all cures can heal all people.
For the chemistry that works on one patient,
May not work for the next,
Because even medicine has its own
Conditions.
Before asserting a prognosis on any patient,
Always be objective and never subjective.
For telling a man that he will win the treasure of life,
But then later discovering that he will lose,
Will harm him more than by telling him
That he may lose,
But then he wins.
― Suzy Kassem, Rise Up and Salute the Sun: The Writings of Suzy Kassem

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The Good Doctor

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be good, always

A doctor, like anyone else who has to deal with human beings, each of them unique, cannot be a scientist; he is either, like the surgeon, a craftsman, or, like the physician and the psychologist, an artist. This means that in order to be a good doctor a man must also have a good character, that is to say, whatever weaknesses and foibles he may have, he must love his fellow human beings in the concrete and desire their good before his own

– W.H. Auden 1907-1973


Patients and Patience

Yesterday I spent my only day off from work to accompany my girlfriend at the hospital, not because she’s on duty but due to the fact that her father is still currently confined at the Intensive Care Unit. She greets me with a smile and once we were permitted to do so, we came in to see how he was doing.

There was still a multitude of wires and IV tubes attached to him, monitoring his vital signs, providing nourishment, cleaning up the toxins. I told the resident on duty that day, I may be a doctor by profession but at that point in time, I was a just a another anxious visitor who wanted to know how the patient was doing, just like everybody else. The same goes for my girlfriend, her role for the past few weeks was not of a doctor on duty, but that of a daughter to her father. Even without saying, I know it is a trying time for their family right now. And contrary to what some people might think, just because a family member is a doctor, doesn’t mean he has all the answers. To paraphrase, we’re also human.

And as this story is still unfolding, kindly allow me to share an article I read about the matter, originally published in the New England Journal of Medicine by Dr. Louise Aronson.

patient asking doctor

“Good” Patients and “Difficult” Patients — Rethinking Our Definitions

Four weeks after his quadruple bypass and valve repair, 3 weeks after the bladder infection, pharyngeal trauma, heart failure, nightly agitated confusion, and pacemaker and feeding-tube insertions, and 2 weeks after his return home, I was helping my 75-year-old father off the toilet when his blood pressure dropped out from under him. As did his legs.

I held him up. I shouted for my mother. As any doctor would, I kept a hand on my father’s pulse, which was regular: no pauses, no accelerations or decelerations.

My mother was 71 years old and, fortunately, quite fit. She had been making dinner and said she dropped the salad bowl when I yelled for her. She took the stairs two at time. Something about my tone, she said.

Together, we lowered my father to the bathroom floor. I told her to keep him talking and to call me if he stopped, and then I dialed 911.

In the emergency department, after some fluids, my father felt better. My mother held his hand. We compared this new hospital with the last one where we’d spent so many weeks but which had been diverting ambulances elsewhere that evening. The doctor came in and reported no ECG changes and no significant laboratory abnormalities, except that the INR was above the target range. The doctor guessed the trouble was a bit of dehydration. He would watch for a while, just to be safe.

My mother waited with my father. The rest of us filed in and out, not wanting to crowd the tiny room. Then my father’s blood pressure dropped again. I told the nurse and stayed out of the way. She silenced the alarm, upped the fluids, and rechecked the blood pressure. It was better. But less than half an hour later, we listened as the machine scanned for a reading, dropping from triple to double digits before it found its mark. The numbers flashed, but the silenced alarm remained quiet. I pressed the call button, and when the nurse arrived I asked her to call for the doctor. When no one came, I went to the nursing station and made my case to the assembled doctors and nurses. They were polite, but their unspoken message was that they were working hard, my father wasn’t their only patient, and they had appropriately prioritized their tasks. I wondered how many times I had made similar assumptions and offered similar assurances to patients or families.

After weeks of illness and caregiving, it can be a relief to be a daughter and leave the doctoring to others. But I had been holding a thought just beyond consciousness, and not just because I hoped to remain in my assigned role as patient’s offspring. At least as important, I didn’t want to be the sort of family member that medical teams complain about. Now that I’d apparently taken on that persona, there was no longer any point in suppressing the thought. Although the differential diagnosis for hypotension is long, my father’s heart was working well, I had adhered to the carefully calculated regimen that we’d received for his tube feeds and free water intake, and he did not have new medications or signs of infection. Those facts and his overly thin blood put internal bleeding like a neon sign at the top of the differential.

I rested my hand on my father’s arm to get his attention and said, “Dad, how much would you mind if I did a rectal?”

We doctors do many things that are otherwise unacceptable. We are trained not only in how to do such things but in how to do them almost without noticing, almost without caring, at least in the ways we might care in different circumstances or settings. A rectal exam on one’s father, of course, is exactly the same as other rectal exams — and also completely different. Luckily for me, my father was a doctor too.

When I asked my crazy question, he smiled.

“Kid,” he replied, “do what you have to do.”

I found gloves and lube. I had him roll onto his side. And afterward, I took my bloody gloved finger out into the hallway to prove my point.

I realize that walking to the nurses’ station holding aloft one’s bloody, gloved hand is not an optimal tactic from a professionalism standpoint — but it worked. A nurse followed me back into my father’s room, saw my panicked mother holding a bedpan overflowing with blood and clots, and called for help. Within seconds, the room filled, and minutes later, when the ICU team showed up, I stood back, a daughter again.

In retrospect, what is most interesting is how much more comfortable I felt performing an intimate procedure on my father than demanding the attention of the professionals assigned to care for him. Abiding by the unspoken rules of medical etiquette, I had quieted my internal alarms for more than 2 hours. Instead, I had considered how doctors and nurses feel about and treat so-called pushy or “difficult” families, and as a result, I had prioritized wanting us to be seen as a “good patient” and “good family” over being a good doctor-daughter.

Although many physicians would have made different choices than I did, the impetus for my decisions lay in a trait of our medical culture. When we call patients and families “good,” or at least spare them the “difficult” label, we are noting and rewarding acquiescence. Too often, this “good” means you agree with me and you don’t bother me and you let me be in charge of what happens and when. Such a definition runs counter to what we know about truly good care as a collaborative process. From the history that so often generates the diagnosis to the treatment that is the basis of care or cure, active participation of patients and families is essential to optimal outcomes.

There will always be patients and families who are considered high maintenance, challenging, or both by health care providers. Among them are a few with evident mental illness, but most are simply trying their best to understand and manage their own or their loved ones’ illness. That we sometimes feel besieged or irritated by these advocates speaks to opportunities for improvement in both medical culture and the health care system. Culturally, we could benefit from a lens shift toward seeing more-vocal patients and families as actively engaged in their health care, presenting new, potentially important information, and expressing unmet care needs. At the systems level, we need to both count (using specially designated sections of the medical record) and reward (through diagnostic and billing codes) the time that providers spend talking to patients and families.

I’ll never know whether such changes would have altered my behavior or that of the medical staff on the night of my father’s massive intestinal bleed, and fortunately we all acted in time. I do know that 8 years later, the most vivid image I have of that night is not my father wobbling in the bathroom surrounded by cold, hard tile and angular metal structures, or a mustard yellow bedpan filling with bright red blood. The image is this, a worst-case might-have-been scenario had I not been there, had I not had medical training, had I not spoken up: my parents, sleepy because it was by then late at night, snuggled up together at the top of the gurney, my mother resting her head against my father’s chest, their eyes closed, their faces relaxed. His systolic blood pressure, usually 130, dropping to 80 and then 70. The monitors turned off or ignored. The lights dim. A short nap and they’d feel better. A little rest and maybe it would be time to go home.


To the new Doctors…

In the now rare moments that I go online and check what is going on in, I look into my social media news feed, and I happily came across this message of a former schoolmate in medical school and her message to the newest batch of doctors who have passed licensure examination.

To the new Physicians of 2014:

By now, most of you are sitting in front of your computer clicking on the PRC website and hitting refresh relentlessly. Relax. The moment of reckoning is at hand. I was exactly where you are 6 months ago. I am familiar with the anxiety and the restlessness gnawing at you right now. If you can, try to savor the sweet torture of the anticipation. Remember the promises that you made and resolve to keep them. If you are still making promises, include this: Promise to be a physician that will serve your fellowmen. Promise to be a healer with integrity. Find your moral compass and follow it, no matter what. Promise to remember that arrogance and achievement DO NOT go hand in hand. But if you find that you cannot help yourself, keep in mind that arrogance COMES AFTER achievement and not before. Congratulations, 2014! Whatever the results may be, you have done your schools proud with your hard work and integrity.

Well said Rocky, well said.


Lest we forget

(c) Wellcome Library; Supplied by The Public Catalogue Foundation

“The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with potions and powders, but with the exercise of the influence of the strong upon the weak, of the righteous upon the wicked, of the wise upon the foolish”

Sir William Osler

Students of Medicine

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The following is a transcript of a post by ‘Egyptian Doctor’ in the thread “Being a good medical student doesn’t mean you’ll be a good doctor” in the forum.facmedicine.com discussion board started October 2013. All copyright including graphics depicted remain with their respective owners.

There is a saying that you enter medical school wanting to help people but exit it wanting to help yourself. It may be a cynical view, but a realistic one. The criteria to being a good medical student are far different from being a good doctor. Medical education may be breeding a legion of self-serving, grade-grubbing, SOAP-note spewing machines rather than the empathetic, compassionate and caring physicians of admission essays yore.

 I was no different. My first two years of medical school, I was largely a disinterested student. I didn’t care for basic sciences, research or pathology. Like many others, my knowledge waxed and waned with the test schedule, and after Step 1, I entered my clinical years an acceptably successful medical student.

 Excellent medical student, terrible clinician

 Third year begins a reign of terror lead by the constant gauntlet of heavily-weighted rotation grades, standardized exams and the looming threat of residency applications and the Match, when, after 20 years of schooling, some pie-in-the-sky computer would tell me if I was good enough or not to be a doctor, and subsequently determine my life for the next three to seven years.

Grades were a priori to make myself the most competitive residency candidate possible. I studied and worked hard. Each patient became an opportunity for me to impress on notes, rapid-fire oral presentations and predict nuanced “pimp’ questions. I learned to charm patients just enough that they’d acknowledge my care to the attending during rounds. I interrogated my patients just enough to write the excellent notes I knew I’d be evaluated on. I learned about my patients by memorizing their daily lab values to proudly recite on rounds.

Patients weren’t people with problems but stepping stones to rack up points with the attending. Once rounds were over, patients became time-sucks from studying time, an exam worth 30% of every rotation grade. Real humans do not follow textbook presentations, but exams do; the warm body in front of me only detracted from my evaluation by cold scantron. By my attendings’ clinical comments, I was an excellent medical student, but I knew I was a terrible clinician, rehearsed only in the games of academia, not medicine.

How I learned to stop worrying about the Match and love patient care

My shift in paradigm came with a shift in career path. My worst fear as a fledgling surgeon was not matching for a residency spot. My worst fear as a fledgling emergency physician was killing a patient. Suddenly playing doctor became very real, and in the middle of my OB/GYN rotation, I started to care not about textbook presentations but real-world ones. I didn’t care for OB/GYN and volunteered to cover the peripartum critical care unit, a similar environment to emergency medicine.

My first day on the unit, I saw a patient roll in as I was in the middle of practice questions on the computer. I glanced up but returned to my test preparation, justifying my delay in evaluating the patient because the resident was still in surgery. Half an hour later, the resident came to evaluate the patient and I followed — the patient was obtunded, hypotensive and sitting in a growing pool of her own blood. It would not have taken a MD to realize that this patient required immediate medical attention, and I kicked myself for not evaluating her sooner. I may have been a pretend doctor, but it finally struck me that I was a pretend doctor on very real patients.

For the rest of my time in the unit, I made it a point to personally round every hour, on the hour, on every patient. I didn’t always write notes for these hourly rounds — getting credit was no longer important to me — patient care was. While they initially questioned my obsessive rounding, the residents quickly came to trust my dedication and leave me to my own in the unit, knowing I’d alert them if necessary.

At my institution, hell hath no fury like an OB/GYN resident unnecessarily interrupted, so I spent my time reading on appropriate treatment courses for the different conditions I saw in the unit. After I rounded, I’d give the resident a list of orders to put in, and the nurses began to treat me as the main provider in the unit. I got to be the first person to make critical medical decisions, responding to truly acute situations and drastically changing the course of a patient’s treatment. I pulled long hours and hardly studied in the traditional sense with prep books and practice questions, but I was constantly reading on my patients. That shelf exam and clinical evaluations were my best of the year. I had learned to stop worrying about the Match and love patient care.

Not “just” a student

After that revelation, I fought to earn more responsibility and trust on each rotation; I learned more, gained competence and became more satisfied in my chosen career in medicine. During emergency medicine , the specialty that started it all for me, I learned more medicine in one month than I did in my entire third year. It was a pass/fail course with no motivation by grading, but I was terrified I would be the first person to evaluate a patient and not recognize a critical condition. That hemorrhaging patient from day one on the peripartum critical care unit still haunted me. People can decompensate quickly and unpredictably — at any moment, you may go from being “just” a student, to being the only medical provider in the room.

At the end of that rotation, Step 2 breezed by with none of the misery I experienced with Step 1. Behind each question I’d see faces of patients with that exact presentation; behind each answer choice, I’d see the clinical consequence of making the wrong decision. Finally, I understood what it mean to be both an excellent medical student, and (at my level of training) an excellent clinician.

The academics of medicine often makes us forget the “59 yo AA M, PMH CHF dx 2010 (EF 20% by TTE 8/2013) p/w SOB x 2d” is a real person, with real vulnerabilities and real fears. We are not “just” students, but trainees and members of the medical profession. Grades and exams do not define us, but are simply checks on clinical competence. Trite as it may be, remember what you wrote about in your admissions essay — why you embarked on this journey in the first place. We came to medical school not to become excellent medical students, but to become excellent doctors.

Always keep that in mind. Everything else, the grades, the Match, the exams, will fall in place.


April Fools and Medical Tools

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Earlier today, I was reading a blog… It had reasons why you shouldn’t become a doctor. Natawa ako. I understood and mostly, I felt what the author was trying to say about the medical field. In summary, he said that you shouldn’t delve into studying medicine if you are not ready to sacrifice your friends before Medical School, your relationships and pretty much your own health and sanity.

Doctors are not the healthiest people on the planet, they are sleep deprived, eat irregularly and do whatever it takes to survive the stress. Maslow’s hierarchy of needs is evident when you’ve been on duty and you had to choose between sleep or quality time with a significant other. Sleep wins. Physiologic needs trump the need for love and belonging, for security. You need to find either a partner who is in the same field or a SAINT who would willingly put up with the craziness you’re going through. However there is ONE reason why you should take up Medicine. If it is your calling, if it is the one thing you see yourself doing FOR THE REST OF YOUR LIFE then by all means, GO FOR IT.

Tomorrow is April 1. What’s special? Wala naman because I don’t have any summer vacation picture to post in my page nor a “mouthwatering” body to display in the beach. Sa totoo lang, wala pa ako maayos na tulog. Hindi dahil nag-inuman kami hangga mag umaga, nagpagulong-gulong sa beach, sumayaw buong gabi ng “Feel this Moment”. Nasa hospital ako, naka duty. Habang pinagmamasdan ko ang pasyente ko pinapa nebulize, sumagi sa isip ko na mag ta-tatlong taon na pala ako nung unang sinabak kami sa hospital bilang doktor. Oo, April 1, trending na naman nyan ang mga hastags #clerkship, #juniorinternship , #lowestformofanimal ,#ninjaintern , #boyatgirltakas , #anakngdiyoskayapullout at kung sosyal ka,#shetwhitelacosteshoeskomayblood

Mahabang pasensya ang kailangan sa #clerkship. You have to survive this step in your medical career even if it means hardly seeing your family whom you live with, even though you won’t be able to see your best friends that much, even though you’re in a group different from your friends, even though you would be seeing your ex’s girlfriend/boyfriend in the hospital every single day, even though another ex is dating your group mate, even though you would miss a lot of events including weddings of friends and christening of their kids birthdays and everything else, even though you would end up not watching your favorite shows or get to watch movies you’ve been dying to see, even though you are going to lose the guy/girl that made your heart skip a beat again (whom you just met a couple of weeks before clerkship), You just got to deal with it. Everything would fall into place if it is in His will.

But before you can go further, you need to be able to fulfill your basic responsibility. As a medical student, that responsibility is to study well. The pervasive nature of mediocrity is such that medical students who get by with “Pwede na,” “Ayos lang iyan,” and “Bakit ko ba pahihirapan ang sarili ko?” later on become the doctors who deprive their patients the opportunity to receive the best possible medical care at the soonest possible time. Remember that every minute of delay translates, not just to inconvenience at your patient’s end, but to another minute of unnecessary pain, or anxiety, or hopelessness.

You’ve already invested so much into this, your parents gave so much for this. Sweat, blood and tears went into your career path and it’s not over yet… There’s nothing else you can do but survive. Let’s take it one day at a time. Matatapos din yan  As I’ve always been saying, by choosing to become a doctor, you make a commitment to pursue excellence, to go above and beyond expectations whenever possible. That commitment starts, not during #clerkship, not when you pass the licensure exam, but on the day you turn page one of your Anatomy book

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About the author:

Francis Xavier “FX” Apostol, MD is a graduate of the Angeles University Foundation Medical Center School of Medicine Class of 2012. Aside from being a highly respected and dedicated doctor, is also a loving father and husband, a mentor, educator and lifelong learner. He also describes himself as pogi.

NB: this first appeared on the author’s social media account, accompanying pictures and words by Dr. FX Apostol. No copyright infringement intended.


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