Category Archives: Daily Rounds

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

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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.


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.


Living, Learning, Earning and Leaving

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helping the sick get better.. that’s my job

“One day I’ll be missing this place”

I read these words from a former staff nurse as a comment to a picture of the hospital where I am both a visiting consultant and a volunteer doctor. And I can’t blame them really, with the economic turmoil and the harsh reality of the nursing profession. Sometimes I myself am asked why I continue to stay despite the difficulties of medical practice and I tell them the story of one patient in particular who helped me place things in perspective.

I went to see this particular patient because she was referred to me for cardiopulmonary risk evaluation prior to a planned open cholecystectomy procedure, nothing out of the ordinary at first but when I looked briefly at her chart, I noted that she came from a far off town, at least two to three hours away. I confirmed this with the patient when I did my rounds and she told me that they even had to take a boat as part of the commute. I recall being to that town before on a medical mission at a friend’s invitation, so I know that it’s really a long way. When I asked how come they happened to be admitted at this particular hospital, she told me, and this would not be the first time, that her National Health Insurance Program (PhilHealth) payments were not up to date and hence, were not eligible for the program.

But the patient continued with her story and told me that she was not looking for a free accommodation and hospital services but rather, where the rates were lower, at least in more affordable compared to the private hospital where she first sought consult and later upon knowing the amount she had to pay, just opted to go back home despite the pain and discomfort she was feeling at that time, simply because she could not afford it. She tells me she has some money with her, but not enough she reckons for the expenses after the surgery; so that is why she will be asking for financial aid from the local politicians, a common practice I observed. She does not want to be begging for alms, but what can she do? She really wants to get well, to be relieved of the pain and suffering she told me. I finished my examination and promised her to help her in the best way that I could medically. I excused myself to make notes and place my written evaluation. The medical assessment would be the easy part; it’s all based on objective and sound scientific and medical data that’s readily available. It’s the human aspect of the healing process that’s a little tricky. The part where our mentors would say the art of medicine comes in, making that human connection and not just treating the patient as a compilation of lab results and imaging studies. In a way I’m thankful that she chose to go to this quaint hospital where it may be a little out of the way, not have the most advanced equipment, and sometimes where things just don’t go the way we plan them to be; but its doors are always open to those who seek medical aid, regardless of creed, race or stature in life. Likewise, the doctors who choose to serve here are more than willing to help out, despite the hurdles and insurmountable odds they have to face. And maybe that’s one of the reasons I choose to stay, because more than just a job, it’s a calling if you may, where I can practice my profession and give back something in return. Besides, here I can be an agent of change and there will always be something new to learn; mostly in the practice of medicine and sometimes, life in general.

In the words of the Blessed Mother Teresa: “Stay where you are. Find your own Calcutta. Find the sick, the suffering and the lonely right there where you are – in your own home and in your own families, in your work places and in your schools.. You can find Calcutta all over the world if you have the eyes to see. Everywhere, wherever you go, find people who are unwanted, unloved, uncared for, just rejected by society – completely forgotten, completely left alone.”

This article uploaded in response to today’s daily prompt


Hearts, Doctors, Love

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lub dup.. lub dup..

Out of breath? Palpitations? Skip beats? It could be signs of heart problems.. That or you could just be in love. Either way, have a date with your doctor today and find out. Happy Healthy Hearts’ Day everyone!


kamote

life lessons 101 in progress

life lessons 101 in progress

I’ve always wanted to become a doctor. My formative years were greatly influenced by stories of the men in white and episodes of E.R. I was eager to experience my very own episodes of Grey’s Anatomy, complete with all the interesting cases, hospital drama, and emotional soundtrack playing in my head.

But that was then. Fast-forward to today, where I find myself working in a tertiary government hospital where, everyday, we are greeted with suboptimal working conditions and huge patient loads. Kayod kalabaw.

I must admit I have turned into a grouchy person who easily snaps and bears his fangs at the slightest provocation. You know. It’s hard to put on a smile at 3am when you have been awake for more than 24 hours, you’re so exhausted because you’ve been running around like a headless chicken, you haven’t studied for an exam that same morning, and you have an unfinished report due that very day. All you want is to be left alone with the work you have to do. Like in my chosen field where, most of the time, the longest meaningful relationship I’d want to have with a patient is just as long as the time it takes to complete his or her abdominal ultrasound exam.

But every now and then, we’d get reminders of exactly why we do the things we do.

His name is Darren, an eight-year old kid from Bicol. His friends and family fondly call him Kamote, a term or endearment lovingly given by his grandfather. A cute little name for a cute little man. It’s barely been a month since I began my rotation in Radiation Oncology, a section in our department that deals with cancer patients.

“Ilan taon ka na?” I asked.

“Eight po,” he answered back, trying to hold up his right arm and feebly attempting to extend eight tiny little fingers. He had difficulty extending his right elbow, likely one of the effects of surgery to his brain. He had been diagnosed with craniopharyngioma, a benign tumor that has a malignant behavior.

He talked about his home and current living conditions, parts of the medical ordeal he went through, and his love for TinTin, his childhood playmate. He thanked us for being mabait, with the utmost sincerity only a child can show – a gesture which struck me because he barely knew us. We had only met a few minutes ago.

“Anong naramdaman or inisip mo nung sinabi nila na ooperahan ka?” I asked.

“Natakot po,” Kamote replied. “Pero tinalo ko ang takot ko para sa mga magulang ko.” My heart started to break. He said that with a smile, his face glowing as if nothing happened. Only the surgical scar by the hairline at the left side of his forehead gave clue to what this kid went through. His spirit was inspiring and his inner strength, palpable.

And just like that, my weariness went away. That heavy felling you get on your shoulders and the dull pain you feel in your legs and feet at the end of a tiring workday just disappeared. In the face of sleepless nights, of inhuman physical and emotional demands, and of incommensurate payoffs, this is why we do it. Why Surgery residents go on duties 3 or 4 days straight, giving beyond what’s expected of them. Why Obstetricians dedicate their lives in bringing new life into this world. Why Pediatric residents lose sleep, pumping Ambu bags which help their patients breathe. Why oncology specialists strive to make the lives of their patients better. And why most doctors miss out on family occasions, rushing back to the hospital to attend to their patients in need. Ordinary people doing amazing things. Darren is an example of the little things that make it all worth it.

“Bakit po kayo nalulungkot?” he surprisingly asked.

“Huh?” I quipped.

“Eh kasi po, bakit po namumula ang mata niyo?”

“Ah wala, yung hangin lang yun. Yung electric fan kasi nakatapat sa mukha ko.” I answered. Kamote smiled.

To all my brothers and sisters who have answered the same calling, here’s to more kamote moments.

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About the author:

Toto Carandang, M.D. is a graduate of UERMMMC Medicine Class of 2003 and is currently pursuing post graduate training at UP PGH. Words and images are all Dr. Carandang’s.


What Ails You?

Recently the following article is being circulated in the social media about the dilemmas that a practicing doctor in America is facing with regards to healthcare and how politics is wrecking havoc on them. Such is the sorry state of heath care providers here and abroad.

And it seems that this problem is not something new, as the following article entitled “A Fighting Chance” by Dr. Michael Hussin Muin written almost a decade ago in the Pinoy MD forums, still ring true to this day.

what's your diagnosis?

what’s your diagnosis?

The ‘Sell Out’ stigma has since died down. It is now a footnote in the obscure pages of Philippine medical history. But the exodus continues and the situation is a fierce topic in conferences. Even business schools have taken up the issue and debated on the reasons of the plight and flight of doctors and the effects on the public administration of health care. And the conclusion has taken a gentler form. No, they now agree, doctors didn’t sell out, they just gave up fighting.

And what are they fighting for? Among other things, doctors—and other health workers—fight for better pay and better working conditions. They fight for protection from bogus health companies and quacks in government. They fight for stronger organizational leadership. They fight for a better government. They fight for their patients. They fight for their families.

It is a sad fact that bank tellers and call center agents get better pay than general physicians in HMOs and residents in training. Bank tellers may get as much as P15,000 per month while GPs get P9,000-P12,000. Call center agents get as much as P21,000 per month while residents in private hospitals are lucky to get anything over P10,000. People who handle money and customer service get better wages than those who handle lives. This says much about industry standards, whatever that means.

But isn’t it true that all Filipinos are fighting for higher wages? Yes, but the fight is done in different ways and have different effects. When factory workers stop working, production goes down. When jeepney drivers wage a strike, transportation grinds to a halt. But when doctors go on strike, patients die.

I have seen doctors fight for a collective cause. They threatened work stoppage at a small private hospital unless conditions for better pay were met. They gathered just outside the emergency room and carried placards and signs. But the whispers and conversations within carried in them the futility of their efforts.

Tawagin mo ako pag may dumating na pasyente.’

Akyat muna ako at mag-a-assist ako sa OR.’

Sandali lang, andyan na yung follow-up ko.’

These are phrases uttered by the doctors on strike. Even the venue of the strike is crucial. They to sit it out in front of the emergency room and scramble in when an emergency case arrives. Once the patient is stabilized and brought up to the floors, they then trickle back into the strike area, anxious and ready for another case.

Doctors are not immune to the effects of graft, corruption and poverty. Some doctors are unemployed, while others take double or triple jobs. Many doctors look outside the field of clinical medicine for extra income. Some are into related fields like academics and research, while others go beyond medicine and venture into medical transcription, nursing, information technology and selling jewelry and health insurance.

Not everyone has government officials and actors for patients. In Batangas, moonlighting specialists settle for P1,000 for normal deliveries and P3,000 for caesarian sections. In the provinces, doctors are often faced with poor patients—and rather than exacting consultation fees, most instruct the patients to just buy the prescribed meds with what is left of their money.

Doctors are pinned to the wall. If they fight back, people die. But if they don’t fight back—well, they go home tired and weary. In any case, the health of Philippine society hinges on the Filipino doctors’ sense of decency—the decency to put the patient first—above anything and everything, even their own needs.

Hospitals and managed health companies exploit this sense of decency to a fault. They know doctors will not abandon patients. Yes, some paper work will be delayed if work stops, but they have administrative clerks for that. Patients will still be treated, surgeries will still be performed, follow-ups will still be done.

So, how will doctors fight back without hurting their patients? How will they go to the streets and protest unjust compensation? How will doctors fight unseen ghosts and forces that threaten to push them to acts of indecency and selfishness?

By bringing the fight closer to home. Everywhere doctors are questioning the choices that lay before them. While society continues to flourish in the notion that doctors get full satisfaction from public service, doctors struggle to face the harsh reality that life is full of syet. There are no right choices, just promises and responsibilities to keep. There are no wrong decisions, just consequences and the courage to live with them.

The fight to leave or stay—and yes, it is a fight—is not found in the loud voices on the streets and the echoing chants in demonstrations, but in the grave discussions at dinner tables and the whispered conversations when the children are asleep. Because doctors are slowly finding out that living—and leaving—for one’s family is a battle worth fighting for.

For some, it has come down to choosing between loneliness and poverty. Some choose to be lonely, while others choose to be poor. Doctors are not leaving, they are driven away. And these doctors carry their own personal battles in foreign lands, where they fight extreme depths of loneliness and immense levels of uncertainty. Those who stay fight their own battles of survival, where each day is a search for some sense of meaning in the care of other people’s lives.

In the gloom spreading all over the country, people are asking for a chance to get past poverty, a chance to make a difference, a chance to rise above the muck of helplessness. In the current state of desperation, people are looking for a fighting chance. And everybody deserves a fighting chance—even doctors.

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About the author:

Michael Hussin B. Muin, M.D. is the Founder and Editor-in-Chief of Pinoy.MD – The Website for Filipino Doctors. He is a professor of Clinical Anatomy and Medical Informatics in Pangasinan.

Photo credits: http://www.backfixer1.com


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