kamote

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.

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]

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.

Chart Wars

After spending four years in med school, one year of internship, three years of residency and some time as a hospitalist, you tend to get the hang of how things work and sometimes writing patient histories and writing orders on the patient chart becomes semi automatic somehow. But sometimes, some things get lost in translation from the native tongue to the standard English language the as the following allegedly actual chart entries in one of the biggest government hospitals might attest to.

Patient has chest pain if she lies over her left side for over a year.

On the second day, the knee was better and on the third day, it disappeared.

She has no rigors or shaking chills, but her husband states that she was very hot in bed last night.

The patient is tearful and crying constantly. She also appears to be depressed.

The patient has been depressed since she began seeing me in 1993.

Discharge Status: Alive but without permission.

The patient refused autopsy.

The patient has no previous history of suicides.

She is numb from her toes down.

While in ER, she was examined, X-rated and sent home.

The skin was moist and dry.

Occasional, constant, infrequent headaches.

Patient was alert and unresponsive.

Rectal examination showed a normal sized thyroid.

She stated that she had been constipated for most of her life, until she got separated.

The lab test showed abnormal lover function.

The patient was to have a bowel resection. However, he took a job as a stockbroker instead.

Skin: somewhat pale but present.

Patient has two teenage children, but no other abnormalities.

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photo taken from http://www.bs757.com

Hearts’ Day

hold my hand..

While I really have no idea on where or how other people spent valentine’s day, I spent mine  doing my rounds and working as the resident on duty in the ward section of the hospital.

And while some people, and probably the rest of the world were having candlelit dinners, watching a musical, a movie or even just having a romantic walk in the park, I did my rounds alone.

I’m pretty sure that at some point in time, while someone else might have been holding a special loved one’s hand, putting on a ring and promising forever, I held on to my 90 year old patient’s frail and shriveled hand just long enough to reassure her that she is not alone; that it won’t be long now, that things will get better soon.

And for a moments I pause and wonder if I’m saying all these for the benefit of my patient or for myself..

[NB: this piece was originally written and posted at my other blog, this event happened during my first 2 months of being a resident in training in Internal Medicine, modified and reformatted for this blog post]

The Sandwich, The Bananas and The Blind

image courtesy of 7bigspoons.com

A patient came in for follow up consult today after being confined in the hospital for elevated blood pressure. She was grateful that I took her case even though at the onset she stated that she did not have any money on her. I told her that if I didn’t take care of her when I did, she might have ended up with a stroke or worse a heart attack. Although she’s still not out of the woods yet she is thankful that she now knows what she has and with the right medications and motivation, she can still enjoy a rewarding life ahead of her. I told her that her consultation today was on me. She can pay me the next time she visits for consult. It was then that she said no, and gave me two bunches of bananas. She insists that she will pay me for my services as soon as she is able, that the bananas were a thank you gift. I could not say no and graciously accepted them.

It made me think of the time when I was still a clinical clerk (4th year medical student) doing rotations in the department of ophthalmology, I had come to see a patient who came in for consult at the outpatient clinics for a much needed eye surgery. When I saw her all she had was light perception, but if operated on there was a chance that she could see again. Being in the charity service, there was a lot of work to be done and papers to be filled out. I did all that I can to help her out. It took us almost half the day to finish, but it was all in a day’s work for me. She asked me what my name was and I told her. I won’t forget you she told me. And they went home to get some of the other requirements. I saw them a few more times in the OPD but then we were to rotate in general surgery already, so I never did know what happened to her after.

Until after a rather busy tour of duty, in the flurry of activity in the surgery quarters, someone called out my name and was handing me a package of what seemed like food. “Your breakfast” he said. “From who?” I asked. He mentions the name and in my half asleep, half awake state I realized that it was the name of the patient I had helped before. Apparently she was already admitted and was scheduled for surgery that day.

Eventually, I did find to time to visit her and see how she was doing. She was already in the ward, but still with bandages over her eyes. “Oh, it’s you” she said when I greeted her “did you get the food that I sent you?” I responded in the affirmative and advised her not to strain herself as she just underwent surgery. Again I thanked her for the kind gesture but she was quick to say that she was just giving what is due to her “doctor”.

At another time, as part of our rotation in the department of obstetrics and gynecology, we needed to complete a month of outside rotation from our private teaching hospital to a government institution, either at East Avenue Medical Center or at Quirino Memorial Memorial Medical Center. Half of the team went to the Quirino Questors while I was with the East Avenue Avengers.

At one time during my duty at the delivery room there was a patient who looked famished and asked, no she begged me actually, if I could call her husband for her. Since I couldn’t leave my post, I said no. But a feeling of guilt and sympathy took the better of me and I asked if there was anything else I could do instead. She said if it was possible for me to text her husband to bring her food. I obliged and a few hours later I found her eating a sandwich, presumably the one her husband brought for her. She had even offered me a bite which I respectfully declined, even if my body probably did need some form of nourishment as well. I was off to my other duties and between assisting in the residents, doing post op orders and generally just trying to survive, I never saw her again. She would just be another nameless patient I had encountered in my tour of duty, nothing of major significance. Or so I thought.

A few days before we were to leave the hospital I heard someone calling by an unfamiliar title “Doctor, doctor!” they said. It was a while before I realized who they were. It was the sandwich lady. I did not recognize her because she was in a much better state than when I saw her at the delivery room. For one thing she was cleaner and looked refreshed. And she did not look famished anymore. But the dead giveaway was that she could now afford to smile. “I’m on my way home. We’ve been discharged already. I just wanted to thank you” she said. “You were the only one who was kind enough to help me.” I was at a loss for words so just I bid them good luck and to take care of their most precious possession, but by the smile upon their face, I knew that whatever the day was still to bring, it was all going to be worth it.

They teach us all kinds of stuff in med school from how to diagnose diseases to what medications to give them, but here in the hallways of an understaffed overworked government hospital a patient has taught me that an act of kindness no matter how small or insignificant it may seem, goes a long way.

So whether it be a bunch of bananas, a packed meal, or simply just a smile and ‘thank you’ I will always be thankful to the patients who remind me why I chose to be in this profession in the first place and why I continue to do so.

On God, Doctors and Nurses

I’d like to think that we work better together

I was still a resident in training when this particular incident happened while doing our morning rounds: one of the patient’s relatives approached us and asked what time a certain surgeon will do his rounds, politely we informed him that we are not surgery residents and maybe he should ask the assistance of the ward nurses. So in a not so subtle voice he proceeded to ask within hear shot of everyone around, “Who is the nurse in charge? Yung alalay niya? ” to quote him verbatim. Loosely translated, he was looking for the “aide”, absurd at it may be, as nurses are professional as well. Anyway, his reason for wanting to see the surgeon was that he wanted to talk to him before seeing the patient and telling her about the biopsy results. According to the relative, since he’s “just” a doctor (“doctor lang siya”), he wouldn’t understand the patient’s needs and emotional state and just give the medical mumbo jumbo of the disease and would nary a care about how the patient feels. I’ve heard enough. I went to proceed with the morning rounds thinking, is this just an outlier or do all other patient relatives feel the same way? I rather hope not, but if that is the way that they do see doctors in general, then that means as a doctor myself, this should be a wake-up call. As all the medical science I have learned in residency training will have boiled down to nothing if I forget the basic tenet of why we are here in the first place: to treat the patient and not the disease, if not cure him of his illness in the very least alleviate him of his sufferings.

The other issue here that I would like to raise is how the relative have belittled our colleagues in the medical profession, namely the nurses. Here we clearly see that the relative downgraded the nursing profession to co-equals in treating the patient to simple being a doctor’s assistant. The world is far from perfect, but it would be so much more a better place if we could set aside our own prejudice and stereotypes of what people are and what they are capable of doing. Nurses are our allies in making sure that our patients get better, and most of the time they do most of the work even if they are understaffed, underpaid and worse, unappreciated. Just to repeat the point, nurses are not our aides, they are our partners in healthcare. And for some us lofty doctors, this story should serve us well to be reminded that our profession is that of humble service. In good days, when we have accolades and praises when we do our job right, should just be viewed as a reward for a job well done. Same way as when we did all we could but things didn’t turn out for the better. We may strive to be, but we are not God to begin with, only his instruments in doing his will. Take it in stride, tomorrow is another day.