Tag Archives: medicine

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


Weathering the Storm

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Image from the author’s original post

I woke up yesterday to the sound of rain outside my window and news that school and work had been cancelled. It had been raining since last weekend and parts of Manila were under water. I literally had to drag myself out of bed because we still had to go to the hospital. We still had patients to see and take care of at the Philippine General Hospital.

While a tropical storm above the northeastern waters of the country was enhancing the southwest monsoon and bringing heavy rainfall over Luzon, another storm was brewing.

My first patient for the day was Gibb, an 8-year old child who underwent brain surgery for a malignant tumor in his cerebellar region. He was scheduled for an MRI of his head and whole spine.

I saw his mother, Precy, hunched over in prayer, her fingers nimbly going through one rosary bead at a time. I began chatting with her about her son.

Gibb began exhibiting symptoms last year when his family noted that he was becoming cross-eyed. This eventually progressed until the little boy couldn’t stand or walk straight. They brought him to a private hospital in Cavite but decided to transfer him to PGH because of financial constraints. Something we usually hear from a lot of our patients.

Gibb soon underwent the operation he needed. Precy told me they had to use all of their savings and money given to them by her sibling for the surgical procedure. She used to work in manufacturing but had to stop. Her husband, Antonio, currently works as a regular contractual waiter in one of the restaurants in Manila. Both paid taxes. Both had very little. She said it cost them around 60 thousand pesos.

For the craniospinal MRI, Precy shared that she was able to get money from other relatives and from people in her baranggay. She said it wasn’t easy, but she was glad that they were able to come up with the money. I saw the sense of relief in their eyes when Gibb was wheeled into the MRI complex. It was another step towards getting better. Another hurdle passed. It cost them around 18 thousand pesos.

Like most cancer patients, Gibb and his parents were advised chemotherapy. For this, Precy had to approach people in government for help. And as people in healthcare know, it’s no easy task. The 34-year old mother had to secure requirements, papers, and had to take several trips to a number of government agencies and offices. It took her a number of weeks. Precy then began enumerating the Guarantee Letters she was able to secure: P10 thousand from Senator Pia Cayetano, P5 thousand each from Senators Recto, Marcos, and Trillanes, and P2 thousand from Senator Enrile. She also received financial help from her congressman, mayor, and vice governor. All of these, she said, will go to Gibb’s chemotherapy.

Aside from that, Gibb will also have to undergo radiation therapy. The young mother shared that for this, they had planned to sell some of their possessions like inherited jewelry. Papers for aid from PCSO and help from their governor were also being processed.

She sounded hopeful. She admitted that they didn’t expect to end up where they were right now. The whole process of giving their son the appropriate medical and surgical treatment he needed was long and arduous. She said they were tired. There were times she felt defeated. “Para ho kaming nanglilimos,’ she said.

Recently, Janet-Lim Napoles and the P10-billion pork barrel fund scam hit the headlines. I felt bothered, disturbed, and angry. As a tax payer, if things people have been saying are true, I am appalled with how my hard-earned money was ill-spent and allegedly stolen. As a Filipino, I am deeply bothered. I weep for my beloved nation.

If all of the allegations are true, I hope Napoles, her family, and all the other people involved can live a day in the life of our patients. Walk in their shoes. And see how difficult things are for most Filipinos, especially the marginalized ones. I hope they experience the panic and hopelessness our patients face when they are given huge hospital bills prior to a procedure. Or the discomfort of sleeping under the patient’s bed on cardboard mattresses. Or being confined in one of our wards instead of a luxurious suite, where privacy is almost non-existent and where every cough, cry, and sneeze is shared by at least 40 other people in the room.

There is now a movement calling for the abolition of the pork barrel fund. While I am for it, Precy’s and Gibb’s story reminds us of where part of our taxes go and the good that can be done if our financial resources are managed correctly.

Some people have been saying that P10 billion could have bought us new roads and bridges, built new school houses or railroad tracks, paid for badly-needed education or healthcare for thousands of Filipinos. I think that absurdly huge amount of money could have given us something equally important – hope. Hope that the government is investing in its people. That Big Brother has your back during your time of need. That politicians can put the interest of the majority before theirs. That things can get better – not just for some, but for all of us.

I usually just go about my business everyday, reading the headlines. Sure, I get bothered by the troubling things I see on the news. Predictably, I complain with my coworkers over lunch about how our country is going to the dogs, like a couple of rants on Facebook, and then eventually shrug things off. Like the pseudo-couch activist that I am. However, things resonate differently within me now. I’ve decided I’ve had enough and I feel I should do something, even if it’s a small thing. I asked Precy if I could share her story to which she agreed.

On August 26, Monday, people will gather in Luneta asking for an explanation from our government. I hope to be there. Things may not change and we may never uncover the truth. But I hope our voices will be heard. And hope, is hope.

Today, Tuesday, I woke up to the sound of rain outside my window. And while I prepare to go to work, I think about our countless patients like Precy, Antonio, and Gibb and the long journey they still have to take.

It’s still dark outside. A storm is brewing.

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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. Our heartfelt thanks to him for allowing us to post his article on this blog.


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]

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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.


Taxation and the Medical Profession

weatherproof

weatherproof

As my car is in the repair shop yet again, so I join the thousands of other people who do their daily commute to and from work. As it was both raining and a holiday at that, someone commented that not only do I have no holiday break, but I’m waterproof as well. I gently remind them that there is no holidays for the sick needing our help as well and I am only thankful that I am the one giving help rather than the one needing it.

During the stall due to traffic, I would hear people complain out loud why the government isn’t doing anything about the road conditions, another would butt in and say a salary increase would be appreciated as well. Me, I stay quiet for the remainder of the trip.

I was doing my regular free clinic at the hospital’s outpatient department when I was called to the Emergency Room. I rushed in to find that they were trying to resuscitate  a patient, whom I later realize was actually the wife of another patient of mine currently also admitted in the hospital. I remember just talking to her the day the day before regarding his husband’s condition. And now this. She had been denying herself of the needed medicines so that her husband could be operated on. I could only do so much to console my patient and empathize for his loss. Looking back earlier at the people in the jeepney and their wishes, none of them simply wanted something for themselves but for something that everyone would benefit from as well. They were not selfish wishes and so I too add my own, a better healthcare coverage for all and better equipped medical facilities for our dear indigent patients.

As a rule I try to veer away from writing about two things that usually invite either criticisms due to difference in opinions. These would be religion and politics. But just this once, I will write also something about the latter.

Some time ago, there was news about physicians not paying their taxes correctly. I wrote about it already in my other blog here so I won’t elaborate on it. The point is, I am a law abiding citizen of the country and pay my taxes. Which leads me to the second point of contention: the alleged misappropriations of public funds (of which I have a contribution to) for unscrupulous activities. Apparently I am not alone. Dismayed, other physicians have vented their thoughts on the social media. A a colleague of mine, Dr. Jaylin Valencia posted this on her Facebook status update:

Last night I had a patient who came in because of severe headache. After my history and PE I immediately informed his relatives that he needs to admitted. From the looks of the patient you can say that you have a case of “can we just have a prescription for the pain or can you just give us a referral letter, di po namin kaya ang mag private” lo and behold, I just got what my gut is telling me. While I was writing, he would open his eyes, telling me his head really hurts. A look that clamors for help… A look that would tell you, “I WANT TO LIVE”.

As I ended my shift and was about to leave, I saw a man being rushed at the ER unconscious. To my surprise, it was my patient last night. As I talked to the wife, she told me that he was brought at a government institution but still, he never got the immediate care that he needs, for the same old reason that we hear: “FINANCIAL CONSTRAINTS”

Ironically, the news on TV for the nth time was talking about the 10 Billion peso scam. I looked at the man, almost lifeless, holding on to whatever a glimmer of hope that it can give for his life. My heart just sank as I look at these people involved with this very gruesome scandal. How many people do we need to see looking at their deathbed shouting from the top of their lungs saying “KAILANGAN KONG MABUHAY PARA SA PAMILYA KO!” or simply saying “GUSTO KO PANG MABUHAY, KARAPATAN KO NAMAN YUN”.
When is justice going to be served for these people? Tsk!

When indeed I find myself asking, when indeed..

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About the contributor:

Jaylin Valencia, M.D. is a graduate of the Angeles University Foundation School of Medicine Class 2005 and is in private practice and teaches future doctors as a full time faculty.


Doctor as Patient

[NB: The following is the editorial reproduced in full from the Philippine Journal of Internal Medicine Vol. 50 No. 1 January – March 2012 issue, it was written byDr. Margarita Cayco. All copyrights remain with their respective authors and the Philippine College of Physicians]

I am the primary example of a doctor cast in the role of a patient.

This editorial is not a scientific or theoretical one but is my way of educating internists on another facet of medical care. To my medical students, may this article highlight to them that knowledge of the principles of medicine is not enough to practice medicine. It is also important to practice medicine in a humane way.

This article is the first time that I have put down in words my experience and my feelings about what happened to me. I hope the readers of this journal will allow me leeway in my choice of topic for this editorial.

I was hospitalized in late 2007 because of encephalitis, etiology unknown. I do not recall my symptoms prior to my admission. I was told I was highly febrile and complained of urinary retention. I ended up on a
mechanical ventilator because I was in a coma for several weeks and eventually got a tracheostomy, percutaneous endoscopic gastrostomy, a urinary cystostomy and had the requisite central lines. I had to undergo multiple lumbar punctures, phlebotomies and even blood transfusions. My case was a real meeting of minds which knew no boundaries or rivalries among graduates of different Filipino medical schools, just like my marriage to a UERM graduate (my being a graduate of UST medicine). My doctors were from UP-PGH, UST and UERM.

I was comatose for at least two months and thankfully I dot not remember anything that occurred in the intensive care unit. When I woke up I had to undergo rehabilitation (physical therapy and visual rehabilitation) for several months.

I owe my life to all my doctors, the residents, nurses and therapists and of course to my family, classmates, colleagues, friends and medical societies.

Being a patient made me realize what my own patients go through and gave me a firsthand glimpse into their sufferings. It made me sympathize and empathize more with them and made me more patient and understanding in my dealings with them. It makes it easier for me to discuss with them whenever the need for a procedure arises, especially a tracheostomy. I just show them my scars and almost always they agree to have the procedure done. I actually have not had a patient refuse a procedure after I talk to them. I tell
them that if I did not have those procedures done I would not be talking and walking now.

My experience as a patient was a humbling experience and hopefully made me a better doctor and teacher.


Chasing Dreams.. Again

[NB: This article was previously published in my other blog as chasing dreams sometime in 2008. This has been slightly modified and updated from the original article for this blog post]

nurturing the dream

While on board a bus in heavy traffic, this thought came into my mind: when we were still kids and the issues of global warming and the environmental concerns were already present, although not yet a tangible reality, we were told to plant seeds in the hope that it will one day become a majestic tree.

Needless to say, that was a long time ago.

Now all grown up, I realized that it was not entirely a lie but it was more of a half-truth if you please. I do not know if it was an oversight of my teachers then, but in hindsight and retrospect, they should have also taught us that it was not enough that you plant a seed and hope that it will grow. It should be nourished, taken cared of and even protected from the harsh elements. Or perhaps they were actually wise in letting us learn that fact of life for ourselves as we grew older. I will never know. What I do know is that seeds are pretty much like our dreams. It’s not enough that we have a dream, it should be protected, nourished, and nurtured until it becomes a reality.

And that’s part of the reason I am writing all of this again now. A good friend of mine once told me that his dreams of becoming a doctor are becoming blurry and his work in the hospital only make matters worse.

It pains me to know about his situation and not be able to do anything about it. He has the intelligence, the skills and most especially the heart and passion needed to be a doctor. Wait, no, a great doctor. All that bars him from being so is a piece of plastic that serve as proof that he has the license to practice.

How 1,200 questions divided among twelve subjects taken in a span of 4 days determines who is “qualified” or not to treat people of their medical ailments is not for me to judge. Why must his his dream of being able to help others through healing of the body and of the spirit so elusive in the first place?

During our freshman medical orientation talk, one of our professors told the story of a young and promising medicine student who wanted to quit his studies because as much as he wanted to become a doctor, he wanted to be a pilot as well. When he told his professor his dilemma, all he was told was “I don’t see anything wrong with that.” Whoever said you could not pursue both dreams? To make the long story short, the young doctor to be did not drop out of school, finished his degree and went on to pursue his other dream. The last time he saw him, our professor said that he maintains his private practice as a doctor while flying for a commercial airline twice weekly.

Likewise, I had the chance once to meet a fellow doctor that not only treats people with pills and prescriptions, but he also heals with the arguably best medicine there is: laughter. And no, he’s not Dr. Patch Adams, although I did have the pleasure of meeting him once when he visited the country. He is Dr. Carlo Jose San Juan creator of the medical comic strip callous comics.

But going back to my friend, he once wrote on his online post, that he was at a crossroad and had asked for a sign. In irony, I had hoped that he failed in getting the promotion so that he can be once again free to chase that dream of his. And I’m still hopeful that his dream will be realized one day.

Our dreams may be grand or otherwise, but what is important is that they are our dreams, not dictated upon us or simply borrowed from others. We may have others who share and support our dreams, but ultimately it is ours to fulfill.


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