One Third

I look back on the decade that is just about to pass and have found that my life these past ten years has been defined by one major thing: Medicine.

Considering that 10 years is roughly one third of my current lifetime, that's a heck of a long time.



Unlike other med people - probably more well adjusted than I was - entering medicine was like going into a state of suspended animation, a kind of extended adolescence. Life and the world marched inexorably on as I was immersed in an educational system that looked more like high school than it did university - same classmates in one huge lecture hall within a small campus, volumes of books to read, endless exams, day in and day out.

My world, not already incredibly big to begin with, grew ever smaller - maybe partly by necessity, but defintely because of circumstance.

It didn't change much with the transition to hospital life. 24 hour duties, 36 hour days being flat out with patient care on top of the academic load didn't really leave me much time or energy to spare. Add to that the fact that most of my friends were from this little world as well, and there really wasn't much impetus to see what else was beyond it.

For me, staying focused on the end-goal was also defending my sanity - something that kept me from questioning why the hell I was doing what I was doing. Which is probably why I railroaded myself straight into residency, 3 more years of same as the above.

It's no wonder that I was a certified basket case at the end of it. MD and Diplomate cerificates in hand, to be sure, but a basket case nonetheless, scratching her head in bewilderment at where all the years had gone and wondering if she even ever wanted what she got.

I decided two years ago to break the pattern, do the unexpected, and get the hell out. In a manner of speaking. Which has brought me here.

I've spent the last two years of the decade out in the real world, but with one foot still inside the door of medical life. Oddly enough, I must admit to feeling a little lost now that my work has stopped being the defining force in my life, but it has been a good time. I still haven't quite figured out if I want what I've gotten or if I really want to go where I'm going but I've found that I can ease up on the quest a little, enjoy the slower and meandering pace, and still keep my sanity.

All that being said, guess what? I'm going back to training next year. It will be, basically, starting from scratch. As if ten years weren't enough.

Crazy, I know. I guess there's a very real, very influential masochist living inside my head. I'm doing it partly because I don't see any real reason not to and partly because it's the only logical way I can actually stay here for the meantime. I'm still not sure what I real end goal is... but hopefully, it won't take me another ten years to figure things out.

Wish me luck. Click here to read the rest of this post.

Welcome to the Real World

To the new set of Clinician Wanna-Bes:

You've probably been waiting on this day for years. Some of you from the day you started medical school; most of you for even longer than that, from the moment you made that firm decision to become a doctor.

After years of hard studying, sleepless nights, and sacrifice, you finally have that crisp diploma in your hand, the hood symbolizing your new status pinned on your toga. Now you can choose to slip on that coveted white coat and apply what you've studied by beginning your practice as you've dreamed of doing.

Congratulations. You've made it through the easiest part of your journey. Welcome to the real world - where the worst is still to come.

Reality is that despite all your exposure and experience as a student, being a doctor is nothing like being in medical school. You will never really know what it is like to be a doctor until you have a patient who is entirely in your hands.

All at once, all the things you thought you knew recedes into the background and everything you know you don't know suddenly takes up center stage. Faced with a patient who hangs on your every word and takes everything you say as gospel just because you're finally wearing that white coat, all five years of learning the science of medicine is negated by everything you didn't learn about the practice of it. And when you need the most to deliver, you are appalled by the thought that 80% of the time, you're bluffing your way through it and praying with all your might that what you did, what you thought, what you said was right.

Reality is that we all have to start out this way... because medicine is about practice and experience, and that the mistakes we make with our patients along the way ensures that we'll be able to make a difference in more patients' lives in the future. Be encouraged by the thought that even the consultants we admire the most or are most impressed with started out exactly the same way.

The more patients you handle, the better you get - at learning, at practicing... and yes, even at bluffing. But despite the growth in your confidence and skill, that staggering terror at the weight of responsibility will never completely go away. Which is a good thing because no matter what we are doing or where we are practicing, it will keep us on our toes. It will drive us to keep our edge, to stay updated, to keep on learning.

You will not always be a young doctor. And doctors only get better with time. But you will have moments - many of them - when you will wonder if your heart can endure the seasoning it will take to become a good doctor... or even if that is what you want to become in the long run. There will be many heartbreaks along the way and your heart will sustain many scars before you are through. And reality is the process of becoming never really ends. It's a lifelong process.

But as real as the challenges are, the joys of practice are also there to be mined to the fullest as well. So take heart and know that it is actually in this real world of medical practice that the best is also always still to come.

Good luck and enjoy the journey!



A contribution to Gigi's TBR at hosted at The Last Song Syndrome - A Letter to the New Medical Graduates

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Walking the WOC

See one, do one, teach one.

There is only so much medical knowledge that you can glean from reading the books. An internist's clinical eye can only be developed by actually seeing. A surgeon's hands can only gain their skill by actually doing.

And for doctors just at the beginning of our journey, the quality of practical knowledge often rests on the guidance of our teachers' wisdom and expertise. Our mentors spend time every week to see our patients with us, and share valuable clinical pearls with us - and many of them WOC - without compensation.

Having worked only in a training hospital and been reared in a culture where teaching is the norm all my years as a doctor, I admit that I never fully appreciated the time and the effort that our consultants put into our rearing.

It boggles the mind how these doctors, now leaders in their fields with busy practices, give precious hours of their time to teach despite the lack of financial return. How surgeons who charge a hefty fee for each procedure serve as first assists to surgical trainees doing a complicated procedure for the first time - and do it for free.

What's in it for them? Cynics will say that the prestige of being associated with a university with such a well-established reputation is motivation enough - but given how easy it is to get the hospital tagged to your name without having to give anything back, it cannot be the explanation. Maybe there are just people who simply love to teach. And then there are those who believe in paying it forward.

Whatever their reasons, these teachers continue to inspire and spur on struggling trainees to reach the standards they have set. And in doing so, they pass on their love of medicine and of teaching, so that despite the many challenges of a medical career, there will always be those who will walk the WOC with them.

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This is a contribution to The Blog Rounds 16 - Unsung Heroes hosted by Doc Gigi.

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Lucky Country

the healing hands fountain in front of the hospital where i work

(photo from flickr)

I've been working here just a over week, and I still can't get over how lucky "public" patients here are. I know that all medical systems have their flaws, and Australia is no exception, but compared to back home, they don't know just how fortunate they really are.

I work in a public hospital (government funded) in one of Perth's outer suburbs, a fairly small one relative to my old medical home. It's a 200 bed hospital that's just inching its way towards secondary hospital status - by Australian standards that is. We don't have an ICU and as a rule (strictly enforced) we cannot have intubated patients or toxic patients here. We don't have complete specialist cover and have to refer some of our patients to the bigger centers in Perth who need consults.

Despite this, in this little hospital, we have access to diagnostics and resources that my fellow co-residents and I would have killed for. All you have to do is order them, arrange for a schedule, and most of the time you get results within 24 to 48 hours. For blood work, you can get them as fast as half an hour. I know this must sound routine to someone who works in a first-world insititution or even a private hospital back home, but for us, it was all but a wistful dream. To top it off, puiblic patients don't have to pay a single cent.

And the drugs! All you have to do is write it in the chart, and it's all provided for. Antibiotics are given regularly, without fail. No need to run around looking for donors, worrying about where you are going to find your patient's next dose. And this covers discharge prescriptions as well. No need to wrack your brain cells and make up unconventional combinations looking for the cheapest option.

I'm often given amused smiles by my fellow residents when I'd give a delighted, "Oh, you have that (can do that/can give that) here? Wow! I've never seen that done (given to a patient) before!" Believe me, I've said it so often, it's become almost embarrassing.

On the other hand, they can't wrap their head around the idea of relatives who ambu-bag patients who cannot afford a mechanical ventilators, let alone patients who ambu-bag themselves. The concept of young patients dying simply because there are no medications to be had is unthinkable to them. And treating empirically based on a clinical diagnosis is almost akin to a joke. Yet these are realities that I and fellow doctors who work in government hospitals in the Philippines lived with every single day.

Being exposed to all this excess, I can't help but being a great deal envious in behalf of the many needy patients back home. And sad, because given the place health is given in our national budget, to have something like this back home is something of a pipe dream. As it is, the government cannot even pay trainee doctors a decent wage for service hours rendered; it is never going to have enough to cover the health expenses of even just the Filipinos who find their way into the hospitals across the country. The ever-upward spiraling prices of health care in the world makes the unlikely almost impossible.

Whenever I hear someone here griping about how lousy their health care system is, I'm always tempted to make the retort, "How about I send you to the Philippines in place of one of the patients we have in the wards?" Just a day in, and I'm sure they'll realize what we all know to be true - they're still pretty damn lucky.
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Mission Impossible

This is not even half of it...

It was hard enough packing up three years of my life away in the callroom last December, when all I had to do was throw things in my car and drive them to storage at home.

So how does a sworn pack rat like me figure out what to bring abroad for a year and stay under 20 kilograms?

My friends have suggested not to buy too much and just buy in Aussie when I get there. Unfortunately, quality clothes and shoes are expensive over there; bargain clothes there are not as good as what I can get here for a lot less. So everything I'd saved up for the past few years not buying new apparel unless absolutely necessary, I've completely blown on the still-growing pile of shoes and clothes in my room that I am in total denial about.

Thankfully, I do get additional shipping freebies up to Melbourne of about 20 kgs, so I really have 40 kgs all in all. I will have to pay for the shipping from Melbourne to Perth, so that part must wait until I have cash to spare. Thus, smart packing is in order - and I have to be able to carry with me all my must-haves for at least two months in my suitcase.

Sounds easy? For normal people, maybe. For a perennially pack-heavy traveler pack rat? It's mission impossible.

As ever, procrastination and denial go hand in hand, and I have yet to sort everything out. Finally putting stuff in a suitcase and a box will finally make everything real - and I am really not ready for that yet. But with less than a week to go, I really should get started on this.

I have been living in a cloud of unreality these past three weeks, and the days have zoomed by without my looking. Don't get me wrong, I am going through with this. But to be honest, I still ask myself why I even want to sometimes.

Okay... time to make a checklist and get my ass in gear. It's packing time! To the seasoned and the experienced - tips will be greatly appreciated. I need all the help I can get!

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Disturbing Behavior

photo still from Grey's Anatomy

Having been figuratively removed from the world for the past few days, I almost completely missed the explosion of the Vicente Sotto Medical Memorial Center Video Scandal into the Philippine media firmament. Now, because of some unthinking, insensitive, and generally stupid health care workers' behavior, the medical profession is once more being given the spotlight - and not in a good way.

My resident batchmates and I discussed this issue over dinner last Saturday. Having been trained in charity teaching hospitals, we are not unfamiliar with being surrounded with so many young student spectators, whether nurses or medical students, while in the heat of an urgent medical procedure - like an urgent intubation or even an on-going resuscitation.

Despite this understanding and experience, my batchmates and I were all hard put to justify the behavior of the nurses and doctors who are involved in the above case. While at the time, I had not yet seen the video, the mere narrative of what had transpired disturbed me. More so after I had.

As a medical resident, I have often taught my medical clerks and interns bedside with the patients themselves. Patients with textbook clinical findings are asked if it is okay for them to be made clinical learning material for medical students during consultant rounds. While their personal information is never divulged, some of these patients' clinical history and course are discussed lengthiliy over medical conferences in order for medical trainees to gain insight on managing similar cases in the future.

The nature of medical education hinges on the principle "see one, do one, and teach one." Unfortunately, there is much we cannot learn by mere lectures and working with dummies - and even more that we must learn with practice. When patients have themselves admitted in a charity hospital, they tacitly agree to becoming "learning material" for medical students and nurses in exchange for not paying fees charged by private hospitals which they cannot afford. If circumstances were different, I am sure the patients would never have chosen to be admitted to a charity institution in the first place, but circumstances simply force them to take the lesser evil of being taken cared of by medical trainees like myself than not being treated at all.

To be fair, I did not see anything technically wrong with the way the procedure was done. I have read blog reactions to this video, and some have commented about the way someone was shouting instructions while the patient was being operated on. This is standard practice in surgery, where the primary surgeon tells his first and second assists to maneuver instruments in such a way that he can perform the procedure with optimal light and exposure. He also needs to do this to inform the scrub nurse which instruments he will need next. In every operation, there is also a "circulating nurse," who does not "scrub in" so that he can retrieve things that are needed outside the operating field so that the team that is already "sterile" remains so.

Also, it is not uncommon for interesting surgical cases to be documented by video or still photos for future teaching purposes, although a patient's consent is always secured before this is done. It is also not uncommon for such cases to be observed by young trainees. Those of you who watch Grey's Anatomy are familiar with the viewing deck for the interns that overlooks the operating theatre where surgeries take place. Unfortunately, in the Philippines, we do not have the luxury of a similar viewing deck. So while the number of people in the OR is often regulated, students are allowed to observe some surgeries at ground level.

The above could explain why there were so many people in the OR that day and why perhaps an "official" video was being made. However, this does not justify the way that even the student observers were taking out their phone cameras and taking pictures of the patient, who was in no state to prevent them from doing so. That a copy of such a video was uploaded on a public server and could be accessed by anyone from anywhere in the world smacks of insensitivity and disrepect beyond the bounds of professional ethics. It completely disrespects the social mores by which we live.

The primary surgeon also shares some fault here, because as "captain of the ship" it was within his power to control the number of people in the OR that day. Instead, for whatever reason, he allowed it to be a spectacle for whoever "usiosero" wanted to come in and watch and tape. The mood of anticipation and underlying amusement was palpable and translated through the camera quite clearly.

The video is no longer on YouTube, but the damage has been done and is not easily repaired.

Again to be fair, laughter is - fortunately or unfortunately, depending on one's perspective - a common form of stress release for those of us in the medical profession. Humor is one valve which we must use from time to time to cope with the enormity of the responsibility we carry from day to day. The "baby out!" expression and the cheering could have been an expression of relief that the operation - by no means as simple or as easy as it looks - was a success, without any untoward events. But these expressions take on a new and less innocent meaning when one of the medical personel takes the canister, faces it to one of the cameras, and sprays it for no good reason. To me, it crosses the line between benign amusement into mockery.

This patient, regardless of the absurdity of his dilemma, certainly deserves much better than he was dealt. He may have been divested of his medical ailment, but the mockery and the humiliation that this incident has caused him has magnified his suffering several times over.

I am a doctor, and I am ashamed.

The public is, understandably, enraged that something like this can happen. Aside from feeling sorry for the violated patient (the fact that the video does not show his face at any point notwithstanding), it triggers that visceral fear in every mind with regards to becoming patients and the power doctors have over them. "What if I go into surgery and this happens to me? What if I get sick, and I have to expose myself - will they be laughing at me, too? Are they making me into a guinea pig?"

This incident has eroded into the already-precarious relationship between the doctor and the patient. Even if in their minds people do know that they cannot make a sweeping generalization that all nurses and doctors are like the ones who were seen in this clip, the gut fear will always be there now that there is solid proof that something like this could happen. It has tarnished once more the image of doctors in the country, at a time when we are being demonized as it is.

I just hope that the public will keep in mind that this incident is an exception rather than the rule. The good majority of medical professionals do not take their oath as lightly and continue to practice medicine to the best of their abilities to ensure their patients' well-being.

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The Lucky Ones

I grew up in the art and practice of medicine in one of the largest tertiary charity hospitals in the Philippines, the UP Philippine General Hospital.

As a leading charity referral center, we received patients coming from all over the country. Most of them, if not all, could ill-afford the medical services they sorely needed. Most, if not all, were riddled by diseases given free reign to wreak havoc on the landscapes of their bodies until they were all but unsalvageable. PGH, for these patients, often became the bastion of last resort.

Even as a medical student, I would see emaciated patients with lumps as big as a melons on various parts of their bodies who would tell me that they have been growing the masses for months. Or the elderly patients with feet all swollen and reeking of gangrene saying their wounds had been there for weeks. Or patients in severe diabetic emergencies who have not been taking any anti-diabetes medications since they were diagnosed. I have heard stories of the same kind from different patients, with different diseases, from all over the country too many times to count.

Frustration was my constant companion. While after so many years I would already know the answer, I couldn't help but ask them anyway. "Why did you wait so long? Why come only now, when there's not much more we can do for you?"

The response was constant as well. They would shrug almost apologetically and say without mincing words, "Ngayon lang po kasi kami nagkapera, dok."(We were only able to come up with enough money now.) Their silent gazes of mixed helplessness and painful hope were heartbreaking. Often all the more so because I knew that without capital and given the late extent of their diseases, there's really not much I could do to help them.

Sure as day, whatever little money these patients have with them runs out within their first day at the hospital. And while there are institutions that could be tapped for assistance, both by the families and by the residents (who are doctors and social workers at the same time), when working with disease, time is a constant and ruthless enemy.

While all of us has had many success stories, both through the generosity of benefactors or sometimes by sheer divine providence, we have also had to watch patients slip away all too often when all that would have been needed to save them was a regular dose of IV antibiotics or other medications regularly given. Or an operation that could not not be done on time because until the last minute, the relatives were still looking for the money.

It was always hard to lose patients this way, but it was a hard reality we came to live with - and had to learn to accept, if, as trainees, we were to stay sane.

On hindsight, I realize now that these PGH patients were actually the lucky ones - because they were the ones who were able to reach our hospital at all. Poor as these patients are, they are not even the poorest of the poor in terms of health care in the Philippines.

The poorest of the poor are those who live in remote places that are hours of travel away - whether by boat, by jeep, by tricycle, or on foot - from any form of health care delivery system. The poorest of the poor are those who live in areas accessible by transport in the heart of the city but cannot even muster the fare to come. The poorest of the poor are those who do not even know where their next meal will be coming from and live from day to day - and will certainly not prioritize a visit to a doctor who will only prescribe medicine they will not be able to afford anyway.

The reason behind this can be over-simplified into one painfully obvious problem: we simply have no budget for health care. Can I offer any solution to this problem? The answer there is painfully obvious as well.

So in the meantime, I and others of my ilk will continue to be small cogs in the wheel of the Philippine Health Care system - a system that does what it can, ill-equipped, severely underfunded, but always working with the best of intentions. But until things can be changed, inequity in health care will continue to be a fact of Philippine life. All that others can hope for is to be among "the lucky ones" as well.

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See the rest of The Blog Rounds, 6th ed, over at Merry Cherry's place.

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The Blog Rounds 3 - At a Crossroads

Welcome to the Middle of Nowhere and the 3rd Edition of The Blog Rounds!

Before anything else, I'd like to thank all the medical bloggers who participated in this edition of The Blog Rounds for their enthusiastic response. Many new voices have been added this week - and I am hoping this won't be the last time they will be joining our particular chorus! Given the very personal nature of the topic for the week, the honesty and candor of all the bloggers have made it a joy to read the stories they have chosen to share.

Now, I would like to help them share their stories with all of you.

Without further ado, I bring you TBR 3 - At a Crossroads.

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The nitty-gritty of the pursuit to the elusive M.D. and beyond is a mystery to most. In Crossroads and Crossed Roads, Dr. Em Dy sets the stage by detailing the major crossroads in every doctor's life.

There are as many reasons behind the choice to pursue a medical career as there are doctors. But as Doc Tes skeptically points out in her native Cebuano, one favorite reason given by aspiring medical students in their interviews is the catch-all reason, "To Serve Humanity."

Given the difficulty of the journey, the choice to continue is presented to one time and again, and, ultimately, not everyone decides to go into clinical practice or even to finish medicine. Kitty Mama was once a doctor-in-training who made the choice to leave that life for a new one. In Margarita, she talks about her experience of being exposed to the hospital for the very first time - one event that she used to sustain her during her stay as a medical trainee. Bubbleman, on the other hand, chooses the Other road much later in his medical journey. In On Choices, he attempts to tell us why he is no longer practicing medicine and to connect the dots of his choices into a pattern that makes sense.

Being at the cusp of a new phase in your life, on a new road you have chosen, can both be exhilarating and terrifying. Merry Cherry, a young doctor to the barrio, recalls the terrifying feeling of anticipation before her deployment and shares her thoughts on where she is more than a year after she first began this particular journey. In Roadkill, new graduate Kai describes the feeling of literally being in the driver's seat for the first time and makes this experience a metaphor for her life in the near future. Doc Whisperer shares with us a poem about the changes that can follow making a choice in Crossroads.

The end of any chapter in a doctor's life always leads to a crossroad - which can sometimes translate into a dead end. In my post, "Stop, World, I'm Getting Off!," I explain my choice to slow down a career that is going too fast for my liking in order to figure out where I want to go. Manggy describes the end of medical school as his Pre-Life Crisis and draws a blank on what to do next as he stands at the crossroads of choosing where to practice medicine. Angel-No-More finds herself at a crossroads of a different sort, as she comes to some realizations upon reaching the big 3-0.

To others, however, coming to a crossroads when one reaches the end of their training causes their life to open up. Midnight Rainbow, in her post Ang Biyahe ng Buhay Ko, likens her life to a highway and talks about the stops and detours that have led her to where she is today - and a future full of possibility. In her first ever Blog Rounds post, Lei Si talks about why she chose medicine and the "everything else" she wants to do now that she's found her life's calling.

Sometimes the choice of the road to take is dictated by circumstance, Fate, or some Unseen Hand. Abner Hornedo chronicles his meandering journey from choosing one specialty and ending up in another in Fate Sometimes Decides. In Megamom's Two or Three, she recalls making a major life decision influenced by her being a woman of science - but whose final outcome was wonderfully orchestrated by God. Ness, a practicing anesthesiologist, shares her experience as a doctor who studied nursing as a second course - but is still practicing medicine in the Philippines.

Sometimes we try to reassure ourselves that we are going the right direction by looking for "signs" along the way. Prudence blogs about the "signs" she has looked out for during her journey through medicine and wonders if they are really worth watching out for.

There are some whose paths have led them to where they feel they are meant to be and are content with the choices they have made. Doctor Joey, another ophthalmologist, talks about some of the major crossroads in her life and her satisfaction with their outcomes. In his post Babies, Bulbuls, and Bonsai Trees, Doc Noel learns of the joys of coming home and the freedom of starting his own private practice in General Santos City. Bone MD recounts his long arduous journey through medical school to starting his present practice as an Orthopedic surgeon in the hinterlands of Mindanao in Nowhere to Go But Up.

We cannot touch on the topic of the choices doctors make and not touch on the controversial diaspora of Filipino doctors to other lands. Often, medical workers are perceived as "the bad guy" in the deteriorating health condition of the country today without being given a chance to have their say. But why do doctors leave? Their stories may be different, but their reasons are surprisingly quite alike.

Dr. Doray of Doralicious is now serving as a councilor in Quezon City - but two years ago she was actually planning to train abroad. Tongue-in-cheek, she shares with us the plans she made then and the reasons behind them, before Fate stepped in and changed them all. With dry wit, RG recounts his impulsive choice to begin a new journey in the land Down Under and the reasons behind his decision in All is Quiet on New Year's Day. Another young MD, AnnKat, talks about how a change in plans does not equal a change of heart in Exodus. Finally, Dr. Martin Bautista, Filipino doctor and former senatorial candidate, blogs about his choice to train and start a practice abroad and how his experiences and his desire to serve have led him back home.

The theme "At a Crossroads" was a bid to uncover the people behind the white coat for non-medical readers while at the same time giving us medical people a common ground from where we can find new insights into our own lives through the experiences of others on the same journey. I hope that this collation of posts was able to do both.

Many thanks for participating - and see you next week at Doc Tes's place for TBR 4 with the interesting topic of The Doctor as Patient!


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Dreams for Sale

I was at Starbucks yesterday as part of my pathetic attempts to get started at studying, and, as part of my procrastination strategy, browsed through yesterday's papers. One header in particular leapt out at me from the middle of the Inquirer's opinion pages. It's a commentary by Juan Morales called, "Wedding Rings for Visas" and it explores another facet of the great Filipino Diaspora - that phenomenon of marrying to migrate.

Much has already been said about the fact that more and more Filipinos are on a steady march out of the country in search of a better life. They leave every day by the thousands, workers and migrants, pitting themselves against daunting odds in order to be able to earn for their families back home. Others, despairing that the system is no longer salvageable, leave their comfortable lives as they know it and take on jobs they are more than qualified for in order to be able to bring their children with them abroad to ensure their future. The rising desperation quotient has caused this tidal wave of emigration to be whipped up to a frenzy. Its battle cry is to get out of the Philippines by whatever means possible. But while I know that the practice of marrying for convenience for the sake of getting a visa has been around for a long while now, seeing the actual numbers is both staggering and depressing.

Forgive me, I am just trying to wrap my closet romantic's head around the concept of marrying for anything other than love. It is just hard for me to grasp the concept of a commitment that entails so much intimacy and trust and risk being undertaken for the most pragmatic of reasons. While I do not deign to question other people's choices, a part of me grieves that life for many here in our country has become so intolerable that they must to resort to this. Each one who has chosen to go by this path have reasons that are, no doubt, valid. And the closet romantic in me continues to hope that many of them, too, have found their happiness this way.

I don't mean to offend or sound patronizing. Believe me, there is no condemnation here. It is part of our being human to want to improve our condition, and I would be a hypocrite if I said thoughts of leaving for good have never entered my mind. (Part of my being in my "middle of nowhere" is the confusion about where to stake my claim and find my niche as a doctor. Commentaries about junior doctors' plight in the Philippines have been written by people with more eloquence than I, and you can read some of them here and here.) I know I am lucky because I have been given opportunities to develop skills I can barter for my ticket to go abroad. That people are actually bartering themselves in order to find their berth abroad is just reflection of the level of desperation we have ascended to. It is that that truly disturbs and makes my heart just a little bit heavier.

In truth, doesn't every overseas Filipino worker who risks his physical and emotional well-being by choosing to place his stake in the country he plans to work in do the same thing? In the end, after all is said and done, we all just do what we can to survive.

It is a sad reality that so few are able to achieve a level of comfort and security to realize that life is not just about survival, but living.
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The Worst Patients Ever

Doctors make the worst patients imaginable.

After several months of being told I should start myself on Metformin for my Polycystic Ovary Syndrome (PCOS), I finally caved and took my first pill this morning.

To be fair to me, I did try to take Metformin the first time my OB-Gyn friend (take note that this was not part of a formal consult) told me it would be a good idea, but I had the most horrendous bout of GI upset after only taking 1 pill... and I swore off the drug completely, advice from my Endocrinology and other OB-Gyn friends notwithstanding. All this despite the fact that I already knew I was a textbook case of PCOS and had the ultrasound to prove it. You'd also think that since we have a very strong history of diabetes and high cholesterol in my family, I would be more cautious. Not so. As a matter o fact, I also threw the advice about diet modification, exercise, and weight loss out the window.

When doctors get sick, it's not a matter of not knowing any better. I think it's part of our medical education to live in some form of denial when it comes to our own bodies.

Take, for example, all the doctors who continue to smoke incessantly despite the very strong evidence that smoking can lead to lung cancer, bladder cancer, and other malignancies, chronic obstructive lung disease, heart disease, and a host of other medical problems. We've all taken the same classes, read the same books, seen the direct evidence of how smoking wreaks havoc on the human body. We all advice our patients with hypertension and heart disease to quit smoking cold turkey because we all know it's sound medicine.

But my smoker doctor friends keep on smoking anyway.

There are many instances when illnesses among medical residents are picked up relatively late simply because they either ignore their symptoms or decide they know what's wrong with them and treat themselves.

There's an interesting article here about a study done in Australia about doctors' health seeking behavior. Participants in the study believed it was acceptable to self-treat acute conditions. A good proportion of the respondents believed doctors are also reluctant to attend another doctor when he is ill. In another article here from the British Medical Journal (BMJ), a review of existing evidence suggests that doctors are less likely than other professions to take time off work due to ill health. The alternative is often self-medication or consultation with colleagues about their illness.

The BMJ article goes on to point out that, "a culture of ‘not being ill’ is seen as inherent within the medical profession." Simply put, many doctors feel that they are ‘not allowed to be ill’, because it is seen as a form of weakness. Heavy workloads and staff shortages mean that for many doctors, it is virtually impossible to take time off for ill health. In our world, if you don't go to work, your already overworked colleagues must take up the slack or else your patients suffer. So you treat yourself and keep on working - until you get well or get worse, whichever comes first.

Ironically, this culture of ‘maintaining a stiff upper lip’ ultimately impacts on patient care - not only are they treated by a doctor who is less than 100%, but doctors with communicable diseases also run the risk of passing it on to their patients.

I've had at least two batchmates who nursed fevers and headaches for at least a week treating themselves with nothing but paracetamol who eventually were diagnosed to have typhoid fever. One of them was eventually admitted for a few days for IV antibiotics. A couple of years ago, an entire batch of neurosurgical residents were noted to be losing weight - a rather normal occurrence for toxic would-be surgical specialists in training. After one of them ended up being admitted for shortness of breath because of having fluid in his lungs, everyone else finally got themselves examined. All of them turned out to have tuberculosis and needed to be treated for 6 months.

But the biggest irony of all is that many of us, especially the junior doctors, are unaware how we would access support for ill health. My resident friends who had to be admitted had to pay for their expenses out of pocket (or their parents' pockets). The expense had a considerable impact on their finances, given their meager monthly salary, slightly discounted bills, PhilHealth, and waived professional fees from our attendings notwithstanding. Medicines are still purchased at full price, and we don't have any drug samples to cover our full treatment. I did an informal survey among my co-residents, and it turns out that none of us have medical insurance.

Is it any wonder why we are in such denial when it is our turn to get sick?
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