Somebody Stop Me!

photo by james m

I think it's pretty obvious by now - I'm a chockful of bad habits and addictions. Ranging from the trivial (i.e. nail biting and a love of diet soft drinks) to the life-altering (i.e. negative thinking and frequent self-flagellation), I am often conquered by these compulsions more often than I care to admit. And since I got my car, I'm coming to realize that I'm on my way to developing yet another one - as if I didn't have enough of them.

It's giving into the siren song of the fast food drive thru.

Yes, despite my resolve to turn over a new leaf and eat healthy to complement my new sporty lifestyle, my new wheels have made it even easier to indulge in my craving for the quick, tasty, and greasy joy of eating fast food. I don't even want to count the number of times I've driven the five minutes down the road for a burger from McDonald's (which is open 24 hours, much to my conscience's dismay), hot-and-spicy chicken from KFC, or a chicken roll from Red Rooster.

My absolute lack of emotional quotient is appalling. What can I say? When I'm diving into hot food that I didn't have to cook myself, I temporarily lose my sanity. But it's hard to resist the call of a Big Mac at the end of a long, harrowing evening call when I can safely drive to the store in my car, pick up a burger, and be home just ten minutes than I planned to be.


Okay, okay - the yogurt and fruit for dinner daily was definitely much more positive than habitually committing this cardinal sin against healthy living. I'm going to have to double - even triple - my time at the gym just to make up for my lack of willpower... and we all know how realistic that really is!

The reason I'm writing about this here is just so people know about my budding addiction and hold me accountable. After having had a McDonald's burger two nights in a row via the Drive Thru (curse the 24 hour service - shouldn't everything be closed in Perth by 5pm?), I am willing to admit I have a problem.

Is there such a thing a Fast Food Addicts Anonymous? Sign me up, quick!

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Managing Older

photo from flickr

It's a reflection of how good the Australian health system is that most of its people are now the second longest living people on Earth. A baby born in Australia is expected to live an average of 81 years old, an average currently bested only by the Japanese. It's no wonder then that most of the patients we see at work are elderly - the mark of an aging population. Here it's quite commonplace to see active and healthy octogenarians and even nonagenarians, some just a couple of years shy of the century mark and a dinner with the Queen.

This is something that, as a doctor, is quite new to me, coming from a country where the life expectancy at birth is easily a decade below Australia's and most of our patients are lucky to get any medical treatment at all. Dealing with such an elderly population has been a learning experience in itself, but it has its own share of difficulties and heartbreaks.

Aging inevitably takes its toll on the human body, no matter how well one lives, so it's not surprising that most of our elderly patients have multiple medical problems. While there are also a number of elderly patients who have reached their grand old age with few serious co-morbidities, arthritic pain and reduced mobility is a common problem many share. A good number of them have been living in late-stages or even end-stages of many chronic illnesses for a number of years, the natural course of their diseases staved off by the good health and community support they are given by the system.

I had never seen many patients with dementia - until I came here, where many of my very old patients have it one form or the other. It's profoundly sad seeing someone struggling to hold on to the bits of pieces of themselves and failing. In the span of my three months here, I have seen many people falling into the entire spectrum - from those who are just beginning to gradually slide into short-term memory loss to those who have to be placed in higher level care because they would be otherwise a danger unto themselves. As heartbreaking as it is to watch as an outsider, I can only imagine how it must be for the patients' families and caregivers.

Strange as it may sound coming from a doctor and someone in the general business of prolonging life, dealing with older patients has made me realize one thing: I do not want to live to grow that old. Friends and I often morbidly joke that the best way to go is by sudden cardiac death after you've been old enough to enjoy life and a bit of your retirement - you won't even know what hit you.

Don't get me wrong, I don't mean any disrespect. I do want to live a long and active life, and I hope to be healthy for the most of it. But I don't want to live long enough to feel my knees, hips, and back start to go even with the aid of modern surgery; don't want to live long enough to lose control over my bodily functions; don't want to live at all if living means losing myself mentally little by little. I admit that this mind-set and very personal preference sometimes makes me wonder if maybe some of the patients who we treat full-on feel the same way.

Having come from a system where financial constraints often dictated the extent of what could be done for our patients and the choices were often limited and thus more clear cut, working here has been different kind of challenge. In this health care system where in medical care the sky is the limit, doctors treating these kinds of patients are faced with many difficult questions.

Issues like pre-morbid quality of life and projected quality of life after admission are no longer trivial questions asked for mere completion of a patient's personal and social history but very important pieces of information that are core to the medical team's approach to management.

I've heard it said often that one of the hardest lessons a doctor must learn in his lifetime of practice is knowing when it is best to fight harder and when it is kinder to let go. In this environment of relative abundance in medical technology and resources, I think that maybe it becomes even more challenging lesson to learn. Click here to read the rest of this post.

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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You're Putting WHAT in my Mouth?!

photo by megnicol

Acting on the wise advice of everyone who's gone an a long trip away from home, I've been spending the past few days (apart from fixing my papers and embracing my new role as an OFW) catching up on my dental work.

Much as I like my dentist as a person, I am one of those who considers a session in the "hot seat" akin to a stint in purgatory regardless of what form of pain she chooses to inflict on me at the time. The less I see of her the better. Now that I've experienced getting a tooth extracted, I have revised my opinion - a visit to the dentist is not a trip to purgatory but a trip straight to hell.

One of my molars has been undergoing intensive root canal treatments for a while - probably another legacy of too much sweets as a child. A few weeks ago, after an x-ray, my dentist gave me the devastating verdict that the tooth was beyond saving. If I didn't want to suddenly wake up with the mother of all toothaches when I'm stuck in a place where all health-related services are notoriously expensive unless you're covered by Medicare, the molar had to go ASAP.

After going through all the stages in the dying process - denial ("Are you sure nothing can be done?"), anger ("I've been getting a root canal for months, what do you mean I have to get my tooth taken out?"), bargaining ("Maybe we can try for a few more treatments and I can have it taken out when I get back?"), depression ("I can't believe I am actually going to have a permanent tooth taken out at 31. At this rate I'll have a mouthful of false teeth by the time I'm 60."), and finally acceptance ("Fine, let's get this sucker out once and for all.") - I finally had my tooth taken out a few hours ago. The trauma is so fresh that I have yet to feel sensation return to my lips and tongue even as I type.

With all due respect to my dentist and all the other dentists in the world -- I really don't know how they can do what they do. I can't even imagine how they grow up wanting to do what they eventually do! How does one grow up wanting to become a dentist? I'm not saying it's not good honest work and a much needed skilled profession. It's just that that someone who actually wants to do this because he enjoys it must have an unacknowledged sadistic streak lurking somewhere. They definitely have it in spades over surgeons - who at least cut and inflict pain on patients asleep and wear the mantle of the but-I'm-saving-his-life syndrome to justify it.

Dentists do their work on a fully awake patient who can feel every twist, scrape, wiggle, and tug as they do it. Despite the advent of anesthetics and modern instruments, the prodding and the pulling that modern dentists do still eerily calls to mind untrained barbers doing the same thing a century or two ago.

At the sight of my dentist laying out the things she was going to need to pull out my one measly tooth, it was all I could do not to squawk in panic at the array of vicious looking sticks, picks, and pliers - not to mention that evil-looking hypodermic needle. The only way I could think of to get through the experience without being scarred for life was to keep my eyes closed. That way I didn't have to give into the urge to screech, "You're going to put THAT in my mouth!" every time my dentist picked up another instrument from her tray and approached my open mouth with it.

The extraction procedure was, quite thankfully, a textbook one despite my fleeting urge to go into hysterics.

An empty stomach did not deter me from popping two different kinds of analgesic right after the procedure to counter the sucker punch of pain that's bound to come once the effect of the lidocaine has completely faded out. The anesthetic is beginning to wear off, so I'm going to go get an ice cream now. Not being able to eat solid foods is a good excuse as anything to get a sundae without guilt.

Frankly, I hope I never, never have to go through anything like that ever again. Or should the occasion ever arise, I'm going to insist on a general anesthetic so I can sleep through every tug and pull.

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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 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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