When It Rains...

I seem to have lost Girl Power Claire somewhere along the way about six months ago, and I've been struggling to find her ever since.

To be fair, I have had quite a lot to deal with these past few months. You would think that after having pulled myself up by the roots to move to an entirely new country, everything else would be a piece of cake... NOT! I don't know, maybe the pressure of a new job just doesn't agree with me. Maybe I'm just not very good at dealing with change.

Or maybe, deep down inside, I am really just a Type B kind of person playing at being a Type A lunatic.

It doesn't help that at this point, I'm still so muddled about what it is that I really want. It's hard to motivate yourself to a course of action when you're not very clear on what your motives are.

What the heck am I doing here and what am I doing it for?

I feel bad about whining when in reality I am pretty lucky to be where I am... but sometimes, being lucky is relative. All I know is that these days, it seems that all there is is rain... and it's pouring pretty darn hard.

Okay, rant over.

*sigh*



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How the Heck Did I Get Back Here?

It's been more than two years since I decided to get off the medical training rat race for the sake of my own sanity. So what the hell have I done by hurtling myself back into the lunacy that I wisely left behind?

It's been three months since I took the plunge back into the world of acute tertiary hospital medicine. It only took two days into the job to realize that I was back in the same situation that I had flown thousands of miles across the ocean to escape. Only this time, I was starting from scratch in an unfamiliar environment, a completely different system, and completely and utterly alone.

Okay, okay... maybe all the stress has made me prone to exaggeration. After all, I have been working in the Australian health system for more than a year now - albeit in a small, laid-back, and friendly secondary hospital in the capacity of someone just one notch above internship. And I have been lucky enough to make my move up to registrar level in a tertiary hospital that is larger and busier but still small enough to be, in theory, less overwhelming.

But let's be honest here - there is no such thing as "less overwhelming." When you're overwhelmed, you're overwhelmed.

It's hard not to feel like you're drowning when you hear a Code Blue announced through the paging system and have no idea where the heck it is. Or when your page refuses to stop beeping while you're in the middle of figuring out what to do with the latest patient you've been asked to admit. Or when a nurse is reaming you out for not having "a proper plan" for a patient who you haven't even seen yet.

And that was just on my second day.

It's been tough going these past three months. And it's also been all too easy to morph back into the high-strung, maladjusted stress ball that I'd always been. The one whose start of the work day is heralded by palpitations and capped by tension headaches. The one who suddenly wakes up at 4 in the morning and is unable to go back to sleep because all of her patients and their problems are running through her head. That stress ball.

I'm coming to the conclusion that maybe I'm just not cut out for the responsibility of being in the driver's seat. Or maybe practicing medical training is bad for my mental health. Which leaves me in a huge dilemma: because medicine is the one profession where: a)one is absolutely not allowed to stop learning and growing, and b) you can't get any more full on in the responsibility department than dealing with life and death.

Is too late for me to try my hand at becoming a lounge singer instead? Click here to read the rest of this post.

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.

Wanderlust

My year here has gone by with astonishing speed. I've made no secret of the fact that the time I've spent here has been nothing short of idyllic. Despite working a steady job and finally getting a life, my time here has been something of a vacation.

In this meantime, I've been able to hold off making some major decisions. I've been able to settle into life without a plan, without a map, and no clear vision of what I will be doing, say, 5 years from now. It's all still an absolute blank.

Is it all the open-endedness that is making me suddenly feel very antsy? Or is it because I am more of a free spirit than I actually thought and that the possibilities are the driving force behind my vague restlessness?

It's crazy. It's radical. It may be the by-product of an insanity resulting from suddenly being lost after being stuck on a plan for most of my life. At an age when I should be thinking about settling down, acquiring assets, making a family... I'm having fantasies about leaving medicine and working as a barista as I move from one country to another, seeing the world one city at a time.

Okay, maybe that's a little bit extreme... but you guys sort of get the picture.

I'd been conditioned to have very definite views on where I would be at this particular point in my life... done with my schooling and on the way to being established in my career; married to a stable, reliable guy; getting started on the 2.5 kids - pretty much on the way to living a comfortable, if ordinary, happily ever after. I'd always fancied myself as a home-and-hearth type of person, and I know I'm the kind of person who will always need to put down roots. I won't lie that I don't want all of the above someday - because I do. But...

Maybe not just yet.

I recently had lunch with a younger but wiser friend of mine - who has lived a much more interesting life than I have even if I have almost a decade of living over him. This is one of the perks of living in a land where people are all raised to indulge their wanderlust. Ozzies, I've found, are born nomads. Maybe it's because they have so much space to roam in.

There I was, whinging about how lucky he was that he could just up and go wherever he wanted on a whim, when he cut me off with a very succint, "And who told you that you couldn't?"

I started to give him a list. Society, family, my own need for security, blah, blah, blah... to which he countered, "But all of that is in your mind. Can't you do what you want and still be living up to people's expectations?"

Tantalizing thoughts.

His last piece of advice to address my restlessness? "Maybe it's just time for you to move again."

The roads are open, the possibilities - while not endless - do exist.
This is not me. I hate change. I don't want to go to another city and start over... do I?
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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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Nine Months

me, trying to bring home an image of Bunker Bay (Dunsborough, WA)

It's hard to believe nine months have passed since I began my "great adventure." Nine months since I'd packed my bags and come to this city I'd never seen with nothing but 2 suitcases and the clothes on my back, armed with nothing but the vague hope that doing this "one brave thing" would open up my life. Nine months into the year I said I'd give myself to breathe.

Time has certainly flown - and, to a great extent, I along with it.

In these past nine months, I've fallen in love with this city on the water, with its slow pace, easy rhythms, and stunning beauty. I've learned to appreciate the value of being on my own and, conversely, to open my heart to precious friends that would once have been so "other" to me. More importantly, I've learned to revel in the gift of this solitude, and to be more forgiving and loving to the "me" that's slowly emerging from her long time hiding place.

Nine months later and I can't believe how far away I am from the straight and narrow road I'd complained about walking on all my life. I've never been more aimless, yet I also don't remember ever feeling as free.

On the other hand, I'm no closer to a definite long term plan now than I was nine months ago. I may have signed on for another two years with my current job, but I'm still thinking in terms of living from the next few months to the next.

I know I have to start sorting out my life, to get into a training track while the opportunities are there. While I love my life here in Perth and cannot imagine leaving, I also know that it's time I started exploring my options. I know I have it in me to start over once more in another hospital, even another city, if that's where the opportunities are - I know because I've done it once.

So, no, I'm not yet up to making plans. But I am open to more possibilities - wherever they may lead me. Who knows where I'll be even just another nine months from now? The thought terrifies me, but it's heartening to realize that no matter where I'll be, I know I can handle it.

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Random Thoughts on a Tuesday Morning

(WARNING: When I say random, I mean random. Don't throw shoes at me when you get to the end of this and think, "And what exactly was the point of all that?")

It's been a while since I last struck up a conversation with you guys.

Not really because there hasn't been much to talk about, but more because since I no longer share quite as anonymously as I used to, I've had to be a bit careful about giving into my verbal diarrhea and emotional exhibitionism. There are just some things that I'm not quite as comfortable sharing with people who know me - or maybe it would be more appropriate to say, people who think they know me.

So why am I doing in front of my laptop instead of using this extra morning time (because I set my alarm too early) to blow-dry my hair?

Because I can't help these occasional descents into random babbling, that's why. Even when the only audience is my keyboard.

I've been toying around with the idea of taking up pole dancing. Seriously! It's supposed to be a great upper body and core work out and heaps of fun - and I just may be light enough these days to actually lift my body weight on a pole without pulling my arms from out of their sockets. Plus, and more importantly, it's something I would never do back home - something which is fast becoming my battle cry these days.

I have no illusions about my dancing ability - as one of my friends put it, I have the grace of a pregnant elephant. But it sounds like fun. And while dancing is probably at the bottom of the barrel as far as my skills go, I actually love doing it especially when no one else is watching. Or at least no one who knows me (and knows I can't dance) is watching. So what better place to learn to pole dance but in this city where no one knows me, in a country where one of the prevailing philosophies is, "live and let live?"

Obviously, it's really self-consciousness that's a curse. And for some reason - I don't really have a lot of time to do actual research on this right now, but I'm sure it's written down somewhere - Filipinos seem to have an overdeveloped sense of "what-will-people-think-itis." Probably because, as a people, we Filipinos have no qualms scrutinizing the lives of perfect strangers and indulging in thoughts along the lines of, "what-in-the-world-are-they-thinking-doing-that-itis!"

Which is why most of us just sit in the sidelines and watch the brave, crazy people doing their thing and having the time of their lives - not really caring that they look funny doing so. And why most of us may laugh and pretend to be appalled by what we see, but inside, we're really just that little bit envious and wishing we had the guts to do that, too.

I'm currently reading a self-published booklet of thoughts written by a 36 year old man who is terminally ill with ALS - like Morrie in Tuesdays with Morrie. He's the very good friend of one of the people I share a house with, and it's the copy that he gave her that I'm reading. He's been battling with the disease for two years now, and, suffice it to say, he hasn't been winning. Which is why he's decided to distill his take on the meaning of life into that little booklet.

It's been interesting reading so far. At times he gets very abstract and a bit difficult to understand - or maybe that's because I was plodding though some parts at two in the morning - but it's a very real reminder of how short and how precious life is coming from someone who knows that his time may soon be up.

One of the things he cites is how toddlers - who are almost as mobile as us but still not fully verbal - live their lives so differently and so naturally compared to how we live them as adults, trapped in all our abstractions. As he puts it, toddlers' only pre-conditioned physiologic motivations are to QUESTION, MOVE, EXPLORE, CREATE, RELATE, and feel JOY.

"Joy is the natural outcome and quality of the organism, expressing and doing what it desires to unimpeded by external guilt or shame."

Basically, he points out that with all our complicated, adult verbal views and self-conceptions, we've basically managed to limit ourselves from drawing on those basic motivations and finding joy - or basically, living life.

And he poses some interesting questions as well.

"No matter what you do, how much you save, who you know, where you go, what you believe - you're going to cease to exist, always sooner than you think. Do you do what you do because you assume (it will) make you live longer? Or do you live knowing your life is on loan, and the only thing that matters is your daily experience of your life?"

As I said, interesting stuff.

All that being said, I hope that the pole dancing school will get back to me on the whether we can get around class schedule issues that conflict with my weird roster. And if it doesn't? I'm sure I'll find something else.

Okay - off to work now!

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Strange Things I Know to Be True

One of my patients passed away at work today.

As a doctor, even one who has only been in the practice of medicine for going on a decade (including medical school), I'm definitely no stranger to death anymore. But the circumstances around his passing reminded me of a few strange but common occurrences related to dying that I've witnessed over the years.

Here's the story: my patient was an 85 year old, slightly demented and not for resuscitation, who had recently had a heart attack. He had been doing poorly for a few days, but seemed to be turning the corner clinically.

But by way of most cardiac patients, after having a restful night, he suddenly just stopped breathing and had no audible heart rate - his heart probably went into an arrhythmia. While we were placing the cardiac monitor leads on him, he spontaneously started breathing again. Given the length of time he was out, we figured he wouldn't wake up. We told his niece to let his family know that the prognosis wasn't good, and she had already phoned most of his relatives, who would be coming in shortly.

The staff and I left the room to give his family private time and so I could update my consultant about what was going on. When my consultant came a few minutes later, we came into his room and saw that while he was awake, we all got the feeling that he would not last long. Sure enough, he passed on within the next two hours - after all of his relatives in the area had come in to see him and say goodbye.

Which leads me to the first strange thing I know to be true: dying people can actually "hold on" in order to wait for certain people who they want to see before they die.

One more strange thing I know to be true - very sick patients, most often the terminal ones, have a final surge of strength or a "good day" shortly before they slip away. Sometimes we get lulled into thinking that these patients are clinically improving, only to be stunned the next morning to find out that they've passed on in the night.

It is also possible to die of a broken heart. And I don't mean that in a physiologic sense. Have you ever tried looking at old gravestones and noted how close apart old couples die one after another? It's probably because after one passes, the one left behind loses the will to live. I had a 80 year old patient recently who was quite well medically and good functionally until his wife died. After that, he was in an out of hospital, and he died of pneumonia six months after she did despite all our medical efforts. Quite simply, he had lost the will to live.

Non-medical people will find the concept difficult to understand, but health professionals - doctors, nurses, carers - can actually spot when a patient is on his or her way out. It comes from experience, of course, but we can tell. But one more weird thing my co-residents and I have noticed in our dying but awake patients - when they ask for water, death always comes close behind. Seriously. I don't know how true that is in other medical people's experience, but it's certainly been true to my and my co-residents' experience.

And you know the one about the dying calling out for people who have died or saying that they see people who have died calling for them? That one happens pretty often, too.

Sorry for the morbid turn. It's just amazing to be reminded that there are so many things that can't really be explained by logic or science but actually occur in the world.

Do any of the other medical people in the house have any other weird observations and anecdotes to add? Oh, there's still that one about what happens to people (specially psych patients) when it's a full moon... but that's another story.

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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.

Breathing Room

I just marked my third month completely on my own, in a city I came to without knowing anyone, on the biggest, bravest, most spontaneous leap I have ever made in my overly-cautious, over-planned life. I know it's an overused cliche, but time does go so incredibly fast - and the year I initially planned on staying here is a quarter done.

I can go on and on about the pros and cons of living abroad. There is so much from back home that I miss - not the least of which are the people I love, the familiarity of home, the lifestyle I am accustomed to. But there is also a lot about being here, independent for the first time in my life, that I am learning to love.

I'm settling into a routine, finding new friends, and slowly beginning to realize that this is not an extended vacation to an exotic place - this is my real life and this is where I live now. Some days I just want to hop on the first plane back home, but some days I also wish could stay here forever. It gets so confusing that I've given up pondering on that for the moment.

I'm living my life out here one day at a time, and I am slowly becoming more comfortable doing it. For the first time in my life, I have room to breathe. Living in the moment has given me space and time to get to know myself better in ways I have never really done before. I may not have done anything drastic or even remotely adventurous, but for the first time in a very long time, I am reveling in an air thick with possibility.

I still have no solid future plans and am still in a free-fall with no clue as to when I will hit the ground. But this early on, I can say that regardless of outcome, deciding to come here and do this was a good decision and one that I do not regret.

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Nosebleeding in English

Yes, I have been raised bilingual. Yes, I have been instructed in English since I've been old enough to read. Yes, I have used it in academic discussion for just as long and everyday conversation for even longer. And, yes, I probably read and write better with it, maybe even express myself with it, than I do with my native tongue - and I have a body of work, a thriving blog, and academic IELTS scores to prove it.

But my first month abroad is quickly teaching me that despite my background, I am, as someone who uses English as a second language in an English-speaking land, still prone to frequent "nosebleed*" moments.

Despite having fair command language, I often find myself suddenly bereft of words to express certain thoughts or questions quite unexpectedly. I find myself stopping at mid-sentence when I would frantically grab for an English word in my otherwise good vocabulary only to find Filipino words floating to the surface instead. At times, when my mouth is running faster than my brain, the occasional Tagalog integrates itself into my stream of thought, only to be met by puzzled glances.

In fairness to me, I've been complimented quite often at how fluent I am in English relative to how long I've actually been living here. My English has been good enough to get me through the basics of day-to-day interaction - asking for directions, following instructions, striking up conversations with complete strangers at bus stops (yes, this actually happens quite often in Australia). This country has become such a multi-cultural place that Aussies take my occasional grammar and pronunciation flubs in stride - and are often way more forgiving than many people are back home would be if they heard me.

But the biggest adjustment so far has been in my interaction with the patients I see at work - something other overseas-trained doctors who work in English-speaking countries probably grapple with as well. Although I was taught medicine in English and my conceptual understanding of medical knowledge is in English, I have gotten used to conducting interviews and asking questions in a way that would be better understood by the patients I used to see back home. All of a sudden the metaphors and the analogies that have served me well for so long no longer work. Explanations of common conditions I've used for years quite effectively must now be reworked for my English-speaking audience. New subtleties and nuances have to be relearned.

I don't think that makes me a worse doctor than I used to be. It just means that, for now, I have to make more of an effort to be understood and to understand. Knowing that I have to keep on my toes works in my favor, and it's that effort that I put in that closes the gap. It's slow going, but I like to believe I'm getting there and getting better every day I come into work, every patient that I interview. It's all just part of the growing pains of practicing medicine in a foreign country.

Nonetheless, no matter how fluent I get at speaking English, I know the nosebleed moments will probably remain a fact of life. And while I may have no real, formal knowledge of Filipino and my actual Tagalog vocabulary is shallow at best, not speaking it for long spells has made me realize that a heart-deep connection with it exists - and I miss using it, in a major way.

(*For people not in the know, the term "nosebleed" is Filipino slang for something exceedingly difficult or takes so much effort that it makes your nose bleed. It is often used in the context of someone trying to conduct a conversation in straight English and struggling mightily with it. I don't know how widespread the term's use it and how accepted is the term's use is in this context - so please free to correct me by posting a comment if I am wrong. :))
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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.

* * * *

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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Off the Edge

photo by timwillis

This is how I feel at the moment.

The visa is in, and suddenly I am careening full speed ahead. While I know I have been planning this trip for months, I feel like I've been suddenly pushed off the edge. Probably because, given my penchant for pessimism, I haven't really given myself any leeway to get used to the idea that I'm leaving.

On the other hand, glitches just keep on coming - some of them due to my own stupidity and lack of foresight. I am still running against the deadline, and since the process of getting the visa took so darn long, my papers there are no longer valid and I have to send new copies. It's a tedious and frustrating process. This is particularly daunting because I have bled my savings dry and if things don't fall through, I will be all but destitute.

Oh, well... nothing to be done now but let what will happen, happen! After all, they don't call it a leap of faith for nothing. Click here to read the rest of this post.

Under the Influence

my co-resident Jill during teaching rounds with her students

Up to my 4th year of medical school, I was going to be a pediatrician after I graduated. Since I'd always enjoyed kids, I thought becoming a kid doctor would be a great way to spend the rest of my productive life.

Then I realized that liking children does not translate to liking treating sick children - it cut me up too much emotionally. Also that practicing pediatrics involved a lot of mathematics - medication doses, ET sizes, IV fluids were always based on weight - which I abhorred. Besides that, children and infants were notoriously difficult to line.

And, most importantly, I fell in love with Internal Medicine.

IM had always lurked in the periphery of my choices ever since we had our first lectures on it in 2nd year. As far as I was concerned, it was the subject that first introduced me to Real Medicine. The thought process of arriving at a diagnosis appealed to my inner nerd immensely. I enjoyed our 10 weeks of lectures in 3rd year despite the weekly Monday exams that completely negated our weekends for the duration. Our internist attendings never failed to amaze me with their clinical acumen whenever they would take us for bedside preceptorials.

But whenever people ask me why I decided to make it my specialty, my answer is always the same - because of my 8-week clerkship rotation in Internal Medicine.

Thankfully, I am a product of an era in medical education when intimidation and "terror tactics" at the bedside are no longer the norm. While my classmates and I faced the dreaded "morning endorsements" with a great deal of caution and respect, the senior residents who conducted them were more focused on milking each case for clinical pearls for the students' benefit than humiliating whoever was in front at the time. They taught us practical points on how to take a clinical history, what to ask, and even practiced us in the skill of arriving at a diagnosis.

I was lucky enough to have been assigned to residents who picked up on my interest and really took the time to teach. My senior resident in the wards would even ask me to research about patients under our care to help solve in dilemmas in their management. As a medical student, it was the first time I had ever been given any serious responsibility for any patient and the first time I felt I was really part of the medical team.

My clerkship experience gave me a pretty good glimpse of what working as an internist would be like, and, on top of the strong leanings of my inner nerd, clinched the choice for me two years later.

In a field where one of the cornerstones of education is "See one, do one, teach one," medical doctors at all levels in their training are obliged to teach. But, as anyone who has ever trained in a teaching hospital can attest to, this is a lot easier said than done - something I have grown to appreciate even more after having gone through residency myself.

I recently saw these seniors of mine at the PCP convention just this past week. They've all started practices in different specialties and are now scattered across the country. I always enjoy seeing them again and updating them on my progress. From being once their high-strung clerk, I am now an internist in my own right - but they will always be my seniors.

During these once-a-year encounters, I let them know, tongue-in-cheek, that I blame them for getting me into internal medicine. Still, no matter how disgruntled I pretend to sound about it, they all know otherwise.


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This is a submission to TBR-9 - Mentors, Tormentors - at Megamom's site.



(As a related post-script, Megamom was actually one of my Microbiology teachers when we were in medical school - and one of my classmates' favorites because of her clear lecturing skills and very practical examination questions. :)) Click here to read the rest of this post.

Where to Next?

Me and Ate Fe at Davao International Airport, August '07

I've always had the heart of a kaladkarin (from the same Tagalog verb which means "to drag; to haul along"). I've never made a secret of the joy I get from going to new places and just drinking everything in, no matter the destination. Whether it's a trip to the glitzy and cosmopolitan or the rustic and back-to-basics, if I'm free, I'm in.

Summers have always triggered a serious attack of itchy feet; this, the longest summer I've ever had since I started kindergarten, is no exception. But now that I've indulged my inner lakwatsera (n. "wanderer"), she simply doesn't want to stop.

So does anyone know where I can take my itchy feet next?

Obviously, I'm trying to make up for lost time and throw myself into exploring the Philippines - a beach lover and traveler's paradise if there ever was one. I'm just beginning to discover just how much there is to see here and to appreciate just how beautiful this land of mine really is.

My friends marvel at how eager I am to plan the next trip... let's face it, even domestic travel costs quite a bit, and I'm not exactly earning anything right now. Neither do I have a good amount saved in the bank - and it's shrinking by the day.

But I've come to realize that there's a good chance that having this much time and freedom to wander and having money to spare to do it might never quite coincide. Once I start working and training again - which is really my long-term plan - I won't be able to indulge my wanderlust this way again for years. Maybe it's a crazy philosophy to live by, but it works for me right now. At this point in my life, when I'm in flux and trying to catch up on everything I missed, it makes perfect sense.

Now I'm scouting for a place to hold our next adventure - and I was hoping one of you could help me. We're targeting just a weekend get-away in May, so it can't be too far or too activity intensive. And of course it can't be too expensive - so travel by plane is out. Personally, I would prefer another quiet beach where I can lie around and just watch the world go by... hey, don't be judgy, it's summer after all!

So, if any of you know of a beautiful, as yet undiscovered destination not too far from Manila, easily accessible by public transport, and won't cost an arm and a leg to get there - please give me a heads up. You can leave me a comment or use my contact form to reach me by email. I've been looking at potential places in Bataan and Quezon, but I'd love to get more input from people who have been there or any other place worth visiting.

I can't wait for our next trip. So, does anybody else want to come along? :)

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I Don't Smoke

photo from flicker

I don't smoke. I've never touched the stuff in my life, and I never plan to.

I don't drink often - maybe once or twice a month at most - but when I drink, I pull out all the stops. But any medical textbook will tell you that that kind of drinking really doesnt count.

But that's pretty much all I don't do.

I love to eat at fast food joints, I'd die without chocolate, and you all know just how much I love anything cooked with coconut milk. Meals are not proper meals unless there is a salt shaker just within reach, and I always dash a liberal amount. Apart from the occasional banana, I hardly actively look for fruits to supplement my diet. In my world, fruit is not counted as a dessert. Ice cream and cheesecake are.

I have had periods in my life when I've had regular exercise - but this period in my life is not one of them. I would love to swim regularly, but there aren't any pools anywhere near my house. Everything else is a no-no because I don't like to sweat and because anything that has to do with athletics makes me feel as graceful as a pregnant elephant.

This is a point of contention between my dad - the worst patient I have ever had - and me. He's diabetic, hypertensive, and his cholesterol is going through the roof. I constantly scold him about the contraband he insists on eating and the exercise program he refuses to start. He's always on my case about being a doctor but not living healthily. I glibly argue that I'm not the diabetic in the family - and by virtue of that being an irrefutable fact, he loses the argument soundly. Still, he refuses to toe the line.

But, thankfully, he's the only one who doesn't.

Apparently, this is one thing doctors get away with just by donning a white coat. My other patients don't really ask what my eating habits and lifestyle choices are like, so I guess they assume that as a doctor, I live clean. Their blood sugars and blood pressures are generally good and their weights are steady when I follow them up, so I assume they're following my advice to live a healthy lifestyle - even if I'm not living it myself.

Quite obviously, the advice works. I just haven't gotten around to following it to the letter myself.

I know that I have to start eating smart and improving my diet. I know I have to get my cholesterol and blood sugar levels screened soon. I know I have to get my requisite 45 minutes of exercise a day, three times a week regularly.

Maybe I'll start tomorrow. Or maybe next week.

But till then, I can still tell my patients with conviction, "I don't smoke."


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For The Blog Rounds 8th Edition - Practicing What We Preach, over at Dr. Emer's blog, Parallel Universes.



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Life Begins at 30

image from flickr

The arrival of May often heralds a serious bout of pre-birthday blues for me. I usually spend the two weeks or so before my birthday wallowing about turning a year older and my often vague dissatisfaction with my life. What can I say? I'm a half-empty glass kind of girl. The spectre of another birthday is about enough to suck whatever is left of my optimism dry.

Last year was particularly bad because I wasn't just turning a year older, I was turning a decade older. I was hitting the big "3-OH" with not much to show for it - a bitter pill to swallow when I'd see my non-doctor friends settling into their successful lives. I was digging myself into rut I desperately wanted to get out of but was too scared to esacpe.

This year, as my birthday approaches and I look back at the year that was, I can't find anything to be blue about.

Crazily enough, my decision to take a flying leap into the unknown and get off the seemingly inexorable course of my life has turned into one of the best I've ever made. Taking this temporary breather has opened up my life in the most amazing ways.

So it's true that at the moment I don't have a job that gives me a regular paycheck and I am living on the lagresse of my parents and my very meager residency savings. (Anyone who's been to residency in the Philippines will understand just how meager my savings really are.) And it's true that I haven't really practiced any serious medicine since last December. And it's true that I am still single, with no prospect in sight. And it's true that I am now wandering around with no definite direction, and my life right now is riddled with more questions than there are answers.

But despite all this... (dare I say it aloud?) I'm actually happy. I'm happy being aimless. I'm happy sitting at the roadside for now, watching everyone else run by. I'm happy despite having a huge chasm of uncertainty gaping at my feet (that is, when I am not being terrified - and that only happens when I think too hard about it). I've finally adjusted to living from day to day for now.

This hiatus has helped me appreciate what I've already done and has given me space to do everything I've wanted to do.

I've had the chance to travel to places I'd never had the time to see before. I am finallly writing regularly again. I have a deeper appreciation for being single and fancy free and simply living for me. I've also realized that I actually like being a doctor, and while I still don't think too much of my skills in that part of my life, I miss medicine and will be glad to get back to it when my break is over. In the meantime, there are things to do and places to see and adventures to be had.

It's been a very good year - and I'm already looking forward to the next.

Yes, life really does begin at 30.
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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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