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.

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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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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Blue Monday

those i'm friend-sick for

People warned me it would catch me unawares. And just like that, it did.

I've had a bad day at the hospital today. I can't go on a comfort shopping spree because there's nowhere open after five. I can't watch a movie because I don't have a car and it's not a great idea to commute at night. I can't even drown myself in ice cream because I missed the last open grocery - which closes at six.

But most of all, it's hit me that there is no one here I can just ask over to whine to... to have some retail therapy with (besides, the shops are all closed!) or have a soothing coffee with or get wasted with. No one to gripe with about the unfairness of life over lunch or dinner. No one to make unsubstantiated and totally unlikely scenarios of vindication with.

I've been in constant communication with my parents - and that had helped a lot - but there are many things about my job that my non-doctor parents will never understand, and bad days at work are among them. Besides, I'd never try to get wasted with my Mom - got to keep up appearances, after all.

My other workmates try to be supportive, but it's early days yet. Nowhere near "Let's-get-drunk-so-all-this-can-go-away" or the "let's-shop-and-comfort-ourselves-with-the-joys-of-materialism" just yet.

I miss my batchmates. And just like that, I suddenly miss home.

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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.

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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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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Diplomate

Every year, three years of exhausting duties, sleepless nights, and hundreds of textbook pages read culminate in one make-or-break examination for each batch of internal medicine graduates in the Philippines. A pass mark would mean recognition as a member of the Philippine College of Physicians, the umbrella organization of all practicing internists in the country.

And... I passed!

I am now a certified internist, at least in the Philippines.

Apparently, all the Starbucks coffee I took by the gallon for six weeks really paid off.

Anyone who has studied for a major certifying exam knows how overwhelming the information you have to review in such a short time is. You just try to cover what you can and hope what you are able to review is what comes out. You also just hope against hope that whatever you weren't able to review you already have as stock knowledge. No matter how hard you study, you are never going to be prepared.

I took my internal medicine board certifying examinations last January 27, 2008. Last Thursday, I finally got the results - a pretty great V-day gift in lieu of roses. Just like my medical board exams, I don't really know how I managed to pass. I am just really, really glad that I did.

Congratulations to everyone who made it! (I'm entry number 81. :))

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(Post script: I planned on writing about our crazy, rainy quirkyalone weekend in Bicolandia tonight; but having just arrived from the eight hour drive and given the pressing need to pack for another out of town gig I fly out to tomorrow morning, I simply didn't have the time. But I will write about it very soon!)

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Six

That's the number of times I have graduated in my lifetime.

Considering that I'm batting at twice the average rate, it's logical to assume I would view this occasion with a lot less sentimentality.

You would be wrong.

Graduations always evoke mixed feelings - a sense of accomplishment that you've completed another chapter, a sense of sadness that you will once more be leaving something behind that has become a big part of your life. There's a complicated cocktail of excitement and apprehension at the thought of an unknown future ahead. There are the inevitable goodbyes as you and the friends you've made reach another fork in the road.

Gratitude is one staple sentiment in every graduation. Occasions like these bring to mind the people who have helped you get to where you are today. It makes you realize that while you may have been the one to offer the proverbial "blood, sweat, and tears" that is the prerequisite to conquering any challenge, you still would not have made it this far without the support and understanding of the people you love.

In the Philippines, it is often said that becoming a doctor is a family project. A wanna-be-doctor goes to medical school at an age when he should already be helping pay the bills around the house. If he wants to train further (in the country), he will be going into a residency program that will pay him a sum that will barely cover his living expenses.

Life goes on for these doctors-in-training - and some will get married and have children at this point in their lives. Despite the growing financial demands of adult life, there really isn't much they can do to catch up.

So it's the families - the mothers, fathers, sisters, brothers, (non-medical) wives and husbands - who willingly and lovingly take up the slack. They make up not just for our financial shortcomings but also for the emotional void we leave behind while we are working our asses off in the hospital, spending more time with our patients and our colleagues than those we love the most.

So tomorrow, graduation number six (number seven for the medical fellows!), we're going to take the time to say thank you to the people who have helped us, believed in us, and pushed us this far. We do not say it often enough - but thankfully, their kind of love understands without words.

(The following video is the reason why I haven't been able to blog regularly. :))



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Un-Doctor Esoteria

First time visitors probably scratch their heads in confusion as they go through my posts. Those who come to my blog expecting a real-life, blow by blow narratives akin to House or ER are bound to be disappointed by the lack of blood, gore, and heart-stopping medical drama perceived to be part and parcel of every doctor's life.

Despite the lack of medical posts, my life as a resident in training has not been uninteresting. I've participated in my fair share of great-for-TV medical moments in the course of my medical training. After working in a charity hospital in a Third World country, I have enough "When I was a resident" anecdotes to last me a lifetime. Code Blues conducted on the hospital floor, dramatic emergency blind intubations - who said only surgeons had all the fun?

However, my blog, like me, is presently in a state of flux.


Medical training is a time capsule until one is unceremoniously kicked out of it. It may help one grow in medical knowledge, but it stunts everything else. After nine years (4 years of medical school, 1 year of internship, 1 year studying for the boards, 3 years of residency training) of immersing myself in the medical world almost to the exclusion of everything else, I am now in between jobs - and feeling unexpectedly free. This state of relative idleness is too new to be boring. I am finally taking a well-deserved break and trying to navigate "normal" for the first time in a long time. Recently liberated doctors in training are starving for normal life.

This is still a medical doctor's blog - albeit an aimless one, at least for the next few weeks or months.

Don't get me wrong, I do have some career plans... I'm just not quite ready to talk about them yet. At the moment, I just want to concentrate on relaxing and having a little bit of non-medical fun while waiting for the next phase of my medical life to start.

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"Would you encourage your children to become doctors?" is a question that frequently comes up in conversation when I get together with my other doctor friends.

It may come as a surprise to non-medical people but most of the time our collective answer is actually a resounding, "No."

I would be supportive of my kid's choice to become a doctor if that was what she really, really wanted. On the other hand, I would be the last one to convince her to go into medicine if it wasn't on her list.

No, I am not contradicting my earlier post about liking being a doctor. But I'm also going to be the first to say that the journey is a very tough one. It can get so tough that even those who come in convinced this is what they want to be for the rest of their lives have second thoughts about what they are doing.

Sleepless nights, the physical exhaustion of going on 24 hour duties, emotional stress of dealing with life and death up close and personal, enormous responsibility - they all take their toll. We survive from day to day by ignoring these almost unrealistic demands on our time and our psyches and accepting them as a fact of our lives. But we can't help but see the stark contrast between our lifestyles and those of our contemporaries who have chosen other careers.

The intellectual gratification and emotional rewards are enormous. But the financial rewards? Non-existent until late in your career - if they come at all. As our consultants put it, hitting it big in medical practice takes more than brains, skills, and a good bedside manner. Just like in any career, being in the right place at the right time is also a huge - sometimes key - factor to success.

Choosing to become a doctor is not the same as deciding to take a job offer in the corporate world. By committing to a medical career you give your tacit consent to be changed, irrevocably, forever. It's not a job that you can shrug off when quitting time hits and you hang your stethoscope on a hook in the callroom. They key word here is "becoming." It's something that insidiously works itself into your consciousness as a result of your experiences until it is seared into your definition of who you are.

Would I willingly take that journey again, knowing what I know now? My answer: I don't know. It still surprises me sometimes that I have actually made it this far. But I don't kid myself into believing that I am all done.

For a career doctor, the process of becoming is a lifetime one.
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Homesick

Over coffee and our latest boyfriends of the past six weeks (a.k.a. Harrison), my batchmate Vicvic and I shared one sordid little secret we were surprised we had in common.

We actually miss PGH.


For three years, we had resented being so firmly shackled to the wards and not being able to go where we wanted when we wanted to, like other people our age were doing. We professed hating the long, long hours we worked - with no overtime pay, mind you - and the weight of being overused and unappreciated. We were stumped by frustration at every turn - with the incredibly red-tape laden system, with the patients we couldn't save for lack of money and resources, with ourselves for not learning what we had to do well enough or fast enough. We felt trapped in a world that had become exceedingly small, mostly revolving around our lives in the hospital and the pitifully all-to-fleeting times we could spend away from it.

But now, after over a month of relative freedom and idleness (our coming exam hanging over our heads like the sword of Damocles notwithstanding), we are actually missing that cesspool of misery we used to work in.

I can't speak for Vicvic, but I know I miss it not just because I miss the people I used to work with. I actually miss... the work itself. I miss being a resident.

I miss waking up in the morning and knowing exactly what I am going to be doing with my day. I miss working in a place where I learn something new everyday, and am taught just as much by my patients and my clerks and interns as my consultants and fellow trainees.

I miss working in a job where the framework routine does not mean each day is going to be exactly the same. I miss the energy of the hospital, the adrenalin rush it gives me when I meet up with unexpected toxicity. I miss the intellectual challenge of a new case, the exhilaration of being able to confirm you got it right and being able to do something about it. I miss the sincere, uncomplicated appreciation of patients I handle and am able to send home better.

No, I haven't suddenly forgotten the frustrations, the heartaches, and the hardships of residency training and am now looking back at it with rose-colored glasses. I guess this distance from it has allowed me to realize that despite everything, I had made the right decision to go into residency training.

Regardless of where my meandering journey will take me, I definitely do not regret the three years I have spent with the department. Maybe there have been opportunities I missed along the way, but all the experiences I have had as a resident have made up for it many times over.

* * * *

One of my lawyer friends dropped by where I was studying last night to see me, and we swapped notes about our respective crossroads. She's also in a middle-of-nowhere stage in her life. After 3 years in a firm she has worked in since passing the bar, she has made the decision to resign to pursue other things. She's thinking of taking the New York Bar, maybe getting a Masters degree in the US... or even maybe starting her own business.

We laughed because that non-plan sounded a lot like the non-plan I've been throwing around in my head for the past year... and, as such, it doesn't seem to show any sign of crystallizing anytime soon.

She says she counts herself lucky to be in a career where her future can be whatever she wants it to be. She can be a lawyer in government, work in a big firm, put up her own firm, go corporate, teach... the possibilities seem to be endless. A doctor, on the other hand... options tend to be rather limited.

I don't think that's necessarily true. There are doctors who are not practicing being doctors but are doing work in policy-making, in the pharmaceutical industry, research, serving in government, even doctors who are lawyers. Limits to what each of us can do only exist in our minds, and in the end it all boils down to what captured our imagination.

One thing I've realized, though, is that in the process of becoming clinicians, those of us who choose this path actually become defined by our work more than we realize. Maybe it's because so much of our training is so intricately woven into our lives that much of the people we have become are inexorably bound to that experience.

Once upon a time, I wanted to be a travel writer... a singer... at one time, I even toyed around with the idea of being a lawyer (another long story for another time). I've envied my friends who went straight to work instead of more school and are now high up the corporate ladder and are starting their own lives.

I guess a part of me will always want those things and re-visit those what-if's every now and then. Maybe I might even pursue those other things on the side, since I love them so much. But there's one thing now I know to be true, something I probably knew before but have forgotten in all the noise.

I actually like being a doctor.
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Toxic!

"Toxic" is one of the most-often used terms in the secret language of Filipino doctors and nurses. It is more a part of our everyday conversation than the abbreviations, acronyms, and the host of medical jargon that roll off our tongues when we meet. It is the catch-all description of our lives.

And it has become such a huge part of our consciousness that we forget that the rest of the English-speaking world uses it in a completely different way.

In the Merriam-Webster Dictionary, the word "toxic" is defined as follows:

1 : containing or being poisonous material especially when capable of causing death or serious debilitation
2 : exhibiting symptoms of infection or toxicosis
3 : extremely harsh, malicious, or harmful"

No wonder I am met by the long blank stares of my non-medical friends when I explain why I can't do something fun with them this weekend by saying, "I'm toxic." They probably think my stint in medical school has completely obliterated my lessons in English vocabulary.

But what do your friends from the Pinoy health-worker universe really mean when they use the world "toxic"?


Putting it loosely, we use the word "toxic" to describe people, places, or things that have the ability to cause inordinate amounts of stress and exhaustion.

A first-year medical student who says he's toxic could mean he's presently swamped studying for several examinations. In contrast, an intern who says he's toxic probably means that he's in charge of many patients that are difficult to handle. A surgical or obstetric resident will probably have a completely different idea of what is toxic compared to a resident training in pediatrics or general medicine.

A toxic rotation is one that is so busy and demands so much of someone - both academically and physically - that she probably won't get to go home longer than the time it takes to bathe and change into a new uniform.

A toxic duty is one where a doctor is called on to handle one patient-related crisis after another - with some occurring with different patients at the same time for good measure - that she barely has time to breathe. This may be due to his patients' sheer quantity (i.e. too many patients for the hapless doctor on duty to handle) or quality (i.e. unstable patients under your care, diagnostic dilemmas) or a combination of both. The toxic duty also goes under the name of "Duty from Hell."

A toxic consultant is one who could be: a) an exacting mentor with impossibly high standards who asks a lot of questions during rounds or small-group discussions; b) an obsessive-compulsive attending physician who is very particular about how you manage his patients and is only too happy to chew you up and spit your bones out if you interfere with his management; c) an intimidating, stern superior whose patients you must know down to the last intake-output determination or else...; or d) all of the above.

A toxic patient is a one who is unstable, with multiple problems that need to be addressed at the same time, and requires close attention and intensive think work. The toxic patient is one who demands a great chunk of our time and effort - but is only one of many other toxic patients you are also responsible for.

A toxic magnet (yes, believe it or not, these people do exist) are people who seem to be eternally cursed by Murphy's Law - to whom anything that can go wrong will go wrong at the worst possible moment. They are the ones whose duties are always toxic duties; those who are buried in an avalanche of "quality" patients. Medical disasters are attracted to their mere presence and occur with alarming regularity to them through no fault of their own.

I've tried to do some research on this particular piece of medical slang on the Internet, and I haven't been able to find an actual definition of "toxic" in the context in which we use it. Apparently, it is only part of the vocabulary of doctors, nurses, and other health-workers in the Philippines - or maybe even just Manila - who have trained or worked in the medical system in the recent past. I don't know how long it has been since the medical community took the word and ran away with it, but I do know that it's probably been around for at least a decade because friends who made it to medical school a couple of years before I did were already using it even then. Chances are, it's been part of the hospital sub-culture a bit longer than that.

To those of us moving within this particular world, "toxic" is more a concept than it is an adjective.

It evokes memories of common experiences and elicits a complex mix of amusement and sympathy when it's the current state of someone else. We have all been in fluctuating states of toxicity since we began our medical journey. We have all had our share of toxic duties, toxic consultants, and toxic rotations. And knowing that there are other people who understand what we're going through does not make our stress-sources go away, but it does make the burdens we bear lighter.

If you're a non-medical person reading this, it's enough for me to know that the next time I say that I'm toxic, your first instinct would no longer be to think of sending me a dictionary or giving me a vocabulary lesson. But I'd like to think that after reading this, while you may not have lived our toxic lives, you have a pretty good idea of what I and my other colleagues mean. Click here to read the rest of this post.

Goodbyes

We had known the day was coming. We had spent the last few days leading up to it packing away or throwing away things that represented the last three years of our lives in the hospital - piles of our patient census, pharmaceutical company give-aways, copies of journal articles used for reports, print-outs of the latest theraputic guidelines.

If only it were as easy to pack away these feelings of sadness and loss at the thought of going our separate ways.

Just as it's harder for us to find friends as we grow older, it is also that much harder to say goodbye to them after finding them at this point in our lives. We have been around long enough to know that no matter how hard you try to keep your friendships as they are, you know things will never be quite the same again.

For us, who have practically lived with one another for the past three years of our lives, the idea of no longer having a callroom of friends to come home to for the first time is incomprehensible. And while a part of us is happy to finally be able to come home to our real families, there is an equal part of us that grieves because we are saying goodbye to our IM family.

Despite it being a half-day, there was a surprising number of people in the callroom on our last day, busily packing their stuff away in preparation for hauling them back to their own homes. Everyone seemed to be putting off leaving, but inevitably it was time to go for each one. And while we promised not to shed any more tears, every time someone took leave and gave the remaining people a round of hugs - we did.

While we are happy to see a chapter in our lives close, another phase in our training completed, our hearts are heavy at having to say goodbye to each other. I don't know if the batches before us also felt this strongly about parting, maybe this marks us as strange, but ironic as it is, it's the mark of true friendship we've forged with one another over the years - and we're grateful for it.

To end this post, I'd like to share the messages some of my batchmates sent everyone on our last day as co-residents.

I can't imagine how my residency life would be if you weren't my batchmates. Thank you for accepting me and my shortcomings and made me feel that I belong in this group. Love you all. :)

I was walking through the halls of PGH, and it was heartbreaking to know that you guys won't be there. :( Thank you for all the memories. But this is not goodbye.

Shet, di ko alam kung angina to o mabigat lang loob ko na maghihiwalay na tayo. Thanks for being my family in Manila.

Marami na rin tayong mga pinagdaanan. May mga oras ng kalungkutan, iyaka, galit at tampuhan, ngunit may oras din ng ngiti at tawanan... mga panahon kailanma'y hindi ko malilimutan. Sa lahat ng ating pinagsamahan, salamat, kaibigan.

We may drift apart at some point in our lives and eventually lose touch. But you know what keeps me smiling? I know that no matter what happens, we will always be friends.

We are sad to part ways because we know that things will never be quite the same again. We leave each other with no promises we cannot keep - only memories and love that we can. And we know that no matter what happens, we are who we are today because of all that we gave to one another... and that is something that goodbye can never take away.

Paalam, batchmates! On to the next challenge!






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My Miss List

It's hard to believe that after more than 9 years in PGH, I am finally going to be saying goodbye to it.

I am both excited and terrified at leaving the only hospital I've ever known. Excited because I am finally going to get to see how medicine is practiced out in the big, wide world. Terrified because I don't know if I am up to the challenge of practicing medicine in the big, wide world. More terrified because for the first time in my life, I will be hurdling the next stage in my life as a doctor completely alone.

And on the eve of my saying goodbye to my mother hospital, I realize that despite the love-hate relationship I have developed with it, there are many things that I will miss about it, both profound and mundane.

I will miss being able to go around the maze of its wards and buildings with confidence I will get to where I am going.

I will actually miss CO-OP food - especially the sisig.

I will miss knowing I am working with and am being taught by consultants who are among the most respected in their fields in my country.

I will miss working within a system that may not always work, but is one that I more or less understand.

I will miss the friends I have made over the years, who will still be working in the hospital long after I've said goodbye to it.

And, while I never thought I'd say this - I will also miss serving the patients of PGH, despite the many frustrations and many heartbreaking moments doing this entailed.

All of my memories and milestones as a doctor are intimately bound to this hospital's wards and corridors. The first time I delivered a baby. The first patient I cried over. My first mortality. These events and more like it have shaped me and defined the kind of doctor I have become today. And I know that whatever meager clinical acumen I have gathered in my years of stay here, I owe to the patients of this hospital, who, perhaps out of sheer desperation, have trustingly placed their lives in my hands over the years.

While I have often complained about the frustrations all residents encounter - lack of supplies, the slave-like work hours, the sorry condition of our patients' health and lives - I cannot deny that the underlying routine of a resident's life has always been a comfort to me. For the past three years, it has been good to wake up knowing what I will be doing for the rest of the day - working at PGH.

At this point, more than ever, the option to pursue a fellowship in the only hospital I've ever known is tempting. But I also know that for me to stay on at this point in my life will be taking the safer option, a refusal to go into the deep.

So despite the wrenching fear that grabs at me at the thought of saying goodbye to PGH and all that it means, I choose to leap into the unknown future with eyes tightly closed, and let myself be led on by fate. And hope that one day, if my roads lead me back home to this hospital, I will still be welcome.

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"Exam Na Naman?!"

One way of looking at medicine as a profession is by viewing it as a series of never ending examinations.


No matter how high up the training ladder you go, there is always one more.

You'd think that after the countless exams we had as medical students, our life would be free from them once we graduated! But the truth is, this constant evaluation is a curse we have to contend with for most of our professional lives.

Lawyers have the bar; accountants, architects, engineers, dentists, and other professionals have their own professional boards to contend with. But for them these major examinations are a once-in-a-lifetime thing -- unless they go abroad and have to take examinations for the country they are getting into. In fairness, doctors who opt to practice as GP's need only take our medical board exams before they hang out a shingle and start their practice. But for doctors who choose the option of specialty training, our medical boards are just the beginning.

It is baffling to my "non-showbiz" friends when I turn their invitations down for a night on the town with the unfortunate excuse, "I have to study."

So, yes, on top of our hospital duties, we still need to pull all-nighters to read our best friend Harrison's for our regular exams. And now, as we're reaching the end of this stage in our training, our reward is... yet another make-or-break exam. *sigh*

I am getting too old for this. Here is proof:




This is my single photo essay on how not to study.

Even the atmosphere and the coffee in Starbucks are not proof to the frailty of the human body - and the wonderfully sleep-inducing text.

Now I wonder how in the world I will be able to get past the next exam.

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Nostalgic

I just wanted to share this slide show I made for my batch on Windows Movie Maker (before I discovered the wonders of ULead).


Camera hams that we are, I think we've managed to document these past 3 years (the fun parts of it) in more than 5 GB of digital photos. I've assigned myself as chief compiler.

I hate goodbyes.

I'm really going to miss these guys.

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Stop, World, I'm Getting Off!

My parents think me all kinds of crazy for refusing to go straight into fellowship next year.

Who can blame them? I am (as they are) not getting any younger. Common sense dictates that the sooner I continue my training, the sooner I can get started on establishing a practice... ergo, the sooner I will achieve financial independence.

My parents do not put much store in detours.

To be honest, I have never been much of a detour person myself.

I think I've already mentioned somewhere that I am a pathologic planner. Having made the decision to pursue medicine as a career in 2nd year college, I have had a definite plan for myself since I started on this career path almost 8 years ago. I've had hiccups of discontent every now and then, when I've felt overwhelmed or frustrated, but I think it's safe to say that I never really seriously faltered in my pursuit of that elusive MD.

Before I started residency, I toyed around with the idea of taking a year off to take a break from the hospital, spend time to pursue other interests, maybe figure out what I really wanted to do with my degree. But the impetus that is also known as Common Sense (and also known as opinionated parents) prompted me to ignore the urge to dilly-dally and go straight into a training program. Voices of reason in my head applauded the decision -- after all, I had already made the choice of making Internal Medicine my life's work, so there was no point in putting it off. At the time, I had no plans of going abroad, so there were no exams to study for that would need so much time away from the hospital. I was fresh from internship, and figured the transition to residency would be less difficult. Besides that, it was a safe choice, and it would mean I didn't really have to think about the hard questions for at least 3 more years.

Looking back now, I realize it might have been wiser for me to have heeded the urge to take that year off.

I can't say I regret what I've learned and experienced during residency - despite the myriad frustrations, there were good days. Friends made along the way, the people I got to help, the feeling that in some way I have been able to make a small difference in my patients' lives - I don't think I would have gotten that from anywhere else. What I do regret is convincing myself I had to go through all the steps of my career choice without taking a break in between. There are a lot of things I can imagine myself doing. I've always wanted to write, to travel, to get some training in singing - things that are just not possible when you're tied to a hospital, going on 24 hour duty every three days, and spending all the time in between those duties on 7-5 days still in the hospital.

Would taking that break have changed things in terms of whether I would've wanted to continue on the straight and narrow path towards becoming a doctor? I don't know. I do think it would be crazy to switch careers at this point in my training... but I have decided to take that year off to reassess where it is I want to go. Maybe all this year will be in the end is just a delaying the inevitable, but I don't want to force myself into a definite niche when I have absolutely no idea at this point what it is I really want to do next.

I have been so immersed in my medical career that I can't imagine what life is away from the hospital. Despite the many frustrations in our work as lowly, under-paid, unappreciated residents, it is work that is not without its rewards, and I will miss it. That is what makes the idea of going straight into fellowship so very appealing - it's the safer choice, it's choosing the familiar, it's staying on the well-beaten path.

I have, however, for better or for worse, made the decision to get off that well-beaten path for a while.

I'm wracked in guilt, I feel like a potential parasite and to be honest, the thought of having nothing certain to look forward to (and no definite source of income) this coming year already keeps me up at nights. But I've refused to take the path of least resistance in order to take a step back and reevaluate where I am and where I want to be (the facts that I am 30, very single, and broke notwithstanding).

At this point, if someone were to ask me where I see myself ten years from now, I'd tell them, "Hell, I don't know." That's in how much of a flux I am in. For a doctor who's about to finish residency to say that is a really big deal. In the medical world world, I've already specialized and ideally at this point should be able to tell you straight out what I want to subspecialize in.

Which is why I refuse to rush to the next step. I know that you can never really be sure in the end, and every decision is a leap of faith, but I don't want to jump into another definite phase in my training with the spectre of "I don't know" hanging over my head. I don't want to wake up two years from now, unhappily stuck with a subspecialty I don't want to pursue after all.

I'm trying to break myself out of the mindset that it's too late in my life as a doctor to make a different choice. It's a really tough, especially when I feel that I've already invested so much in my medical career at this point. I think that refusing to go on to fellowship has been more a leap of faith for me than continuing with my training would have been.

So if you're like me, a doctor in flux, take that well-deserved sabbatical and find yourself. I dare you to yell, "Stop, world, I'm getting off!" Let's be terrified together.

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The Gift of Friends

People say that as you grow older, it becomes harder to make friends. Sure you get to meet more people once you start working, but many of these people you meet are mere transients in your life. Maybe it's because we rarely have the time to invest in building friendships once we've graduated from school; maybe as adults, we are more wary and less trusting, less inclined to open our hearts to strangers in the hopes that they can be something more to us. Or maybe it's because, as adults, we no longer have a common drama to share with others outside our homes, no common experience to tie us to others who are not a part of our families.

But sometimes, life hands us unexpected gifts.

My batchmates are my unexpected gifts.

I entered my Internal Medicine residency on my own, none of my good friends from medical school in tow. Most of the names on the roster of my batch were simply just names to me in the beginning. A few I had had rare conversations with in medical school. More I had never talked to at all, though I knew of them vaguely. A couple I had never even heard off until I saw them on the roster. I knew we would have to work together for the next three years, but I had no real expectations that they would come to mean as much to me as they have.

Boy, was I ever wrong.

It's hard to explain to someone who hasn't lived the life of a resident just how important the people whom you work with are to keeping your sanity intact. Looking back at these past three years, I cannot imagine how I would have made it this far without the support and the friendship of the 19 other people with whom I shared this experience with. At the end of a long exhausting, frustrating, emotionally draining day, sometimes knowing that there are people you can share this experience with who would understand even without words what you're going through is all you can look forward to, and we had this with each other.

Our batch is far from perfect. We're an uneasy mix of strong, eccentric personalities put into a highly stressed situation -- a potential recipe for disaster. But thankfully enough, over the years, we have managed to work around our differences, and instead have fed on these differences to become better doctors and better people from what we have learned from each other.

In the process, we have become friends.

The kind of friends you'll get to be the godparents for your children someday, the ones you know will be dancing at your silver anniversary with, the ones who will be at the forefront of causing trouble with you when you're little old people with canes in the same retirement home -- the kind of friends you never thought you'd find at this point in your life... but have.

All of us stand on the threshold of a new chapter in our lives. Some of us have opted to stay in the hospital to continue subspecialty training. A few are definitely going to be leaving for abroad for at least the next few years. One is going back home. Some still have no definite plans. All are solitary journeys.

We leave each other with the knowledge that things between us will never quite be the same again. We leave each other knowing that we will probably never find anything thing like this wherever it is we are going.

But despite these goodbyes, there is another thing that we know for certain -- we are better people for having been friends, and we will carry this unexpected gift with us no matter where we go.

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Arrested Development

Most doctors and doctors-in-training will agree -- committing to a career in medicine is akin to jumping voluntarily into a time warp. While our friends and contemporaries take more advanced steps into the world of responsible adulthood -- becoming financially independent, starting their own families -- those of us who chose to pursue further training in medicine are inexorably stuck in this very small but dramatic world called our training hospital. This is especially true of those among us who have chosen to take our residency training here in the Philippines.

Don't be fooled -- we may deal with life and death at work and are still able to think on our feet even after a 36 hour shift, but, for the most part, our personal lives show the emotional maturity level that is closer to adolescent than adult.

It's hard to make plans to invest in a new condo or to plan on getting married and starting a family when you barely make enough in a month to get from day to day. To be brutally honest, a good number of us are still firmly covered by our parents' financial security blanket even as we're pushing 30. It can get pretty frustrating, especially during those days when everything seems to be going wrong, you've done 48 hours straight and are still on the clock, and you can't figure out what insane impulse made you decide to make this your life. When you're pushing 30 and feel that you have nothing concrete to show for it, it seems so much easier to just give it up and be normal.

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