Uncertainty Captured

Yesterday was a viewing of "Ang Nawawala" and "Sana Dati" in Teatrino, Greenhills. Seeing the first film after 2 years was rewarding. I've written a piece inspired by "Ang Nawawala" Warning, do not watch both films at the same time unless you want to feel some intense emotions.

And this piece would be about the other gem of the night: "Sana Dati". Honestly, I just went to Greenhills to re-watch "Ang Nawawala" and buying the ticket for "Sana Dati" was just an afterthought. Might as well indulge, I said to myself. Little did I know, it was a very good film.

Unlike "Ang Nawawala", the film's strength lies in its very crisp storytelling scenes. It doesn't regale you with songs and complex narratives of a past tragedy. It's a simple story. A woman who's about to get married but then there's a mysterious wedding videographer who has some ulterior motive in going to her wedding. Sounds simple right? Intersperse that with scenes from Alaminos, Pangasinan and solid acting skills shown by all performers and you're drawn in.

"Doubt is not a pleasant condition but certainty is absurd" from Voltaire and the starting epigraph of "Sana Dati"

How many times have we fallen in love (well, in my case, just once) and we've told ourselves that at this moment in time and space we're certain. But in hindsight, it's not true. Whether because of our own emotions, events or Time itself; there will always be uncertainty. There is no such thing as "I will always love you".

Lest you think I'm a cynic, when I speak of Love in this case, I'm pertaining to the rush of emotions at the sudden onset of a new love interest. Those feelings of puppy love and willingness to offer oneself to a lover; these are things that will not last. And that's the quandary of real Love: that it is not certain.

Real love is marred by compromises, by flaws and by circumstances. It is rarely fair. For instance, is it fair that the true love of the bride dies suddenly with no explanation? Fate is fickle, even in matters of love. So in an act of impulsiveness the bride settles for a man she clearly does not love and this man is aware of this fact but again, because of his love for her, he's willing to overlook this. Some may say the man is stupid but love is rarely smart.

And perhaps that's what enthralling about falling in love: the uncertainty. And a wedding certainly isn't going to make it certain. As the movie ends, with the bride and the groom already married, the bride finally says "I love you" to the groom. However, notice how she gazes along the road while the groom is driving. Yes, she has visited her true love's grave and placed all mementos on his grave-marker. She even left those blue shoes she swore she was going to wear at their wedding. But then, are we really sure her "I love you" to the groom was sincere?

So "I love you" becomes nothing more than a scream against an uncertain future. Who's to say the bride isn't going to cheat?

To First Loves

"As long as you have love you still have hope" - from "Love of Siam" by Chookiat Sakveerakul

I've put my heart out on a metaphorical plate a few times in my relatively short life and all times, I've been rejected. Does it hurt? Of course. But the more important question: do I regret it? Surprisingly, no. Well, the immature me would have regretted it and put up more defense mechanisms. However, in this moment in time, writing this while sitting in a coffee shop, I can now really say: NO.

After all, love is intrinsically tied to hope. Hope for a better future, better self and better possibilities. But, we really aren't sure what these outcomes are. We can only put ourselves out there and embrace whatever. As one of my former college professors/masters put it, "real hope isn't tied on a tangible outcome".

We love and we hope. That's all anyone can do. Unless someone can invent a device that can see the future but of course that'll open up many more paradoxes. So better the uncertainty of hoping.

"You don’t get to choose if you get hurt in this world, old man, but you do have some say in who hurts you. I like my choices." - from "Fault in Our Stars" by John Green

To "Red Dress": I haven't thought about you for awhile. Heck, the only reason you've resurfaced in my mind is that my college batchmates brought you up during our 50th Alumni Homecoming. I laugh at my naivete then. But now, I'd like to thank you. Without you, I wouldn't have matured. I wouldn't have the current drive I have now.

It's easy to call you "the Bitch Who Made Me Cry On A Sidewalk" but now, with enough Time, I can look back at it as a necessary path to growth and maturity. And I can honestly laugh at the entire thing. Without you, I wouldn't have one of the reasons to keep exercising and pushing myself beyond my limits.

To "The Dilimanite": what can I say? You were the one who I showed the real me. I haven't done such a thing in a long time. I've put up these barriers in the fear of getting hurt but you're the one who made me tear them down. In that short time period we shared, October 2012- November 2012, I felt like a kid again.

The first time we met has even some tinge of literary genius in it. Imagine me, sitting down on the floor, ignoring other people, reading the class transcriptions because I was so busy studying for Biochemistry then you walked in the room. When I looked upon you, I felt something. Literally, the room stopped and all I could see was you. I was compelled to win your heart there and then at that moment.

Then, you graciously rejected me but not without coming to my room and talking to me. You propped me up during that November 1. It was the nicest thing anyone has done for me in a long time.

And approximately a year after, in a coffee shop, while studying Cardiac Pathology, I cried. Apparently, there is such a thing as a Type IV hypersensitivity reaction of the Heart. That's how much you affected my life. 

"I’m going now. I’m sorry I couldn’t be here for your battle; I was fighting my own. But we won, right? I can feel it. There’s a shiver in our legs, a tremor like the Earth speeding up, spinning off into uncharted orbits. Scary, isn’t it? But what wonderful thing didn’t start out scary? I don’t know what the next page is for you, but whatever it is for me I swear I’m not going to fuck it up. I’m not going to yawn off in the middle of a sentence and hide it in a drawer. Not this time. Peel off these dusty wool blankets of apathy and antipathy and cynical desiccation. I want life in all its stupid sticky rawness" - from "Warm Bodies"(book) by Isaac Marion

To the future: of course, I don't know what you'll be. I don't even know if there'll even be a "Who". But that's the beauty of it. The uncertainty of Loving and Hoping is now tied to the rawness of Life itself. We can easily wall ourselves from pain but that essentially walls us off from Life. So I live on, I bleed, I write, I read and I move. What I won't do is become an apathetic Being, afraid of pain and action. While it's tempting to be stuck in a drawer; it simply won't do for a Living, Human Being like myself.   

A simple toast to uncertainty that thing which makes all things exquisitely beautiful. 

“On the one hand, getting shot in the chest hurt, like a lot. But on the other, it felt good to bleed, to feel pain, to feel love.” from "Warm Bodies" (movie) by Jonathan Levine

The Path of Medicine and Atheism

One of the risks of entering Medicine, especially for a theistic student, is that one will lose his/her religion. And so far, the subjects have further cemented my rational reasons against the existence of a benevolent and omnipotent deity.

Last year, the subjects of Anatomy, Physiology and Biochemistry have utterly destroyed my views of a benevolent creator by revealing the imperfections inherent in our bodies. From Anatomy, we see vestigial muscles and structures present in the human body that points to a faulty design. From the route of the recurrent laryngeal nerve to the senseless decussations/crossing-overs of nerve tracts. To Physiology wherein the human body is not a superb work of art after all. And finally, Biochemistry with its study of genetics. And not to mention that every disease has a biochemical basis

And for this year's subjects, it has only served to give more rational basis against the existence of a benevolent and omnipotent deity.

Pathology, the study of diseases, while fun has given me more reasons to argue against the existence of a deity. It would surprise the reader that some disease process are due to an exaggerated response of the immune system. In the Philippine setting, it's no other than Mycobacterium tuberculosis, the causative agent for tuberculosis. The bacterium itself does not attack the human body, it's the formation of granulomas that make up the pathogenesis of tuberculosis, in the lungs or elsewhere in the human body. And another bacterium that shares the same pathology would be Treponema pallidum, the causative agent of syphilis. However, instead of granuloma formation, syphilis is characterized by gummas.

And we move on to Microbiology-Parasitology, the study of organisms that can harm humans. You see how bacteria cause infection and what are the necessary factors to help establish infection. Another tidbit of information applicable to the Philippine setting would be the reason for dengue hemorrhagic fever. It's not the virus per se but the response of the body to the virus. The immune system releases chemicals that causes platelets to leak out of the circulatory system decreasing the patient's platelet count. Thus, we see another supposed benevolent bodily response that backfires and causes a very dangerous complication.

And then, moving on to the clinical subjects.

Medicine, with its study of the common pathologic conditions found in adults like hypertension, cough, thyroid problems and heart attack, to Neurology and its study of stroke and seizures gives one a chance to apply what has been learned in Pathology and also gives this very important insight: some of the common conditions are actually preventable. It's because of peoples' adoption of unhealthy habits that makes them more prone to develop say hypertension and diabetes.

Surgery and its sub-specialty of Orthopedics gives insight on how fragile the bones are contrary to common belief. And the many factors needed for proper bone healing. Unfortunately, we are not yet at the point in which bones can be regenerated instantaneously. It needs a period and support for proper healing or else the fractures may not re-unite.

Pediatrics and Obstetrics makes one realize how hard raising children is and also pregnancy. Contrary to what is being preached by say, the CBCP, the making and raising of children is not easy. Well, if we're talking about copulation then its very easy and pleasurable. But if we're talking about the process of development in the woman's uterus then it's another thing. And then, raising children is no easy matter. You have to give them immunizations and proper nourishment. Funny, I don't see the CBCP with its millions sponsoring the many women and children they so love.

Finally, Psychiatry gives insight to the human condition via the study of human behaviors. It is very vague, yes, but it gives additional knowledge about how humans defend their egos and also some destructive responses to common stressors like say losing a loved one or being confined in a hospital for a very long time. And if there's any destructive response to be spotted early in a patient it would be suicidal ideation.

At this point, it would be easy to either conclude all medical practitioners will become unbelievers or warn parents against sending their children to a medical school. But that's not really the observable reality in the Philippine setting at least so rest assured, dear reader or parent. This is just me outlining what I've learned and using these facts to bolster my unbelief. If there's one thing I want a potential reader to pick up from this: it's really up to you. Yes, it's a personal choice, not an imposition. Nothing more, nothing less. 

Moments of Craziness

Or moments of irrationality if you prefer the more formal term. Anyway, I believe everyone has them and contrary to belief; I actually have moments like this. Foremost would be the decision to enter medical school. So far the greatest irrational decision I've ever made. Still waiting for the results of the promotion boards and well, still seeing what would be the results 10-20 years down the line. And the other moments, well again, you would be shocked. 

1. Got crazy-drunk in the middle of a public field in school during high school. (I didn't get caught officially).
2. Pined for someone with the song, "Officially Missing You" by Tamia for 1 whole year *insert snicker here*.
3. Wrote this on my Facebook wall. 
4. And 1 year later, after getting friend-zoned by the person in no. 3; cried in a coffee shop. It didn't help that "A Thousand Years" by Cristina Perri was being played on repeat. Not to mention, was studying Cardiac Pathology.
5. Wrote and staged my own monologue with a partner. Oh and said partner was the same person in Nos. 3 and 4. (Shhh no one but friends from that event knows about this one).
6. Drank many vodka-laced shots and smoked an entire pack in a party staged during the night. It was a school night but the finale was making out with someone. (Hey, at least it wasn’t on-stage where every people can see; oops a different event and time).
7. Finally, cried my entire being on the side of a sidewalk at approximately 2:00 am in the morning.

No. 7 was during the last year of college. I was getting crazy enough to go to parties. And, to put it simply, I was dumped. But we're getting ahead of ourselves.
Semi-last year of college and I was walking along the SEC-B foyer when I saw a poster of a certain someone. A person sliding alongside a motorcycle or it seems to be because of the photograph. It didn't help that "Sexy Bitch" by David Guetta feat. Akon was playing. I was drawn to the figure wearing a red dress and sliding on top of a red motorcycle. Maybe it was the pose or the expression but it seemed to me, the person was sliding or maybe melding with the red motorcycle. Red happens to be my favorite color; something about red representing bravery, audacity and passion. It got to me. 

Funnily enough, it was a "human auction" or an event to bid the highest to win a date with said person. Whoever was the brainchild of that smoldering poster is an effective marketer. It was effective on me! I bid the highest on "Red Dress" and had the audacity to use my YM id (Facebook wasn't "in" during those times or maybe I was ignorant). My rationale during that time was that if "Red Dress" didn't like me then I could be messaged and I'd abandon my bid.

Classmates cheered me and "Red Dress" didn't message me. So I was feeling jittery and thinking this could be the start of something.

During the Bionight which was the event wherein the winning bid would be announced, I was so excited. I even wore something nice, shaved and gelled my hair. Things I would only do on very rare and special occasions then. However, an unexpected twist happened. Someone bid against me. Doing the very crazy thing, I bid more and even borrowed money from my friends.

Unfortunately, he had more money. I kicked myself then for spending my spare money on online games. And the knife-thrust to the gut and the arrow straight to the heart happened: it was Red Dress's boyfriend who bid against me. My illusions were shattered. Imagine an atom suddenly imploding inside and, all at once, exploding. It was a sudden release of all the tensed energy and for one night, I embraced craziness. I drank all the available alcohol and smoked all the available cigarettes.

“So why’d you bid for Red Dress?” asked someone as he was driving me and my friend home. I just smiled and brushed it off but inside I was slowly imploding and embracing that rush of melancholy like a long-lost friend.

And we finally get to number 7. While walking to the town house, my college residence then, I broke down on the side of the road. Cried. I let the tears explode. Suddenly, I was reminded of how insignificant I was. How deluded I was that a human person would actually fall for someone who was ugly, a bit on the thin side, someone wearing glasses and having a brownish complexion. At least I wasn’t making noise and waking anyone up with my inconsequential breakdown.

And 3 years after no. 7, I’m reminded of a comment a groupmate/friend made about my behaviour. “People actually find you weird and creepy”. Yeah, I know. It was all an elaborate defence mechanism to make me an unattractive person. And it worked. If my classmates are reading this, well here is a psychoanalytic explanation for my crass behaviour falling under Axis 4 of the DSM IV TR guidelines. Damn you Psychiatry!

Yes, the fact that I’m writing this online instead of saying it in person is pathetic but hey, I’m getting somewhere. The mere fact I’m writing about it and posting it on a platform wherein anyone can see it is progress enough. Or who knows, this will stay buried here. Maybe it’s all for the best. Maybe this will serve as a notch, as a mark, that I’ve moved on.

If anything at least I have a very strong reason, among many, to have a work-out routine even during the rigors of medical school. 

Brain or Heart

It's a given that physicians are smart. However if given a choice what should be the number one trait that a physician must have. Should a physician be so intelligent and wise hence have a well-developed brain? Or should a physician have the drive, the passion and the empathy for patients hence have a big heart?

Well according to Neuroscience, we live and feel with our brains. Our feelings and emotions are found in the limbic system of the brain. Our hypothalamus releases chemicals that influences the rest of the limbic system. For instance, you have an exam and you need to get a very high grade. The limbic system gives the necessary drive for you to study all-night. In addition, the hypothalamus releases a signal to the pituitary gland. The pituitary gland, in turn, releases a chemical signal to your adrenal cortex. The endpoint of which is a release of cortisol. Cortisol now gives you the energy to study all-night albeit for a short while.

So really, the graphic representation of our feelings into a heart is a mistake. The better representation would be our brains with all its gyri and sulci. But it is not completely wrong to represent our feelings and emotions with a heart. The brain influences the heart rate through the autonomic nervous system. The heart makes manifest what we feel in our brains. That increased heart rate and sweaty palms when your crush passes by that's your autonomic nervous system making its effects on the body. However, I highly doubt that people will shift to representing emotions with a brain.

At this point, it was all a long-winded explanation to get to the point that the brain and heart are interconnected. In terms of what should a physician have, it's not far off from the truth. A physician must have both Brain and Heart. One cannot become a physician if one aspect is deficient or not in synergy.

Because a physician with only a Brain will only see the patient in terms of his/her organ systems. If said patient is suffering from a cancer then that doctor will only see the cancer and how it is disrupting the organ systems of the patient. The brainy physician will ignore the signs of distress evident on the patient's face. How his/her family members are holding back tears. And if said patient is a parent, how his/her child is suffering in school. The patient becomes Homo sapiens but not anymore a human being.

Conversely a physician with only a Heart will see the patient as a human being but will ignore the disruption in the organ system brought about by the cancer. The physician will then forget about making differential diagnoses and cry with the patient. The hearty physician will not know which drugs to prescribe or when to refer to a surgeon. Or if the physician is a surgeon, he/she may not be able to perform surgery on the patient. So in this situation, the patient is a human being but the physician is helpless.

The Brain now refers to the physician's arsenal against disease and disability. The Brain supplies the medical knowledge and pharmacology of drugs. The Brain is a reservoir of many specialties enabling the physician to make a scientific and economical choice for treatment. And if the disease is beyond the physician, the Brain enables the physician to know when to refer to another physician. The Heart is the physician's drive and motivation. It is his/her humanity. The Heart enables the physician to remain motivated to keep updated with the latest medical advances. Medicine, after all, is an ever-changing Science. The Heart keeps the physician grounded with his/her patients. The Heart motivates the physician to serve his/her patients because service to others is the ultimate manifestation of the Heart.

So Brain or Heart? The answer is Brain and Heart, in synergy, together.

A Soon-To-Be Tax Evader and Burden

An ad courtesy of BIR, Bureau of Internal Revenue, the tax collecting agency of the Philippines. 

I should be studying for Microbiology-Parasitology but every time I finish a class transcription this
BIR ad comes to mind.

A soon-to-be tax evader and burden. I let that sink in. Now before anything else, I'm not denying that some doctors do not pay their taxes. However, in this ad, it clearly states DOCTOR. So all doctors are tax evaders and burdens? What about those who chose to go to the barrios, to those who chose to go to the under-served provinces of this country and to those who work in government hospitals? And on a personal level, how about my personal reasons for going into Medicine. I certainly didn't do it for
the hypothetical income found in this ad which amounts to approximately P1,000,000.00 and the paltry tax.

I went into the noble profession of Medicine to serve and to learn. But according to the BIR, I'm a soon-to-be tax evader and burden. I let that sink in again. 

And I had to read the comments in this Rappler Facebook thread. 

It's full of the entitled Filipino mentality and ignorance. "Bakit ang PF ang taas! (Why is the professional fee high!") says one commentor. "The truth hurts eh doctors," says another. On and on again, the same entitlement, negativity and selfishness permeates this thread. It was as if all the life-saving functions of doctors are forgotten. The sins of a few doctors becomes the sins of all. Now, I am numb and speechless.

These are the people who I decided to serve upon having a revelation at the Rizal Library! This will be what my future Filipino patients will say to me and what hurts is that they'll say it behind my back. They'll generalize that my lifestyle is funded by my very high professional fees; never mind if I chose to do a medical mission or get involved in a community. Never mind if I do pro bono work.

The idea of a doctor charging a moderate professional fee is sacrilege. All things should be free. Never mind if the doctor has expenses and wants. 

I now have a sudden urge of re-thinking my original consideration in taking the USMLE and then getting an ECFMG certification which will then allow me to practice Medicine abroad. Any place far away from the BIR and these entitled Filipinos who might I add will have the audacity to ask for a discount from their doctors. How these Filipinos can face their doctors after deriding them online is beyond me.

Maybe it was a mistake in being adamant about staying in the Philippines to serve my fellow Filipinos.

On Touching a Woman's Breast

Before anything else, this was because of an academic requirement for a subject that encompasses 4 specialties. It was a breast examination for Clinical Evaluation. Essentially, for our 2nd year, we have a synthesis subject that has doctor-professors from four specialties: Pediatrics, Medicine, Neurology and Surgery. One requirement is a graded 2-on-1 patient encounter. You have a partner but you are graded individually. So you can divide the history-taking and physical examination. However, the discussion and the clinical impression is done individually. Also, the patient rapport and professionalism are noted.

Anyway, a day prior to the encounter, my mind froze because studying for 4 specialties is really too much. You will only know minutes before the said encounter what specialty you'll be under in. So in essence, if you didn't study well enough months before for Pediatrics, Neurology, Medicine and Surgery; you are screwed.

Personally, my least favorite specialty is Neurology. Not only because of its difficulty, during the 1st semester half of our class failed one block exam of Neurology I, but because of the sheer technicality of doing a neurological examination. This in addition to doing the routine physical examination that falls under Medicine.

On that day, I was hoping to at least fall under Pediatrics or Medicine. I got Pediatrics for the non-graded 2-on-1 encounter and I wouldn't mind repeating that. Well, sure doing a physical examination on a squealing, non-cooperative toddler is challenging but I'd take a chance on that rather than doing an intricate neurological examination. I'd even hope for Medicine, which I loathe, because of its encompassing nature. Medicine or Internal Medicine is basically the jack-of-all trades in the medical profession. Browsing through their textbook which is "Harrison's Principles of Internal Medicine" tells you a lot about their specialty. Oh, it consists of two volumes. So it is the only specialty that has 2 big books as its main reference material; all the other specialty has only one.

Imagine my surprise when I landed in Surgery. In the out-patient setting, surgical patients are those who have a)masses, b)blockages in the gastro-intestinal system (so think gallstones, diverticula and the like), c)hernias and d)hemorrhoids. In essence, structural problems that cannot be corrected by medication or lifestyle modification; these have to be taken out by a surgeon. So you asses whether these patients are eligible for surgery and of course, if they have any other medical condition. Having diabetes mellitus, for instance, instantly qualifies said patient as a risky patient because diabetes mellitus affects every part of the body. It slows down healing, affects the cardiovascular status of a patient and increases the chances of complications post-operation but I digress.

So, no we weren't required to do a surgical operation. We just had to interview the patient and physically examine her. My partner and I had a prior agreement. If the patient is male and has an abdominal or genital complaint; I'd do the required physical examination and if the patient is female and has a breast complaint, she'd be the one to examine the breast.

Our patient was female and went for a follow-up check-up on her breast and ankle. For the breast, she noted a mass on the inner quadrant right breast and on ultrasound, the mass measured only 0.3 cm. And for the ankle, the patient tripped causing her slight pain yet both range of motion of the joint was intact. As another digression, "both range of motion" in this sense means ACTIVE range of motion, the patient is moving the joint on her own, and PASSIVE range of motion, the examiner is moving the joint itself.

Anyway, we elicited the history and asked the right questions (for the breast: was there pain before menses, when did she first notice the mass, the rate of increase in size of the mass and was there discharge. And for the ankle: how was it injured, can she still climb the stairs and walk around and intensity of the pain on a scale of 1-10).

And following our prior agreement, my partner did the breast exam. And then the unexpected happened; the preceptor called me to do a breast examination. In my head, "oh shit" and "okAAAy, I'm going to touch a female breast!". I have never done it before the encounter; I only read the technique in "Bates' Guide to Physical Examination and History Taking". I was bit nervous because I'm a male and the patient is female and for women, the breasts are one of the private parts. So I swallowed my nervousness and proceeded to do the breast exam asking first permission from the patient. Thankfully, it was not an issue for her that I was male.

So I inspected one breast at a time, the other breast was covered. I looked at the nipple and the areola. And palpated the uncovered breast in an orderly manner; thinking inside "this is one of the sacred places for a woman and am I doing this right?!". And finally, I touched the areas near the armpits. But outside, still composed and relaxed.

And when the feedback came, well the preceptor commented I could have participated more on the history-taking. My partner did most of the talking and I did most of the writing. What can I say, one of my weaknesses is human interaction. Not that I didn't say anything, I asked some key questions that were missed but for the most part, my partner was the one asking. One of the pitfalls of being a BS Biology graduate; I would rather stand back and analyze the data.

Finally, commenting on my technique, the preceptor commended me for doing a good job and making the breast examination comfortable for the patient. She noted it was done in a professional manner (part of doing it properly is not uncovering both breasts but rather, only uncovering the breast to be examined). And I was thinking, "whew reading Bates' paid off!" and "wow, it wasn't noticeable that it was my first time doing it".

Well, I guess touching a woman's breast taught me that you can really never be fully prepared. It helps that you read ahead of time and study but ultimately, it is how you react to the unexpected that will be final judge of competence in the medical profession. Imagine what would have been the reaction of the patient had I loudly exclaimed, "Oh shit, I'm touching a woman's breast!!!". That sure would have earned me a very low grade and not to mention a very loud slap from the patient herself.