Future Writing Directions

Although I'm loathed to put a direction to what I'm going to write, it somehow helps if I have a guide. And I have ideas for essays really; I just haven't put my mind into putting them down in words. So here are some tidbits of what I plan to write (so I actually put them down in words instead of being in a month-long hiatus). And it ties me down to this blog so again I won't be in a month-long hiatus.

1. Exercising and Medical School, is it possible?

2. Health in the Philippine Setting (argh, a bit general and requires so much research and that's partly the reason why I'm loathed to write it but I want to. So if anyone can put some inputs in the comments or email me at torres.ryan550@gmail.com; it may help me.

So far, I'm thinking how the closed economy, centralized and Presidential system of the Philippines is directly responsible how a) patients have to pay out of pocket for the medical expenses, b)all the doctors, general practitioners and specialists are concentrated in Imperial Manila, with exceptions of Cebu and Davao and c) how our Secretary of Health have to beg Congress for their budget because of the separation of powers, Executive and Legislative. Hence, instead of cooperation, the department secretaries have to 1) compete against each other and 2) compete against Congress, remember department secretaries are appointed by the President and the Congress is elected by the people.

See, ambitious essay so inputs are really welcome.)

3. Journey through Medical School So Far (I promise none of that cliched "Oh medical school is so hard". I'll think of an alternative angle. For instance, it can be fun)

4. Unbelief So Far (if I think of any)

5. If I feel anything (Okay, here's my writing process. I actually have to feel something before I write anything actually. So I feel nothing there is nothing to write about). 

Anyway, let's see if I can do all of this in the list. And again, I put it in list form so I have a clear direction and it's sort of a commitment.  

The Ethics of Death and Dying

(Sidenote: This is the final essay for the requirements in our Medical Ethics class. I've somehow missed the way Ethics was taught to me during my undergraduate years. Yes, I'd had to read through Kant, Confucius, Foucault and Aristotle. Well, a little of each; I didn't exactly finish all of the required readings for the course but I got the main gist of their ideas. And indirectly, being forced to read so many readings that have no connection whatsoever to my course did benefit me during Medicine. At least now, I can honestly say, although the readings are long at least they're straight to the point. Unlike those philosophers, with Ricoeur as an exception

Anyway, what are your thoughts about Death, Life and Dying? Please leave a comment and again, I apologize if I'm not able to reply instantaneously. Oh, this was written in reaction to the film, "Wit", more specifically the scene where Dr. Vivian Bearing was given the option of being resuscitated or not by the nurse.)

There is always something unknown about death. However, this is in direct contradiction to health professionals who require certainty. A health professional performs a very detailed history and a thorough physical examination. And then orders all sorts of diagnostic imaging to arrive at a certain diagnosis. All of this certainty is built on avoiding the greatest uncertainty of them all: death.

            What happens after we die? Nobody knows and no one can really say for sure. Some say there is an afterlife, some say there isn't  One thing is for sure, a human person ceases to be when he dies and this is what is at the root of death. A human being cease. No one can really say if he went to heaven or became one with the Force or any other primordial energy. What is left is the pain of loss among the dead person’s loved ones and those who knew the person during his life.

            No one can really explain death. Sure, we health professionals can explain the pathophysiology of a patient’s cancer and we can explain how the glutamate cascade is responsible for the death of neurons in a stroke patient but we really can’t say why that particular person. No amount of explanation can wash away a person’s cessation of existence so it is but natural we stave away death. We invent all sorts of contraptions and interventions to avoid death and prolong life just so we can avoid the biggest uncertainty of all.

            Yet there are times when patients opt for a DNR, Do Not Resuscitate. For a physician it may seem like a slap in the cheek. Here you are trying to save this patient’s life yet this patient has given up hope and prepares for the inevitable. Is the DNR patient less than human for giving up? And conversely, is it always the default position to fight for life at all costs? 

            The resounding answer is a big no. A DNR can be seen as an acceptance rather than giving up. Sometimes life at all costs can be too high a price. Can we say that a person is truly alive if he or she is hooked to a machine? Far from being seen as a sign of weakness, a DNR simply means another option. It is but another choice for which nobody can be condemned for. Just as long as the circumstances were made clear to the patient and he’s been given all the time.

            How we treat the dying says about how we think of Death in general. Treating them with scorn and prolonging Life at all costs shows how we secretly fear death. Does a person cease to be a human being if he accepts he’s going to die? Of course not for Death is but a part of being human. There can be no Life if there is no Death.

            Far from thinking Death as a big uncertainty, it can be thought of as another journey that all of us have to take. We can try to delay it as much as possible by living a healthy lifestyle or by heroic measures but inevitably we die. On a personal level, we can never be sure of what is going to happen but for those left behind, we leave a legacy. So really, a DNR is but another option. What is more pathetic are people who can’t come to terms with the inevitable and prolong life at all costs.

            There are a lot more things worse than dying. What we can do is treat Death with humanity instead of fear and scorn. 

Revelation

(Side note: This essay was written in response to a lecturer asking all of us why we chose to be in medical school. I have written about it in great detail here:  http://thelukanmd.blogspot.com/2012/11/start-of-lukan-medical-journey.html. As I was writing this particular essay, I focused on the particular event that started it all. And as the title suggests, it really did come to me like a revelation, a sudden jolt or realization. It's somehow of a refresher essay for me of why. I've changed since I've written the very detailed reason but somehow the reason is still there although somewhat modified.)

            It starts with a crazy idea as these things go. As I was nearing the end of my college stay; I absolutely had no idea what I was going to do after I graduate. Initially, I started like those traditional medical students who right after high school wanted to go to Medicine. I even chose the quintessential pre-medical course. And yes, these decisions solely came from me; my parents never forced me into anything. The only thing they chose was what university I’d be entering. However, when I entered into college; I never imagined it would be that hard. I breezed through high school getting high grades without breaking a sweat.

It got me thinking that if I went to Medicine; it would be harder and there would be a lot more reading to be done. I didn't exert much effort back then. And before I knew it, I was graduating and with no clear direction. So yes, I was an underachiever back then. I didn't study throughout the night. And I even slept early.

            I remember it was a morning during my free time. I was sitting at a computer terminal in Rizal Library. I suddenly had a revelation that I didn't like animals or plants or even microbes. What I really liked was studying humans. I've been denying to myself that I was born to be studying and learning. So without any prior notice to my parents; on that same morning I registered myself to take the NMAT and enrolled myself in review classes. All that was left to do was choose what medical schools to apply to.

            As I was late in planning for medical school; I didn't know the choices. I couldn't apply to the medical school of the university because I lacked units so I had to search for other options. So I searched through the Facebook profiles of my batch mates and through that search I made 3 choices. Initially it was only 2 but I added a 3^rd option because of my unspectacular undergraduate GWA. And to cut the story short, I was accepted to only 2.

            So far, I can say I made the right choice. Although, sometimes it depresses me because I’m 24 yet I’m still in school and still dependent on my parents. However, it brings me unspeakable joy when I get asked by people about medical knowledge. Heck, every parental visit sometimes becomes a medical consultation. And I haven’t even obtained the mystical “M.D.” added to my surname. It comes with a pressure to be updated but I've learned it only drives me to learn and read further.   

The Ethics of the Patient-Doctor Confidentiality

(Side note: This essay was written in reaction to this: http://www.youtube.com/watch?v=MoP7xgW1A9U. To summarize, the doctor in question posted on Facebook some sensitive patient details. The doctor didn't post the patient's name. However some people want the doctor to be fired because she violated patient confidentiality. How about you, what are your thoughts about patient confidentiality? Please leave a comment below )

            At Mercy Hospital, there was an obstretrician/gynecologist who upon posting on her Facebook wall patient details; she was fired. She was merely venting her frustrations because said patient was late for her appointments. She did not post said patient’s name or photo and only included some medical data that is not specific for any patient. Her post ended with “May I show up late for her delivery?”

            In the USA, there is no law prescribing the exact specifications of the patient-doctor relationship. Instead it was based on the Hippocratic Oath with this passage: "Whatever, in connection with my professional service, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret." And information divulged by the patient can only be said to fellow medical professionals as evidenced from this passage, again from the Hippocratic Oath: "Those things which are sacred, are to be imparted only to sacred persons; and it is not lawful to impart them to the profane until they have been initiated into the mysteries of the science."²

            And instead, doctor-patient confidentiality is centered on ethics and there has to be a doctor-patient relationship to warrant secrecy for effective healthcare. Laws only specify up to what extent such information can be made available. Such cases include notifiable diseases and medical databases although patient identifiers are not included. Finally, only the patient can void the doctor-patient relationship and in medico-jurisprudence cases where medical information is necessary.²

            First and foremost, there was no patient-identifier present in the doctor’s Facebook post. The patient’s photo was not even present on the doctor’s wall making it difficult to say that the doctor was pertaining to a specific patient. The obstetrician/gynecologist was merely expressing her right to free speech and venting because of her time wasted due to the patient’s lateness. It can be argued that her post was demeaning to the patient but only up to a certain extent. It can be likened to an employee in a company venting about her customers but we seldom hear complaints about these people. However, it seems that the doctor is subject to higher standards than most employees.

            The doctor-patient relationship is a relationship that is based on trust. This means that the patient can trust the doctor to always do what is in his/her own best interest. The doctor is tasked to always be professional towards patients and is trusted that he/she will prescribe the necessary medical interventions. This element of trust is crucial because without it; healthcare cannot be effective. ¹

            What people are reacting in this doctor’s case would be the issue of trust. Even though there were no patient-identifiers present in the Facebook wall; they feel that the trust people put in doctors has been violated because details that can only be obtained from a real-live patient has been announced in public. There is an implied understanding that parts of the medical interview is confidential; there are exceptions but even then, these are rare.          

            And when doctors reveal intimate details, it was as if the doctor was undressing a patient in public and exposing the patient’s body. It is this act of nakedness that is inherent in the doctor’s seemingly harmless Facebook post. The doctor may not have posted the name or photo but she has still exposed part of the patient to the public.

            Which brings us to the final point: should the doctor have been fired for exercising her right to free speech? And the resounding answer is no. Instead she should have been given a reprimand. Medical professionals are subject to a higher standard because there is an element of trust in order to deliver effective health care. The difficulty lies in determining where does this trust end and where does it begin. With the advent of new technologies such as social media; information is easily spread. For instance, post an embarrassing photo and it will spread like wildfire.  

            As such, all medical professionals must always be cautious in posting details about patients even if they are unremarkable and innocent. It also helps if the tone is in a neutral manner. It is not that medical professionals are to be silent but they should be highly aware that whatever they say is subject to higher scrutiny because they deal directly with people’s lives and can affect them. Whether we like it or not, we will always be under intense scrutiny and as such we will have to deal with job pressures in a professional manner.

References:

1. “The Doctor–Patient Relationship Challenges, Opportunities, and Strategies”. Susan Dorr Goold,  Mack Lipkin, Jr. 25. Jul, 2013. J Gen Intern Med: 1999 January; 14 (Suppl 1): S26-S33.

2. "Healthcare - Doctor-Patient Confidentiality." Encyclopedia of Everyday Law. Ed. Shirelle Phelps. Gale Cengage, 2003. eNotes.com. 25 Jul, 2013. <http://www.enotes. com/healthcare-reference/>. 

Integrity

(Side note: This essay was written in response to a lecture about integrity. The funny thing was, I had to cut that class because I wasn't feeling that well so I had to rely on 2nd hand accounts of the lecture so that I know what the lecturer was talking about. Anyway, what I've written is not just for the sake of passing the class but it comes from the heart. Who knows, maybe someday I'll come back to this post if ever I feel like giving up or taking shortcuts detrimental to a patient's health and life.) 

            Integrity is something that is important in all aspects of life. It is not the sole monopoly of medical doctors yet due to the high expectations placed upon medical doctors; it is highly stressed upon us. For instance, a doctor without integrity will easily prescribe drugs just because the drug company gave him a huge financial incentive without even thinking of the possible side effects that the patient can experience due to the drug. Worse, it might not even be indicated for the patient’s condition.

               However, integrity is not something that is easily passed on or easily taught. It is not something that can be learned through a class. It is something experienced and observed. Also, it is something that is imbibed meaning that a person must choose to embody integrity. And in choosing to do so, that person must have a very deep reason for embodying an abstract yet important idea.

                Practically, a medical doctor with integrity will be visited by more patients because he can be trusted to give cost-effective medical interventions without being swayed by the pharmaceutical companies. On a much deeper level, said medical doctor can sleep better at night because he did not place any human being in harm’s way. Either way, a medical doctor with integrity is a full-fledged medical doctor.

                But then what does it mean to embody integrity? The most important thing is that this is an ongoing question that the medical doctor must answer everyday of his life. This question is re-asked and re-answered whenever new situations arise to combat the medical doctor’s values or outlooks on medical practice. That is not to say that integrity is limited to the medical practice. It is not. The question of integrity permeates even outside of the medical doctor’s practice. It permeates the life and relations of the medical doctor. Even the simple act of being on time for every appointment, however small a gesture, is already an act of integrity. And yet integrity is a question. It is something that is redefined and cannot be sequestered into a well-defined box.

                Finally, integrity can be likened to an ongoing re-evaluation in the sense that it requires re-updating of one’s outlook and values. To put it more concretely, what may seem an act of integrity then can be an act without integrity today. No act can really be defined as full of integrity for definitions will invariably exclude the person who will execute said act. One can only be guided by his own values and other human being’s own values. It is important that a medical doctor always strives to better himself. In the fullest sense of this phrase: a medical doctor is not just a medical doctor. 

Apologies (or Excuses)

I apologize to my regular readers (if I have any) for the lack of blog posts these months. 2nd year Medicine in the Philippine setting is a bit more challenging. Many more subjects hence more books to read. Thick and heavy books.

Anyway, I'll be posting a few essays I've written for my Medical Ethics class. Not just because they got high grades but well, someone might benefit from them.

Finally, to describe 2nd year Medicine in a few words: exhausting, endless readings but fun. Here is where what I learned in 1st year (Human Anatomy, Human Physiology, Medical Biochemistry, Foundations of Medicine and Preventive and Community Medicine) blends into these subjects: Pathology, Microbiology and Parasitology, Pharmacology, Clinical Evaluation, Medicine I, Neurology I, Preventive and Community Medicine II, Medical Ethics, Pediatrics I, Basic Science Research. 2nd year is where diseases, drugs and how to conduct a physical examination and medical history are taught.