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.  

Flashback Sequence at Horatio De La Costa

Passing by Horatio De La Costa Hall brings memories. If I can encounter my past self I think this would be the dialogue:

Past me: Shet, bagsak ako sa oral exam. Pati mga quizzes ko at 2 long tests. Bwisit, mabubuhay pa ba ako...(seeing a taller and muscular-built person). Sino ka? Bat parang kilala kita?!

Future me: Oh hi, I'm you 6 years from now. Guessing from your look; I think you just received your pre-final standing under Fr. Dacanay's class. F+ right?

Past me: What?! Pati paper namin bagsak?! Wala na, dishonor to the family name! Lecheng Theology oh!!

Future me: Ay...sorry; masyadong maaga. Anyway maniwala ka; mas marami ka pang mumurahing subject in the future.

Past me: Like?

Future me: Neurology, Pharmacology, Physiology, Obstetrics and Clinical Pathology.

Past me: Hah? Wala yan sa curriculum ko ah. What are you talking about?

Future me: Oh right...ayaw mo pala mag-Medicine at this point in time

Past me: Huwat?! Di ba mag-mamasteral ako sa Biology? Di ba dahil sa tamad ako at medyo bobo kaya di ako papasok ng medical school?

Future me: (chuckles). Well, hindi ka naman bobo eh; tamad lang. At ayaw sa hirap. Sabihin na lang natin makakayanan mo ang intensity ng medical school at maraming mangyayari sa iyo 6 years from now.

Past me: Talaga? At bakit ako papasok ng medical school, baba kaya ng grades ko at parang hindi naiisip na maging doktor. 

Future me: Sabihin na lang natin kapag last semester mo na...mababaliw ka sa Rizal Library. Ma-rerealize mo rin na ayaw mo sa hayop, halaman at mikrobyo. Gusto mo sa tao. 

Past me: RIIGHT...sige sabi mo eh

Future me: Anyway, don't sell your self short. Magugulat ka na lang na kapag nandito ka na sa puntong ito; gusto mo pala magbasa ng maraming impormasyon.

Past me: Eh paano yan, wala akong Biochemistry...di na ako pwede sa ASMPH

Future me: (laughs) Hahahaha...basta there is a medical school for you and in your 2nd year bibigyan ka ng 75% scholarship

Past me: What? Me, a scholar?! 

Future me: Ooops I've said too much. Well, let's just say I'm finding it difficult to maintain that scholarship. Anyway, you'll survive Fr. Dacanay's class and you'll even thank him in the future for pushing you and making you read non-sensical texts. At least in medical school; straight to the point na ang mga babasahin mo. Sige...

Past me: Last question, anong klase akong doktor?

Future me: Nako, kahit ako sinasagot ko pa rin yan ngayon. Sige, may exam pa ako.

New Year's Eve

Days will pass by until once again it is time again to return to listening to lectures and reading notes and memorizing a lot of information. During the vacation there were rituals to attend to like feasts, gift-giving and going to mass.

Well, it's not like I can instantly say that I don't believe anymore. Given our country and it's religiosity, you really can't be sure how open the reaction of people will be. So far, I haven't encountered any negative reactions. Let's just say for the sake of my own safety and sanity, I've decided not to divulge my current belief system to the family. But the funny thing; I don't find going to mass a drudgery. However, honestly my mind was blank during the entire service.

But then, why do we do these rituals? One can say there's a cultural, social and psychological reason for these rituals even though we think of them as drudgery. For instance, the typical Catholic mass. It's the same readings all over again. There's even a scheduled reading for a particular day. Yet many Catholics go to mass again and again. One can say they've been conditioned given the early indoctrination but that's more of a psychological reason; something not in the scope of this essay.

And then there are my rituals. In a regular day (Monday to Friday) it's: 1)go to class, 2)sleep in class, 3)eat lunch, 4)chat with friends, 5)go home, 6)eat dinner, 7)work-out, 8)read class transcriptions and 9)sleep. These sequence of events will vary if it's a weekend or a holiday but generally that's it. Pretty repetitive and simple and yes, boring. Yet why do I do it?

I'll venture a guess and say it's because of meaning. Now that's an overused word: meaning. You may have heard this, "what gives meaning to your life?" And well my answer to that would be the very rituals a person does during his/her lifetime.

Going back to the example of the Catholic mass if you really think about it, why would an

omnipotent and omniscient being demand worship from his creations. Of course, there is a convoluted theological explanation which I'm not going to place here because quite frankly I've forgotten it. Anyway think about it. What comes to your mind when a being demands worship? Dictators in the form of Mao, Stalin and Hitler. Worship would be a sign that that being is insecure because if a being is all-powerful and all-knowing and perfect why would it require impotent, ignorant and imperfect humans worshipping it? Do Catholics worship this being because they're afraid of its wrath? Then that makes this being no different from the aforementioned dictators.

So, at least in my view, Catholics go to mass again and again because it gives meaning to their own lives in the same manner my ritual gives meaning to my own life. Before I continue on, note that I am not discouraging Catholics from going to mass. It so happened I thought of using that as an example. If that's what gives meaning to your own life go ahead; just don't force other people to go with you.

On this New Year's Eve, think of the rituals you've done the past 364 days. Did you do them because
they add meaning to your own life or were you just forced? Were there some rituals you adopted because it became routine? Not that there's anything wrong with routine. But keep doing something everyday without pausing and thinking its significance; this action becomes routine. It is this becoming routine that unhealthy habits such as eating salty foods and a sedentary lifestyle becomes
ingrained and very hard to change. On the other hand, starting a work-out schedule is hard because of the opposite reason: it's not routine.

And I anticipate that one of the common New Year's resolutions out there would be to get fit. And expectedly, these resolutions would all fail because that person didn't make "getting fit" part of his/her own routine. The rituals one adopts reflects the meaning one attaches to one's own life.

The message is simple:

On this New Year's Eve if you're thinking of adopting new rituals and discarding old rituals you better re-define the meaning you give to your own life. You cannot blindly adopt a new ritual thinking you'll get the desired results without first re-defining your own meaning.

As The Year 2013 Ends

It's that time of the year again. After surviving 4 block exams; I have time to breathe a little bit. Well not too much because I have block exams approximately 10 days after the first day of class in January. And I have to say, I never thought I'd encounter so much difficulty.

For instance, I actually mourn if I get a grade that is low. I metaphorically flagellate myself and imagine I have brought intense dishonor upon the family name; just to give you a very clear picture. I have never done this in high school nor in college. Heck, in college, I'm satisfied if I managed to pass the core subjects. The major subjects come easily to me, for some reason. For the major subjects, I study until 9 pm the day before the exam. And that's it. But in here, I'd actually spend an entire day at a coffee shop reading and re-reading the class transcription and books. I would even maximize the 2 am closing time of said coffee shop.

My diurnal cycle is pretty much destroyed. Before, I easily get sleepy before 9 pm. Now, my minimum sleeping time is 12 midnight. Sometimes, it reaches 2 am. Of course, this means I sleep most of the time in class. At first, I'm embarrassed but as time passed by I can't help it. Sometimes the lectures literally sap your strength away. I'm not even sorry I snore; thankfully, my seatmates wake me up. And yes, one of my friends pointed out how stupid this is but my reasoning is that I earn so-called "guilty points". Meaning I missed the lectures therefore I have to spend the entire night reading and re-reading the transcriptions.

For the love life, well that's pretty much demolished as well. I mean I go out and meet people. But sometimes, I don't tell the truth. I don't tell that I'm a medical student and instead disguise myself as a yuppie. Sometimes, I even regret going to further studies because you're in different worlds. As much as you want to spend your nights and weekends boozing and cruising along Tomas Morato; you can't because it's either you have an exam coming up or you just want to sleep. And let's not forget the difference in intellect. It's a bit difficult meeting someone who can keep up with you in an intellectual conversation so sometimes you have no choice but to dumb yourself down or stay silent.

To be honest, sometimes I question why'd I'd gotten that revelation in the first place. Sometimes I doubt if I'm going to be an excellent physician.

But that changes when I meet patients. Well, at this point I'm not yet the one prescribing drugs or treatment. At first, I felt a bit intimidated because I have to speak in Filipino. Unfortunately, years of watching foreign films and my particular college have obliterated or at least made Filipino words coming from my mouth a bit awkward. And, I always feel anxious because there are some classmates around me and I think, I'm going to make a fool of myself. In short, my nerves always gets the better of me.

However, as time passed by with more patients and with more reading of Bates'; I've gotten used to talking to patients. Filipino will always sound awkward coming from me. Or sometimes, I can't think of the right Filipino word to say in that instant but I push through it. As the year progresses and my knowledge of diseases increases thanks hugely to Pathology; I more or less know what questions to ask and what signs to look for.

Doing a physical examination now comes a bit easier with more patients and more reading. Of course, the neurological examination will always be out of reach. Let us just say, it is so detailed and requires skill in hitting the nerve to elicit your deep tendon reflexes.

And oddly, it feels gratifying knowing the right knowledge and the right way to deliver it to potential patients. May it be a simple cold or a fever. I include the delivery because let's face it, we're dealing with human beings not rational creatures. There are times wherein being direct is not optimal. It may even force your patient not to face his/her diagnosis. So you really have to empathize with a patient. Not all patients are the same and it requires a highly skilled eye and an empathy sense to determine which approach to use.

As I type this, that is the reason why I keep fit: for the potential patients. For what use are you to a patient if you're the one suffering from a debilitating disease. It also increases your chances in getting a date but that's not my only reason. Well, of course it's not easy keeping a work-out schedule in the midst of multiple reading assignments.

So yes, there are lots of things I'd have to sacrifice and I hope I don't become one of those physicians who patients loathe. Also, I don't want to become the stereotypical physician who can't jog or even do push-ups yet will prescribe to his/her patients exercise.

In short, I don't want to become a hypocrite-physician.

Typhoons and Unbelief

The recent typhoon "Yolanda", international name Haiyan, has reeked devastation in the Visayas region. And the only thing I can feel when I saw the images, children drowned, people homeless, the entire city of Tacloban wiped out, is despair. As a human being I am deeply saddened by the meaningless loss of life. As a Filipino citizen, once again I am mad at the idiot in Malacanang following this news. He is totally unfit to be a leader but that is for another post. He is once again proving the need to correct the 1987 Constitution. Anyway, I digress.  

This is not going to be about how the typhoon could have been prevented by a benevolent and omnipotent god. It would be like rubbing salt in a recent wound. This would just be about how I felt and reacted to the news.

It can be summed up by a feeling of helplessness and hopelessness. I feel for the people affected by this super typhoon.

Which brings me to another point: how do I deal with religious patients. Currently, we are meeting patients and asking their history. One part of asking a patient history is asking for the patient's religion. There is a medical basis for that; for instance, a religion might not permit blood transfusions. No matter how dire the consequences if the patient does not allow for blood transfusions then we must refuse. Patient choice and autonomy.

A patient's religion goes beyond the medical because sometimes it is through religion that these patients find relief. An 18 y/o pediatric patient goes blind suddenly. In his history, he mentions that it is through his religion that he found hope. Prior to his blindness he was an athletic person so imagine how he initially felt and remember he's an adolescent. Remembering psychological developmental stages, it is around this time that a human being strives to be independent.

A mother of 33 y/o patient with recurrent urinary tract infections (UTI) is stressed with her son's condition because urine culture has shown that the strain responsible for the infection is resistant to the first-line antibiotics necessitating more expensive medicines. The patient himself finds relief in serving in church activities.

There are many more stories of such patients. Who am I to strip these patients of hope? So as to avoid challenging these patients, I create a space within myself. In those moments, I become a doctor, nothing more and nothing less. Their stories pass through me.

In conclusion, I'm not going to deny that religion gives some people hope. I'm not superior nor inferior to religious people just because I don't rely on religion for hope. It's just that I have other sources of hope. Anyhow, let no one use the recent tragedy for any end whatsoever. At the end of the day, we're all human beings capable of empathy and feeling. Let us not ever forget that, ever.

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.

How Medical Missions Actually Make People Poorer

You're all familiar with this: health professionals wanting to help their fellow countrymen/women. And since they are trained for giving services to others, what better way to help then to give a free medical check-up and free drugs a.k.a. a medical mission. I am not against people helping other people out that is a very noble gesture. However, we have to look at the unintended consequences and the long-term effects of these missions.

Sure, you may have helped people by giving free diagnoses and free medicines. But without looking at the systemic cause of their ailments; the people you've treated will just get the same disease. Also, with the current set-up of medical missions, you've removed their agency and made them into mendicants dependent on health professionals for good health. 

Any medical mission will thus have to be based on this premise: would you give people fish or teach people to fish?

In any case, my specific recommendations would be the following:

1. Remove food supplements from the roster of drugs you'll be giving to people. You're really not helping them. In the medical mission I participated in, the people almost always requested for food supplements for themselves and their own children thinking it was the norm. Sure, you may keep people in good nutrition for a short period of time but that doesn't attack the root cause of their malnutrition in the first place which is poor eating habits.

Think about it, where do you get vitamins and minerals from nutritious food like fruits and vegetables right? So people should eat more of fruits and vegetables rather than junk foods. Of course, the usual counter of the people being helped would be a) because their children doesn't want to eat fruits and vegetables and b)the parents are busy working so they cannot guide their children into eating proper food. Impress upon them that is it their own responsibility to maintain their own health and of their children. It is their job to teach their children and caretakers proper eating habits not the responsibility of health professionals.

2. Only take drugs for diseases present in the community you intend to help. This I admit entails a lot of homework because before the medical mission proper some people will have to go into the community and ask around. This saves time and effort. Why would you stock up on drugs that have no recipients in the first place? And this is connected to point 1. It also removes the temptation of people stocking up on unnecessary drugs. Remember that all drugs have side-effects and should not be taken unless directed by a medical doctor.

3. Eliminate "tuli" missions for they are really not that medically necessary. Honestly, there are minimal benefits to be gained by circumcision. Sure, it decreases the chance of acquiring sexually-transmitted diseases; however, the better approach would be to educate the people on sexuality and how to prevent transmissions of STDs. You may ask why I include sexuality. Well, any talk on STD prevention will always need a talk on human sexuality. People will have to be aware that their own sexuality is something beautiful not abominable. Also, educating males about proper cleaning of their penises is much better than mandatory circumcision. Anyhow, I digress.

There is a strong stigma against uncircumcised men in the Philippines but ask yourself, are you health professional or a "datu"? You are there to help with medical emergencies and cultural passages of manhood need not concern you. Does it really make sense that a 10 - 12 y/o boy is forced to undergo mutilation of his foreskin just for the sake of being called a "man"? The better option is to let the boy decide for himself.

And to make this point inclusive of all medical missions: only prepare for medical interventions that are necessary to improve overall health. So giving antibiotics after being examined by a medical doctor, dental work and referring to the nearest hospital is okay. These sorts of interventions.

4. Frame your medical missions in the preventive aspect not on the curative aspect. Curing diseases is good however it makes better sense to prevent these diseases. Take for instance pulmonary tuberculosis and hypertension. These were the common diseases I encountered and in fact common diseases found amongst Filipinos. The Department of Health already has its TB-DOTS program in order to provide early detection and treatment of tuberculosis. Inform the community that tuberculosis is not something to be scared off and there is the TB-DOTS program. I am aware that it is not that simple; however, we have to start from somewhere.

And hypertension is really connected to point 1. If you really think about it, poor eating habits contribute to the high incidence of hypertension found amongst the poor. The cheapest foodstuffs are those with a high salt concentration. So if you don't correct their poor eating habits; you've really not helped them at all. Remember that maintenance drugs of hypertension are expensive and have to be taken everyday.

So in the long-run the economic costs will outweigh whatever curative intervention you hope to accomplish with the current model of medical missions. Not to mention the unnecessary loss of human life.

The list is not exhaustive. There maybe some other aspects that can be improved; however, always remember that it is the people's responsibility to good health not the health professionals.

Now, I anticipate that these recommendations would be met by hostile resistance amongst other health professionals and the people you intend to help. Filipinos are great enablers after all. But it is precisely this behavior of Filipinos that these changes must be implemented. And I also anticipate that the number of people who will attend your medical missions after these changes have been implemented will drastically decrease.

However, at the end of the day; it is their responsibility to maintain their health. But to be realistic, introduce these changes by "breaking it to them gently". For instance, inform the community leader that there will be changes to your medical missions and your intentions behind the changes.

Change is always hard and it's easier to keep to the status quo but really, the status quo just produces mendicants.

A Dichotomy

It's one of those things that you don't intend to do but you are forced out of familial pressure. Me, visiting a shrine in Manaoag, Pangasinan. I've been here before but this time it's different. I no longer belief in anything supernatural for it is an insult to the scientific training I've received and the medical training I'm currently undergoing. Well, I just sucked up my disgust and walked around. It has improved. Before there was no canteen, the rest rooms sucked and the big statue of the Virgin Mary was hidden away. Currently, it's now at the center of a grandiose structure with candles placed around it. I can imagine at night the big statue being illuminated by candlelight.

How I hated it.

Contrast that with the Philippine General Hospital. I can honestly say it has not improved. You have diagnostic laboratories just across PGH and you have the Faculty Medical Arts Building just inside the premises of PGH. For those unaware, FMAB is a private hospital. Anyway, what do these two points imply? Simple, the Philippine General Hospital currently sucks. Well, to put it more substantially: a) why would you have private diagnostic laboratories across a hospital that is mandated to provide the health needs of the the common public and finally, b) why would you have a private hospital, FMAB, inside a public hospital, PGH?

And I hesitate in going to the provincial hospital in Pangasinan. It might even be in worse condition than the Philippine General Hospital.

But somehow, I'm not surprised at this strange dichotomy. The religious when sick ascribe their healing to the intervention of a supernatural deity despite the clear evidence that it was the medical intervention that saved them. And let's not forget the placebo effect.

It is time to move forward. I am not saying that all Filipinos should be atheists/agnostics although it would warm my heart if we were to become a purely atheistic country. Rather, it is time to prioritize rational actions over divine interventions. Gods will not save us from our wretched conditions. Humans are the ones responsible for these conditions and it will be humans who will solve them.

When we were done with the visit; I noticed something else. There were fewer people. I mean during the 1990s, the time when we visited the shrine, there were lines just to get inside the basilica. And the area where you put candles was crowded. Of course, I can't conclusively say the number of visitors to Manaoag decreased. But you can't help but wonder.

This Time...Something Political

So haven't blogged for awhile; blame the vacation. I have absolutely nothing to rant against...maybe except for those missionaries preaching in buses. Now, I'm well aware that they have the right to freely express themselves but it is so tempting to make their activities illegal. What about my right to freely enjoy the bus journey itself? But enough of that. It's April 2013 with the May 2013 elections looming and guess what; I'm not voting.

Let's see, between you and me; it is such a waste of time and effort. Now, now...before you dismiss this as a rant born out of laziness, lack of civil duty and disgust for my country; in fact, I love my country but I'm not blind to its defects. Kind of how I love my college alma mater. I respect how it molded me and how I currently view the world but it doesn't mean I am not blind as to how some of its graduates are flawed and that's putting it lightly.

Ever notice that most Senators, Congressmen and Presidents, with President Aquino as the very epitome, are idiots. Worse, they win solely on name-recall. In fact, if Corazon Aquino didn't die just before the May 2010 elections; her son wouldn't have won the presidency. Even if some Filipino with some brains campaign; they have little chances of winning. Our current system favors the popular so it is no wonder why Filipino politicians are a)idiots, b)celebrities and/or c)have famous last names. So potential voters like myself who are not easily bought into popularity and have a tendency to scrutinize everything are diminished against the majority of the Filipino populace who tend to view things in a more simplistic manner.

Not saying that the Filipino masses are idiots because that will tend to put the blame entirely on their shoulders. They are partly responsible yes, but the current system is the bigger culprit. Notice how the senatorial candidates campaign as individuals whereas in other countries; politicians campaign as parties with solid platforms, policies and programs. And who can help not notice that our parties are just instruments to power with candidates shifting to the favorable party. In short, when politicians are voted into power; they are voted as individuals with no regard for cooperation.

Our entire system is flawed. There is no escaping this stark reality. You will have some Filipinos proclaim loudly onto cyberspace that "THERE IS NOTHING WRONG WITH THE PHILIPPINES!" but the bitter reality is there is something utterly and devastatingly wrong with the present country. And the sooner one realizes this; the sooner the Philippines can become better.

Let's take poverty: it has remained unchanged since 2006. And this despite the Aquino administration's massive spending on its CCT, conditional cash transfer, programs. Gee, when you tend to provide dole-outs (let us not kid ourselves, no matter how many word-plays the Aquino administration provides; it is in essence a DOLE-OUT), it makes people dependent on other people to succeed. In other words, you are just promoting a culture of free-loading and mendicancy.

So do we take to the countryside and wage open war on the current government? Let's see, an armed group has been doing that for so long: do you really want to give your lives for an outdated ideology that has already been proven inapplicable in reality? 

I propose these solutions:

Let us start at the personal level. The sooner you realize that no one can save your self except for your self; the better. Take for instance alms-giving. I used to give money to those who were asking but thanks to encountering a very self-entitled man along the avenue of E. Rodriguez I've longed discontinued the practice.

Seriously, I mean imagine me walking alongside E. Rodriguez when I get accosted by this man, along with his family and child, asking me for money because he forgot to bring enough to commute back home. So I asked him all sorts of questions but for some reason I felt he was a scam artist; by an act of coincidence, I also encountered a scam artist along E. Rodriguez. In the end, I didn't give him money. And he had the nerve to get all high and mighty with me! Imagine, the very nerve! I was seething inside because first of all, not my fucking fault you forgot to budget enough money to commute back home and second of all, you should be ashamed that a grown man like you is begging for money from a complete stranger in front of your child. I just stared at him, not wanting to make this father seem more impotent in front of his child; I'm not that cruel.

It may seem a sadistic philosophy but what would you prefer, babying other adults? It is this sense of mendicancy that pervades the Philippines and you wonder why we don't progress. And by extension, how some politicos get into office. And how the Catholic Church got its stranglehold over the populace in the first place.

And the more far-reaching solution: support Constitutional Reform. See, those idiotic politicos are given the chance to assume political power because our 1987 Constitution is especially designed that those with popularity win. And by extension, why jobs are so scarce here. The very ultimate example: our UPCM, University of the Philippines College of Medicine, doctors are working as doctors...IN THE USA! Oh, don't get mad at them; get mad at the 1987 Constitution with all those economic restrictions.

Until that wretched 1987 Constitution is corrected don't expect our politics to progress beyond popularity and name-recall. Don't even get shocked if Nancy Binay manages to become a Senator because that's how our Constitution is designed.

Until that time, don't expect me to vote.