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.