Breaking the hiatus

It’s been a while since I was able to write anything on my blog. But for the past weeks, I’ve been very happy balancing my teaching with real world experience, both in the field and in engaging with health policy researchers and decision makers.

For instance, thanks to my friends in a health policy consulting firm, we are helping public health program managers develop integrative policies. In another project I’m doing, I am mentoring colleagues who are developing their skill in health policy and systems research in government health agencies. In yet another project with foreign colleagues, we are aiming to identify points for improvement in health financing in Asean. On top of these is my work with #HealthXPh and mentoring our community medicine rotators in an urban poor community in the south of Manila.

There has been so much to learn from my interactions from various collaborators, both within the country and internationally, that I have been very enthusiastic to bring the learnings back to home turf, in the college where I work. Melding these lessons with my own experiences in public health strengthens my drive even more. I feel a certain sense of responsibility to share these things to my students. I have to show that in aiming to serve the poor and marginalized, the way to go is to be ready to accept different views, insights and changes.

But, expectedly, change will be unacceptable at the start, just like the evoked feeling of unusual pasalubong that relatives bring home from a foreign country. Sometimes, the seeming initial rejection is enough to frustrate, even leading one to move on and look for more appreciative venues.

Nonetheless, this isn’t enough reason to give up.

Though I will agree that it takes skill and practice to pitch one’s ideas, change and progress have to be embraced. Change is never easy. Like how stressed aquarium fishes tend to get after the water gets changed, it’s understandable if one’s efforts towards increasing awareness and building self-reliance seem to backfire at the start.

This brings me to why I try to adjust the way I teach: the world isn’t getting kinder.

Five Filipino doctors, three in public health and two in clinical specialty fields, were killed within the past six months. These deaths may be due to a variety of reasons, but as someone who shared in their career paths at one point of my life, I feel that these deaths are a manifestation of how our health system is enmeshed with politics, governance, business and other seemingly unrelated pursuits, and how future doctors have to be well-equipped. Meanwhile, an increasing number of colleagues have been victims of doctor shaming, where doctors exercising their ordinary care and diligence are being berated on social media for various reasons.

We need doctors who will not rest on their laurels.

I believe that getting ready to practice in a world afflicted with these things requires a balance of versatility, proactivity and discipline. Those traits may well be cultivated in good class attendance, in diligently solving a biostatistics problem, or recognizing the merits of producing a creative work. Meanwhile, the lack thereof may well be demonstrated in cases in which health professionals would fail to provide the prescribed intervention to destitute patients, by not making do with limited resources, or doing something to address the lack. This is the kind of situation I would like to prevent, since lives hang in the balance.

Despite the odds, I am optimistic. I know it may be difficult for my students, but I hope this gets to them: we are in this together. I share in the difficulty, since learning how to be an effective mentor is difficult as well. Nevertheless, for the sake of our changing world and the patients we serve, the journey has to be trod. The good news though is we can moderate the pace of the journey.

But not too slow. The world and our patients anxiously await.

Class attendance and mutual respect

A rising concern in medical schools is the growing phenomenon of people not showing up in class.

It’s quite understandable. We are in an age of instant gratification–people nowadays want instant results, or else they look for better ways to achieve the results they want. This way of thinking has seeped into various aspects of daily life: the way we eat, the way we work, and yes, even the way we study and learn things in school.

Relating to the latter, students in post-graduate settings like medical school have developed a sense of which activity is high-yield and which isn’t, thus leading them to decide against attending an activity that has been pre-judged as low-yield. In addition, an MIT study noted that the two strongest factors that lead to a decision to skip class included the poor quality of lectures, and deadlines for other academic work.

Meanwhile, medical school professors, who are usually busy for various reasons–clinical practice, research, and other academic pursuits–end up feeling disappointed and enraged for not gaining the satisfaction of being listened to by students, who will most probably be their future colleagues. The poor attendance in these lectures have resulted in what I perceive as disrespect of seniors, which is quite a serious infraction in a hierarchical field like medicine.

I am no stranger to this phenomenon. In my biostatistics class a few weeks ago, for instance, there I was, eager to teach students about hypothesis testing. Out of around 60 medical students, only less than 20 showed up. Already frustrated but also appreciative of those who made it to class, I tried my best to sustain the enthusiasm and teach the lesson anyway. Upon investigating the reason for the poor class attendance, I was told: “Doc, everyone else is busy cramming for the test coming after your lecture.”

Expectedly, when the topics I lectured that day came out in the long exam for that subject, most of the class failed miserably. For the students, the pain of failure may have been felt only once: at that one time they flunked my examination. But for professors, such a poor performance is an added insult to a pre-existing disappointment. It leads the professor to reflect and ask oneself: “Did I do anything wrong?”

Preparing for a lecture takes hours, even days, and a lecturer can only hope that the effort wouldn’t be in vain–that is, that there are actually students who would be able to listen to the lecture, and master the concepts well enough to excel in examinations and put the knowledge into meaningful practice.

But perhaps, taking the students’ perspective, these lectures may need to morph into more intellectually stimulating activities that turn “students into active participants rather than passive listeners,” as this study published in Science suggests.

Nonetheless, I also think that even if we train all medical school professors to adopt the aforementioned paradigm and design more stimulating learning activities (which obviously appeals to a generation accustomed to instant gratification), we can only do so much. There will always be topics that would be more appropriately taught through lectures.

A more important point though is the fact that medical school, in my humble opinion, is a different setting altogether. It must be pointed out that the studies cited previously were carried out in undergraduate degree settings, where learning is usually an individual affair, and one chooses to undertake courses to accumulate adequate knowledge to get employed.

On the other hand, I firmly believe that the practice of medicine is not mere employment. It is a lifetime of service.

As such, I believe that medical school cannot be likened to a knowledge vending machine where one selects courses to attend. Attending medical school for me is choosing to immerse oneself in a culture of lifelong learning to which one must wholeheartedly adhere for a lifetime. This way of life is pervaded by this one single virtue: mutual respect. This virtue reinforces the central dictum that governs the practice of medicine: to do no harm. It is the sense of engaging with one’s client, colleague or co-worker in a way that is consistent with the human dignity we all share. To put it in religious terms, it is giving what is due to another person, who like all other human beings is an image and likeness of God, to love one’s neighbor as one loves the self.

Following this reasoning, it behooves medical students to listen to their professors and attend their classes, for it is a matter of respect. On the other hand, mutual respect, to be fair, does not only admonish students to attend class. It also requires teachers to be sensitive to the needs of students, and adjust strategies accordingly.

Admittedly, the issue of class attendance is influenced by a myriad of factors. Notwithstanding, mutual respect requires that these factors be discussed through compassionate dialogue, that eliminates double standards in dealings between faculty and students, lays out all issues, and resolves them with firmness, finality, and political will. In my humble opinion, compassionate dialogue would be able to address issues such as the quality of lectures, or overlapping schedules for exams and deadlines for school work, which have been shown as influencing factors in class attendance.

I also believe that medical schools deeply rooted in the virtue of mutual respect are bound to produce doctors with unimpeachable character and genuine compassion for patients, colleagues and other health staff. I believe that students who give due respect to the efforts of their professors are those who would think twice before leaving duty posts without permission and engaging in unethical acts inimical to the sacredness of the medical profession. I likewise believe that students who are raised in this virtue are those who are consistently motivated to perform their best in hospital and clinic duties.

Conversely, I believe that professors who practice mutual respect are those who sense if students aren’t very interested in the topic anymore and are willing to learn new strategies in medical education, who are concerned if students are overburdened with coursework, and who are genuinely interested in their well-being.

Finally, I believe that upholding a sense of mutual respect in medical schools redounds to better patient-doctor relationships in clinical and public health practice, and eventually impacts positively on the health outcomes of the patients we serve. For me, class attendance and the lack of mutual respect are not just problems related to medical education. They are public health problems. I choose to think that solving this problem sustainably addresses many health inequities and challenges that we face today.

In summary, I look at poor class attendance as a symptom of a deep-rooted concern: we need to strengthen the virtue of mutual respect. It is a concern for medical education, and more so, for public health.

How I wish we learn to address this soon enough. I still have one more long exam in biostatistics and I am hoping my class would #ShowUp and not flunk again.

Soul-seeker

“What is your specialty, Doc?” I got asked this question by a wide-eyed, enthusiastic third-year student in the medical school where I teach.

“I think I can call myself a public health specialist,” I replied.

“But did you take up residency?” referring to the usual post-graduate clinical specialty track taken up by majority of medical graduates.

I relented. “No, but I took a master’s degree in public management for health systems. I’d say that would be my post-graduate training.”

“Then, Doc, you are a soul-seeker.” He explained that he considered as such those medical graduates who have not pursued residency. I tried to suppress a look of shock. “I guess I am,” I replied.

What disturbed me a bit in that encounter was this realization: that, as far as majority of people I know are concerned, the choice to exclusively pursue an academic or research career after pursuing a medical degree is still considered a transitional career choice towards a goal of eventually obtaining a clinical specialization. I cannot blame them.

To be fair, he is not entirely incorrect. I had just come from an almost yearlong hiatus in my academic career, having come from a live-in vocation discernment program for men considering religious life. I ended up not getting accepted to the religious order I had desired, but my experiences in discerning my true calling bolstered my conviction that my calling is in the academe. Soul-seeker I really was, in this sense. But I digress.

That encounter made me think hard. By now, and especially after my yearlong discernment last year, I now have a stronger conviction for my career choice; that, instead of pursuing the conventional career path of clinical specialization, I am choosing an academic one. Instead of aiming to become a specialist in, let’s say, surgery or psychiatry, I am aiming to gather enough academic exposure and experience to earn a professorial chair instead.

My colleagues in the medical school faculty, majority of whom have finished their respective residencies, have told me that I can do both anyway. But for the past few years, I realized that, as a medical graduate orientated more towards a population-health perspective, going through the path of clinical specialization would introduce bias in the way I would do my public health work and advocacies.

This leads me to one instance three years ago, when my former research institute director asked me this question: are you geared towards specializing in ‘content,’ or in ‘process’?  He further explained that specializing in ‘content’ would mean studying all aspects of that field, exclusively, with the expected consequence of getting heavily invested in a topic. If that would be a field like road traffic injuries, that would require studying factors that affect it, its special considerations, its prevalence, and even how it affects popular culture.

My director told me that doing so for a particular field would open up a Pandora’s box, and would lure me towards studying the field further, and potentially ignoring other important public health matters. I’d now call it an option of getting attached to a particular topic. Nothing bad with this at all, he said, but it represents a lost opportunity to study about other health concerns that pose similar risk to the general population.

On the other hand, it is his explanation of specializing in ‘process,’ that attracted me. It meant that I had to specialize in a particular way of analyzing public health matters, like epidemiology, health technology assessment, or even philosophical analysis.

By specializing in epidemiology, the study of how diseases spread, I gain tools that can analyze how much of the Filipino population would be prone to any health risk.

By specializing in health technology assessment, I gain the skill of assessing which intervention would be the most economical and answer questions like these: for instance, would implementing a large-scale healthy lifestyle program lower down the percentage of the population suffering from high blood pressure, or a government-sponsored distribution program of medicines? What is the more economical option?

Finally, by specializing in philosophical analysis, I can explore how lifestyle diseases, or any health matter in general, can ultimately come from the individual’s ability to reflect on his daily existence, to make logical and ethical decisions, and make sense of his role in the world at large.

These three modes of ‘process’ that I have been exposed to can be applied to any public health topic, which makes it possible for me to affect the lives of people millions at a time. When I decided to pursue medicine, my goal was to help as many lives as possible. I now feel that by choosing to specialize in ‘process’ and not ‘content,’ I can potentially contribute towards solving any health problem by using a particular way of analyzing the problem. I just had to know what problem needs to be analyzed. This required frequent introspection, zooming out from the situation, as well as sensitivity towards concerns that impact the general population. I know that by specializing in ‘process,’ I am becoming the kind of doctor I want myself to be.

However, I also realize now where specializing in ‘process’ led me. It eventually led me towards an appreciation of discernment, and even led me to think that perhaps a life of continual soul-searching within a religious context was for me. But events and circumstances led me towards where I am now, and I was never this affirmed of where I am called to serve.

Notwithstanding, my experience in specializing in ‘process’ also points to me that I have to free and zoom-out myself enough so that I can serve as many people as possible: my personal definition of why I am a doctor in the first place. Needs and circumstances change rapidly, however. This inner search should therefore be a way of life. Specializing in ‘process’ led me to be what precisely that student called me that fateful afternoon: a soul-seeker.

This leads me to pay attention to what is happening in the Philippines nowadays. I think that we are beset by problems that are mostly resolved by focusing and getting heavily invested on the situation, instead of looking at it from a non-biased, zoomed-out perspective. My experience in public service tells me that government can only do so much within its means, but my renewed perspective in studying ‘process’ also reminds me of the value of unbiased points-of-view.

Moreover, I think that as a nation we need to have a better sense of our identity. Specializing in a particular ‘process’ of resolving matters of national importance is one part of making sense of this identity, but I think that we need to search for what is indeed our soul and our purpose as a people. I learned that one leads to the other. Perhaps we need more people who specialize in ‘process’.

In sum, I never realized that such an innocent question from my student would set me off towards rationalizing my career choice and my reasons for choosing ‘process’ over ‘content,’ and realizing how the study of ‘process’ requires continual discernment. Continual discernment requires that, imperfect as I am, I should have the attributes of a soul-seeker in good faith: resolute, passionate and untainted. These are attributes that I am not so sure now if I can confidently claim them for myself.

I take solace that being a soul-seeker was who I am in the eyes of that student of mine. I hope he is right after all.