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.

The Interview

(originally published 30 January 2009)

I just sat for an interview this morning.

Last night, as I stayed for the night in my friend’s condo unit, my mind was already filled with questions about my future and about what I am to do with my life after, God willing, I get my medical license and become a full-fledged doctor. I wondered if the decision I made earlier that day would finally answer those.

There had been an intense urge, since that day began, to do something that will change my life forever. I eventually felt this urge being satisfied as I finally walked in the scholarships office and signified my intention to apply for a unique scholarship program.

Admittedly, half of me wanted the benefits. These times are tough times for me and my family. Petty quarrels have been becoming quite frequent at home, because of how that very precious wad of bills is being spent. I felt badly that I had to do something about it.

Initially, I did just that by entering a business venture with some fraternity brods. During the past months I had built a business of my own, which was grounded on the principles of free-enterprise and private franchising.

But, now, it seems to me that prospecting and showing business plans occupies too much space in my already complicated mind. My ideas and feelings about building a business may change in the future, but I really feel that I have to focus. Right now I wanted to fixate my mind on this objective: To study hard, and become the best doctor I can be for other people.

This time, I wanted to find a way to augment the family’s finances without having to lose my focus in becoming a dedicated physician. With this in mind, I finally applied for a scholarship grant that will take me to a far-flung area right after passing the medical boards.

Yesterday I had been told that the interview will start at 7, and found the day opportune to staying for the night at a nearby condo unit of a close friend. Just this morning I readied myself, imagining what questions will be asked and what expectations are to be met. I tried to answer each question sincerely and with heart.

I told them how much I would risk to serve my nation. As corny and as patriotic this may sound.

I told them how much I felt ready to be part in building the nation one rural health unit at a time.

And I told them, that in the future, I want to establish a medical practice that will make my family and friends proud.

Right after I sat for the interview, I called my parents and thankfully I heard from them how much they supported me for a decision I made on my own: to pledge two years or more of my life to serving the underserved. I have yet to discuss these personally, I am still here in an internet joint across the college, searching for experiences of people who have trodden this path ahead of me. Some reassuring, others even discouraging.

But all of them, heroic.

I know, I am not yet leaving for an island town or a barrio nestled in the middle of the Cordilleras. But it is quite a different feeling waking up early in the morning and doing one’s daily tasks in the hospital while thinking of the future two years that you will spend in the barrios.

I have been told that the slot will be secured once my parents give me their blessing.

I can’t wait to talk about it with them tonight.

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EPILOGUE: I did get assigned to the Cordilleras. I have been at times doubting my motivations, even to the point of questioning myself why I did this. But after reading this and looking at the pictures of the areas I’ve served, absolutely no regrets.

Removals

I have a confession to make.

Despite having the opportunity to study medicine through an accelerated program, I never felt fully convinced that a clinical career was for me. In fact, I felt that it was just a stepping stone towards a career that is more suited for me.

However, obedient son as I am, after having qualified for the program (which I did not really aspire for, I just did my best to get accepted to my dream college), I just studied to pass.

My way of studying at the time was through reviewers. I did not use books. I wanted to understand concepts from a bird’s eye view that reviewers offer. As a result, my grades weren’t as stellar as they were supposed to be.

As a result, exam after exam, I find myself near the bottom of the list. Growing up as an academic achiever back in high school, initially this was hard to swallow. I took it with much bitterness, but eventually I learned to let it go.

But I didn’t really study harder. Instead, I felt that I just had to strengthen my other skills. I joined the student publication of the medical school, eventually rising as its chief. I became active in some organizations and initiatives.

This was my way of doing things until reality caught up with me. Class standings were posted, from which I learned that I was to take a removal exam for Pharmacology.

Pharmacology was not really easy, but neither was it a subject impossible to excel in. There were a lot of things to memorize about mechanisms of action, the way drugs are metabolized and distributed to various parts of the body, and the variations that occur within drug classes. I knew that I hadn’t been doing my best, and I knew this was what I deserved.

Reviewing for the removals was a great pain, not just because of the regrets that accompanied the preparation, and not only because of the prospect of repeating this subject and getting delayed. It was also because of the realization that if I really had wanted to become a doctor in the first place, this would not have happened.

But it wasn’t time to hit the books and expect to learn a year’s worth of topics within a short time. Reviewers were precisely what was needed for this type of exam. With a chuckle I realized that my style of preparing for exams actually equipped me well to take removals!

We were sizable bunch of second year medical students who were to take the exam. During the examination I barely mustered the confidence to shade my answers, as question after question tested my so-called bird’s eye view of Pharmacology. The stress was palpable as we gathered in the examination room. To calm my nerves I said a little prayer to God: make me pass and I’ll make sure I won’t get to this point ever again.

Happily, I came to know a few days after that I passed. Not only that, I almost topped it. It was my first time to score near the top of any exam in medical school. Something that actually never happened again. Thankfully though, I likewise never removed a subject ever again.

It was a personal victory for me.

Additionally, I think this was my turning point: I developed a genuine desire for medicine, knowing that if I am to become a good doctor, I needed to have extensive knowledge of how drugs work.

Zooming out further, I think that this also made me think hard of what I wanted with my medical degree. Looking at things from a bird’s eye view made me think that perhaps medicine is just a vehicle through which I can sustainably ensure health for all.

There was something bigger to be achieved. But definitely, something that required me to pass Pharmacology. And something that demanded me to change my strategy in studying. I learned how to appreciate books, and the in-depth knowledge they provide. Though I continued medical school with a less stellar record despite my best effort, I did my best to make it up with extra curricular activities.

I found it a good balance to strike: a sustained effort to hit the books, while exposing myself to public health-oriented opportunities even as a medical student. Notwithstanding, my involvement in extra-curricular activities came with the responsibility to pass all my subjects. Thank goodness, I did, every time.

Now, as a professional, I was never asked about how I performed academically but how I made use of my knowledge and skills. Isn’t this what matters more?

Nonetheless, for all the medical students reading this, I cannot stress this enough: read your books. Before aspiring for a bird’s eye view of everything, know the material well. Master it. Live it. And imagine life putting the knowledge to good use: for the benefit of the patients and communities we ought to serve well.

Happy Easter everyone!

Assisting at Anointing

(originally published 26 Nov 2009)

I just assisted at anointing one of my patients, who presented at the emergency department with a very poor prognosis. Unresponsive to all of the stimuli I tried to rouse her from sleep, and her pupils not responsive to light, she looked as if death were waiting around the corner.

Since I started rotating in the hospital as a clinical clerk, in other words a junior doctor, the phenomenon of death has never failed to perplex me. It seems so fast as it comes, snatching life out of those whom it calls to. I once had another patient who, after being suctioned of his phlegm through his breathing tube, suddenly became agitated and died. Death is as scary as it is abrupt, all that has been with the person is now over. The heart stops, the eyes cease to respond to light, the breathing stops, and the blood pressure goes down to 0/0.

It is not a comfortable feeling to have one of your own patients die.

I have often been exposed to death as though it were something to be expected, something after which, life could go on for the rest of us in the hospital. Back to work. No debriefings. No processing sessions. Just getting back to work. One still has other patients to work on. One still needs to study. One still needs to go on, move on.

I have not gotten used to it though. There is still a part of me that wants to grieve.

My friend, a religious novice, once asked me how we medical professionals manage to cope with witnessing death. I told him there is no single way.

I imagine myself suffering with the family, and the dying patient as my own flesh and blood. This brings tears to my eyes, in part, because this person has been loved and cared for by his family and loved ones.

I cry. I slowly realize that all that this world has to offer has its end. And I slowly get reminded to work for riches that will at least earn me a place in heaven. Or, to put it more altruistically, to work so that I can help other people earn their respective places in heaven too.

Witnessing death may have caused me sadness. But if I were to look at death as a path towards life eternal, I ought to feel that death is also an opportunity for those living to realize how we should make the best out of the life that has been given us.

Assisting at this morning’s anointing just made me realize this: God is still calling me to do greater things than this.