Who is a barrio doctor

A few days ago, while mentoring junior medical interns doing their community medicine rotation, I received a text message from a fellow doctor-blogger. It wasn’t good news.

Jim pls check out FB and twitter another DTTB killed

Still reeling from the impact of the yet-unresolved killing of Dr. Dreyfuss Perlas, who graduated from the Doctors to the Barrios program one year after I did, I barely managed to keep my composure as I excused myself and caught up with the news. It turned out that the victim was Dr. Jaja Sinolinding, brother of DOH-ARMM secretary Dr. Kadil Sinolinding Jr. Dr. Jaja and his security escort were shot Tuesday morning, 18 April, by a gunman who had pretended to be a patient in his Cotabato clinic.

Notably, as news about the tragedy spread through news and social media, Dr. Jaja was tagged by DOH Secretary Dr. Paulyn Ubial as a “barrio doctor.”

Strictly speaking, at the time of his murder, he wasn’t part of the DOH Doctors to the Barrios program. He was an ophthalmologist who chose to establish his practice in Cotabato instead of putting up shop in more affluent areas in the country. His death has shown that the risks of serving the underserved do not only affect physicians who have chosen to join the Doctors to the Barrios program, nor those who became municipal health officers or rural doctors. It affects all health professionals, regardless of one’s specialty, as long as one has chosen to unflinchingly stand up for what is right.

Notwithstanding, in my opinion, amid the horrific circumstances of his supreme sacrifice and despite his specialist affiliation, Dr. Jaja has affirmed what it really takes to be a “barrio doctor.”

By choosing to put up practice in the provinces, he shared in the commitment to provide care to the underserved, despite the risk. Dr. Jaja provided free consultation services, and, as affirmed by people who worked with him in Cotabato, was a well-loved doctor.

By choosing to consider medicine as service and not a means for personal profit, he shared in the commitment to ensure that health is accessible to all.

Finally, by choosing to serve despite existing threats, he exhibited unparalleled courage.

Definitely, he was a barrio doctor.

A barrio doctor who, along with Dr. Perlas, deserves swift justice.

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.

Engaging people

Public health is essentially a field that requires engaging people. But in my years of working in public health I realized that engaging people does not only entail having to design policies and programs, and promoting them to the people who will benefit from them. Instead, I learned that I had to listen to the people, and cater to their actual needs.

These needs aren’t what you usually ask in relation to the programs one plans to implement. You don’t go out and ask people around their knowledge, attitudes and practices related to vaccination, for instance. What’s needed is knowing their context, their culture, and their daily life.

In my two years in the field, while implementing programs for preventing non-communicable diseases, I realized that the right question wasn’t about their attitude on taking maintenance medications. The right question to ask was what has been leading them to an unhealthy lifestyle. I’ve found that answers to this question come from precisely these: their context, their culture, and their daily life.

In the Cordillera region, for example, in my practice I’ve been seeing a lot of people with elevated blood pressure. I’ve come to know that this trend was not really attributable to the failure in taking maintenance medications. I also didn’t think that exercise was a problem: navigating daily the difficult terrain was more than enough. However, because of the Cordilleran preference for meat and salt, some of my patients not only develop hypertension, but also develop gout and kidney disease.

This is also similar to my experience with an urban poor health program, shown in the picture, where non-communicable diseases are related to food choices, as well as lack of safe spaces to conduct healthy lifestyle activities.

The clinical approach is usually to respond with medications. What appeals better to me is the public health approach: nip the problem at the bud.

In the case of my host municipality in the Cordillera, we instituted a program for monitoring blood pressure, blood glucose, and cholesterol, in cooperation with senior citizens and the local women’s organization. In turn, the municipal employees’ association and our nurses implemented a healthy lifestyle campaign that focused on increasing physical activity through zumba dancing. We launched the campaign in what would be the best date for cardiovascular health: Valentines’ Day, 14 February. The Department of Health has since implemented a similar approach nationwide.

Meanwhile, in the case of the health program with the urban poor, we trained health workers in monitoring blood pressure and vital signs, which is the first step in recognizing the presence of health issues in the community.

It’s a source of pride for me that my host municipality did it first in the province. I plan to go back and monitor its progress within the context of a research project, but with the pictures I see on Facebook, I’m happy the effort has survived after a few years. Similarly, the effort with the urban poor health program blossomed into a corps of community health volunteers. The long-term impact of our little training program remains to be seen and the efforts need to be sustained further, but I am happy it has impacted positively on the health-seeking behavior of the community.

All because of a genuine interest in the lives and well-being of people.

All because of engaging people.

What to research? A health policy perspective

Research is the real-world application of the “scientific method” which we learn in high school: after observing a problem, we come up with a scientific question, formulate a hypothesis, test it and analyze the results.

But it isn’t easy. Often, substantial resources and skills are needed to design a study, and more so to implement it.

In medicine, for instance, research involves clinical trials: patients are assigned treatment alternatives whose safety and efficacy have been established in previous studies, and their clinical effectiveness is assessed. In history, records are unearthed and accounts of various events are compared with contemporary documents. And in health policy, my field of work, it involves engaging with various health departments, interviewing patients, payers and providers; and investigating ways to improve efficiency and health outcomes for patients.

But in a country with meager resources for research, there is a need to set priorities for research, which not only optimizes the use of limited funds, but also responds to health needs.

Thus we come to this question: As far as health is concerned, what do we really need?

This is actually a difficult question to answer. A credible needs assessment requires a reliable health information system that collects data on what diseases are prevalent, what new diseases are emerging, how many people can’t pay for their healthcare, how much is healthcare, and other related questions.

I was of the notion that the rise of information technology (IT) and social media will somehow facilitate needs assessment. Yes and no.

No, because right now, individual health programs have their own ways of collecting data. My friends in the telehealth sector, a field of public health specializing in providing health services to faraway areas through IT, tell me that these programs need to talk to one another and agree on one way to collect data across all programs, to make it easier for policymakers and researchers to investigate causes that underlie health needs.

But also, yes. I know that the current difficulties in gathering information will be surmounted by just that one effort to integrate data collection and analysis. That way, we can ensure that the true health needs of the community are indeed identified accurately, and we know what indeed to research.

So, what to research? I say, it’s how we can know what’s really going on out there. The key is reliable health information.

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.

{}{}{}{}{}{}{}

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!

Why health policy

Today I’ll be writing about the reason why I’m in health policy, which is a reseach-oriented field that responds to health needs through policy interventions such as laws, guidelines and rules.

For me it wasn’t crystal clear that it’s something I wanted to pursue as a career. It developed out of a desire to be helpful to more people.

It was a usual morning in my clinic. I was assigned as a municipal health officer in a mountainous region in the north of the country. I usually arrive in the clinic seeing patients already in line to see me, most of them having crossed hills and mountains to see me.

Normally, I try to greet them with a welcoming smile, looking forward to listen to their stories but also concerned about what ills have forced them to see me. I see the kindly old lady from the nearby village, following up for her usual blood pressure check-up, who greets me with a warm smile and an enthusiastic nod whenever I ask her to take her medications. I see a couple coming for advice on their family planning options. I see babies brought by their mothers for their vaccination.

Then I saw this middle-aged man, with impending doom written on his face, holding a plastic envelope containing various documents. It turned out that he wanted to seek advice about an important concern: how to pay for his hospital bills.

To be fair, the existing national health insurance system has paid for much of his bills. But he still had to pay for a few thousand pesos, which he cannot produce within the week alloted for him to pay his balance. I advised him that perhaps he just needed to see a social worker who can refer him to the proper channels for financial support.

But that was an encounter that got me thinking. I thought:

“What is the point of prescribing medications and treatment plans to patients who can’t afford them in the long run?”

I then realized that perhaps health policy was a good career after my stint in the health center. Not because it was a lucrative career option, but because I knew that I could at least work towards making sure that patients achieve better health because the health system works for them.

After my two-year experience as a municipal health officer, I received an invitation to apply for a researcher position at the Institute of Health Policy and Development Studies, a research institute under the aegis of the National Institutes of Health in UP Manila. With my director, I had the opportunity to do research on health insurance, health management and human resources for health, aspects of the health system which directly affect the health of patients in public health facilities.

Now, a few years have passed since I made the decision to pursue health policy as a career. I have been given the opportunity to present my work in some fora, gotten the chance to network with like-minded people and broaden my knowledge in dealing with complex health policy issues.

But I still wonder about that man who approached me in the clinic years ago. I think the best measure of my success as a health policy researcher is whether or not I have done something that directly impacted him and millions like him. The task is far from over. In fact, I think I’m just getting warmed up.