Abusive

Over the weekend, some of my colleagues and I were in discussion over text consultations by patients to their doctors and the ethical dimensions surrounding text consultations.

With over 93 million active mobile phones AND 130 billion text messages being exchanged each day in the Philippines (yes, ONE HUNDRED THIRTY BILLION) you can undoubtedly state that text messaging has been widely used, and may I say, disproportionately abused by the Filipino patient.

Text messages fly back and forth between the patient who 99.9% of the time triggers the initiation of text messages, and the physician.

During the discussion, we asked how many of us gave out their cellphone numbers to their patients. Three out of five had their mobile numbers on their calling cards, prescription pads and 100% available to their patients. I give my mobile number to about 30% of my pool of patients. Only one of us REFUSED to give her mobile number to any of her patients.

Some of us buy a second phone (which I think is impractical) or even go to the extent of having a dual SIM phone so that one can be a private number while the other number is an office phone number on the same cellphone. Whatever it is, the bottom line is that once you give out your mobile number - your privacy has been invaded.

Many (if not most of us) do not give pre-arranged instructions which should be something like:

1. They're not allowed to call! I am not your text mate, I don't plan to be and I don't like it when people who are NOT in my contact list call me IF and WHEN they want. I do not save the numbers of my patients in my contact list. And I cannot stand the temerity of some patients who ask me to SAVE their numbers! Duh!!! Most of all, I may not be in town and if I am out of the country, I end up paying for the roaming charges because someone just wanted to find out what they can give their son because he apparently has fever of 37.8C!
RULE NO. 1: TEXT BEFORE YOU CALL. It's only but fair and etiquette dictates it, to see if the other party can pick up your call.

2. They should include their names or identify themselves when they send text messages (because I don't save your names). You should also not expect an answer in the next 5 minutes or when you want a reply. (I may be at meetings or in a plane somewhere or in a movie house [YES we have a life outside of the clinic my dear patients], or doing something in private [ahem, I hope you people get what we mean] or seeing other patients or driving.) In short, we are NOT at your beck and call.
RULE NO. 2: IDENTIFY YOURSELF. Don't waste my money having to text back - "who is this please?" or have to guess "this is the mother of Joaquin..." Joaquin who?!?!! It's not like your son is the only one that has the name Joaquin in the Philippines. You can ask the National Bureau of Investigation and you will get gazillion hits with that name alone!

3. They should be more specific with the concerns that they text us with (if the patient has fever - describe the pattern of the fever and not just text "may lagnat si Junior, what to do?". The reason for this is because we spend replying back to them as well (usually I don't reply back if they don't observe the rules I inform them when I give out my mobile number from the get-go). But because the text message service is probably UNLI, these patients think that it's alright for them to waste other peoples time by engaging in texting back and forth. Of course, if they pay more for the text message, I guess this should put them in the proper perspective of having to think what to text before they send a text message.
RULE NO. 3: Complete the description of the concern. Please avoid having to make me guess what the hell the concern is about by just texting me that there's fever or there's tummy ache or other one liners. Try to be as comprehensive as possible. Be considerate with other people's time.

4. In case of emergencies, DO NOT CALL ME! I am not an emergency room. Just bring the patient to the ER. Period. The ER will call me.
RULE NO. 4: I am not an emergency room.

5. No MMS messaging please! There are those that actually send pictures of a lesion on the skin of their child and expect me to make a diagnosis and a prescription!!!
RULE NO. 5: First of all, I do not prescribe through text. It is unethical to do text consultations and against the LAW to prescribe prescription drugs by text messaging. Besides, sending a picture of patients is like pathetically altogether wrong. You don't see the whole picture and cannot make a clear diagnosis without a good history and thorough physical examination.

6. I can't stand it when patients text me in the middle of my clinic asking if "they can call me" because their kids are sick. They know my clinic hours. They know my schedule. They can call the clinic. But NO!!!! They don't want to do that!!! They don't want to call the clinic because the secretaries are busy assisting me and other patients. They don't want to queue. You can even see how inconsiderate the others are because they will call the clinic, ask the secretary they want to talk to me because his kid got bitten by a mosquito a few seconds ago and they're afraid of dengue!?!?!!?! I want to slap someone today. But puhleezzzz, gimme a break! My secretaries are trained to tell patients that "I am seeing a patient currently and that we will get back to them after office hours".
RULE NO. 6: There is a secretary in the office. Do not text me if you want to find out if we have clinic or not. Text the office or call the clinic.

While these are but a few among my many concerns, these are basic rules that I make patients follow if they want my number. It is ironic that many of them seem to have early onset Alzheimer and forget that these rules.

So there's got to be a way where physicians and patients know that there is and there needs to be a yardstick distance between them. After all, the relationship between doctors and patients is strictly a professional one. We are not removing the human factor of having to relate with patients - showing empathy, explaining the burden of the disease, explaining in layman's terms the treatment options, and most of all staying within the ethical boundaries in the practice of health care.

Somewhere along the way, technology has provided a vast avenue of easier communication between people anytime, anywhere. And like anything that's highly accessible, comes abuse. Without anyone or any other way to regulate this abusive practice, it's bound to get virally blown out of proportion. While text messaging has its positive attributes, it should be relegated to before and after service only. Before service which means that patients inquire only for consultation hours and minor concerns on whether the doctor is around, and after service means that the patients may have concerns on medications or instructions after the consultation or discharge and text messaging is only for clarification purposes.

There is a need to get the whole equation back to professionalism, ethical relationship, and most of all the etiquette of mobile phone usage has got to be taught to the general public ONCE AND FOR ALL.

Family ties

The other day, the mother of my patient was frantically texting and calling me concerning the illness of her niece. Apparently, her 14 year old niece was being seen in one of the big hospitals here and was diagnosed to have Dengue. Her niece was never under my care at any point in her life. I do not know any of the relatives at all. And she wanted my opinion on whether what the doctors at that hospital were doing was right or wrong.

I understand how it is when it comes to family ties, most especially in the Philippines. I hate saying it, but I will. The Filipino will take family relationships to the extreme. It takes a Filipino to rub it in you that they are relatives with so on and so forth, even to the nth degree of consanguinity. It takes a Filipino to rub it in you that the father of the mother of the sister of the brother of your third cousin's cousin 's in-law is "closely" related to you. Even being godparents alone for the Filipino is taken to the extreme. I cannot imagine how anyone can have 24 godparents for their baptism - but believe me when I say - only the Filipino can! As my partner would say - OA!

And here's the rub. As a physician, I am aghast whenever I see patients with gazillion relatives at the bedside of my patients when I make rounds. It's like the whole "barangay" of relatives happen to be there and I need to defend my dissertation in front of them. After I explain the illness of my patient to the "crowd" and go through the academic exercise of explaining at my findings, my work-ups, the medications to be given, and of course the prognosis or outcome, it's question and answer time. Parang Miss Universe beauty pageant!!! Santissima madre de Dios!!

Most of the questions come from the kibitzers. Yes. The kibitzers! These are the relatives (many of whom are probably not related directly) of the patient. While I don't mind questions being asked for clarification purposes, I take a direct hatred (with seething eyes) on the kibitzers that come up with comments like "YOU KNOW MY SON HAD THAT DISEASE ALSO BUT HIS DOCTOR GAVE SO AND SO MEDICATIONS TO HIM. WHY AREN'T YOU GIVING THE SAME?" And I ask "SO WHO ARE YOU?". And you get the reply, "OH I'M THE 3RD COUSIN OF THE MOM OF YOUR PATIENT." And then I want to slap somebody in the room.

In short, while I am open to questions, especially when it comes to the illness of the patient and that I believe that the doctor should clarify all things with the patient and that the patient (or his/her legal guardian - usually the parents) should be made fully aware of the situation and that all consent are INFORMED CONSENTS, I have this place in my heart that loathes kibitzers and their uncalled for comments.

And so I told the mom of my patient that:

1. Your niece is not your daughter.
2. You do not have the right to decide for your niece. Her parents are there and you are a kibitzer. All you need to do is listen. If you have a question, you can ask the doctor of your niece. You can clarify things with him.
3. You should not ask me to approve or disapprove the management of another physician on a patient that is not mine, that is not your responsibility, and that I have never seen in my life.
4. It is not ethical to ask for an opinion only because you want to show off to other people that you may have some "knowledge" in the illness and then brag about the little knowledge you have. This is not the part wherein you "Phone a Friend" in order to get haphazard opinions on patients we have never ever seen in our lives.
5. When something goes really bad or really wrong with the patient, remember, all decisions - right or wrong - are the responsibility of the parents. If something terrible happens because you were interfering in the management, that your opinion compromised the outcome - you should be blamed for interfering with the management.
6. To stop texting me regarding the condition of her niece! She's like a resident updating me the platelet count day in and day out! Susmaryosep!

As for other doctors reading this blog, let me remind you that it is NEVER GOOD TO PROVIDE YOUR OPINION UNLESS YOU HAVE SEEN THE PATIENT. Always give the reply - NO COMMENT!

We have no right "auditing" our colleagues behind their backs unless your professional opinion is sought for by the primary party concerned and not by the kibitzers!

Confusion is brought about by entertaining strangers at the bedside of our patients.

Cancer - the in thing?

Another one of my friends had succumbed to Cancer. Another one bit the dust. When I told my partner about this, his reply was "It's the In Thing".

On my trip to Europe last July, I had bought my copy of "THE EMPEROR OF ALL MALADIES: A Biography of Cancer" by Siddhartha Mukherjee at Fully Booked, for the long haul read. The 571 pages (actually 472 pages of an excellent dissertation and approach to the origins and current knowledge of cancer and 99 pages of references and bibliography) provided a radically new approach to understanding the malady that has afflicted humans since time immemorial.

Cancer is not something new. Siddhartha writes with poetic brilliance as he describes his own insight into patients he currently sees and then intertwines the history of cancer to its first documented beginnings. He truly deserved the Pulitzer Prize for the writing of this book.

"Recall Atossa, the Persian queen with breast cancer in 500 BC. Imagine her traveling through time - appearing and reappearing in one age after the next. She is cancer's Dorian Gray: as she moves through the arc of history, her tumor, frozen in its stage and behavior, remains the same. Atossa's case allows us to recapitulate past advances in cancer therapy and to consider its future. How has her treatment and prognosis shifted in the last four thousand years, and what happens to Atossa later in the new millenium?...In 500 BC, in her own court, Atossa self-prescribes the most primitive form of a mastectomy, which is performed by her Greek slave. Two hundred years later, in Thrace, Hippocrates identifies her tumor as a karkinos, thus giving her illness a name that will ring through its future..."

Perhaps the literary ingenuity of Siddharta in this non-fiction novel is how he has pored through voluminous published literature and historical facts on the origins of cancer and managed to write it in a way wherein even laymen that read this book would be highly engrossed in the vivid explanation of cancer diagnosis, treatment options, drug discoveries and outcome.

Advances in cancer have come a long way since Queen Atossa. It has taken centuries to reach where we are in the science of oncology, and we still have a long way to go. While we slowly discover that there are risk factors that eventually cause cancer (some of which was the normal "trend" decades ago, such as smoking and binging on alcohol), we also now discover on which type of patients are at highest rate for cure and who are genetically predisposed to poorer treatment outcomes.

"Cancer, then, is quite literally trying to emulate a regenerating organ - or perhaps, more disturbingly, the regenerating organism. Its quest for immortality mirrors our own quest, a quest buried in our embryos and in the renewal of our organs. Someday, if a cancer succeeds, it will produce a far more perfect being than its host - imbued with both immortality and the drive to proliferate. One might argue that the leukemia cells growing in my laboratory derived from the woman who died three decades earlier have already achieved this form of 'perfection'."

"Taken to its logical extreme, the cancer cell's capacity to consistently imitate, corrupt, and pervert normal physiology thus raises the ominous question of what 'normalcy' is. 'Cancer', Carla said, 'is my new normal', and quite possibly cancer is OUR normalcy as well, that we are inherently destined to slouch towards a malignant end. Indeed, as the fraction of those affected by cancer creeps inexorably in some nations from one in four to one in three to one in two, cancer will, indeed, be the new normal - an inevitability. The question then will not be IF we will encounter this immortal illness in our lives, but WHEN."

And as man fights to survive aging and strive for longer lives and search for the fountain of youth or the drug for immortality, so will the cancer cells that live normally in our bodies, waiting for the time to take us to be part of the next in thing.

This is a must read for all, especially my students and all students and practitioners of medicine. It makes you understand and realize the wealth of knowledge in the discovery and researches in an aspect of medicine that we see in our daily lives.

The flip side in 60 seconds

During our last staff meeting for the Department of Pediatrics at Asian Hospital and Medical Center, a colleague of mine commented that I should probably blog about my being the incoming Chairman for the department. I laughed when she teased me that it would be my "hell" and that it was a most appropriate description for my blog writings. This is my final blog for the month, so let's take it from there.

I take my job or whatever I do seriously. While I may flip flop on a few decisions at the start, I also have a vision for a generation.

And so I blog about this new turn of event in my life and accept with humility the task of being the next "Captain of the Ship".

When I retired from teaching medical students three years ago and went into private practice, I felt a void in my academic career. I missed the grand rounds, the training and drilling of students with the daily cases, the teaching skills and poring over loads of information in pediatrics, pharmacology and infectious diseases. After all, I had been the residency training officer of two hospitals - one government hospital (Ospital ng Maynila) and one teaching hospital (University of Santo Tomas) - in my not too distant past. So teaching and training to me was the core of my daily habit. My decision to retire from teaching was like having to give up coffee at the break of dawn.

When I was asked if I was willing to take the post as the incoming chair, there was an initial hesitation on my part. After all, I had found a new comfort zone. I have come full circle in my career, have been part of the lives of so many successful and great doctors and at my age, life should simply be about preparing for retirement.

Yet a part of me felt that there was a need to make my colleagues realize that the art of medicine is not about myself or how much I make or how many patients I have made better or cured. Coming full circle is about paying it forward.

At that singular moment when I was asked whether I was willing to take this new post, I felt that the next 60 seconds of decision making was moving in very slow motion. It was not the impulsive me that played central role in saying yes. My flip side, the cautious me, was tugging me back.

The 60 seconds saw my previous life pass me by.

All of us at Asian Hospital have come from a great residency training program. We're all board certified and specialty and subspecialty certified. I've always believed in how great this circle of physicians are. We may come from different schools or have trained from different hospitals both here and abroad, but we've learned from the best.

Call it a legacy, but the best of leaders and healers will always pass the torch to the younger colleagues - to teach them and learn from them. It's only by paying it forward that we learn to be appreciated in life and thereafter. Even after we're gone, somewhere in other people's lives, we leave our mark in their lives. My mentors have left a bit of themselves in my life and I am eternally grateful to them for this.

And the 60 seconds ended with the flip of the coin of accepting this daunting yet humbling task.

And so as I begin the new role of leading a great bunch of pediatricians and friends starting next month, I pray that I lead well.

They say that the true mark of a great leader is succession planning. We simply cannot be invisible men living our own lives. We owe it to our great teachers and mentors to continue the task of passing the torch.

The decision at the flip of the coin was probably a challenge to see "hell" as my colleague said.

All I can say, "I've been to hell and back. But with everyone's help, this new task may just be purgatory. Who knows, if we all pitch in together, we might all get a glimpse of heaven in the end."

Conflicts of interest

Almost the same time last year, I had talked at the postgraduate course of the Department of Pediatrics, University of the Philippines-Philippine General Hospital on the continuing saga of the doctor and the pharmaceutical industry.

I had mixed feelings giving the lecture. After all, the audience were doctors. They are all my colleagues and many are my friends. Choosing the right words to say was going to be a challenging task. My talk was eventually published in the Philippine Journal of Pediatrics last year.

The issue of conflicts of interest has touched raw nerves in the medical-pharmaceutical community in the Philippines.

Over a decade ago, the Philippine Daily Inquirer ran an article entitled "The Med Rep is OUT - with the Doctor". The article highlighted the extraneous relationships between the physician and the pharmaceutical industry through the medical representative. With the increasing scandals involving various forms of gift giving of the industry to physicians, many pharmaceutical companies and medical organizations are dissuading physicians from getting entangled in situations that may question their credibility due to conflicts of interests.

The other day, I overheard in a meeting that a bunch of doctors had decided to boycott a pharmaceutical company because the company did not accept their request to go to a convention somewhere in Europe! The doctors arrived at the conclusion that since the company had not supported them to conventions in the last 2 years, the accumulated 2 years was equivalent to a convention in Europe. Now that took a lot of gall, if not KAPAL NG MUKHA on their part and I felt ashamed that there are doctors that stoop this low just to attend a convention.

Let me call a spade a spade. You may want to un-friend me in your Facebook account after reading this blog. It is my final blog for the month and while I have been quiet, I also thought deeply about writing this entry.

First of all, the fact that doctors are wined, dined and given gifts is NOT an obligation by the company. WE DO NOT HAVE RIGHTS or ENTITLEMENTS to what the company gives as dole outs. If we accept these gifts, so be it. If we don't, then so be it as well. No one coerces us to prescribe a drug. It's not like they put a gun in our heads and then threaten to annihilate our families if we don't provide them the number of prescriptions they ask for. If we prescribe a drug in exchange for a gift, it is a form of indirect bribery. As doctors, we are already paid by patients our professional fee. That is payment in itself. Prescribing a treatment for our patient entails due ethical and medical consideration of the whole clinical spectrum or condition of the patient, before we write down what medicines they need to buy. If the drug is not needed, we should desist from writing down a prescription only to pay back or please the last pharmaceutical company that sent us to some out-of-town lecture or pleasure trip to never-never-land. If the patient does not need a prescription, tell the patient that. Our prescriptions should not be clouded by the incentives or perks that come along with the "field trips" or "excursions" or "lunch baskets" provided the industry. I will go direct to the point - there is no gift that is given without an exchange awaiting. The bigger the gift, the larger the investment of the industry, the larger the expectation.

These conflicts of interest have begun to be scrutinized lately by several ethical, academic and governmental institutions both abroad and locally. Ironically, while it is the industry that now calls on the moratorium to the excessive spending and lavish wining and dining to doctors, it is also the industry that started this marketing ploy that has now caught them in between the devil and the deep blue sea. Like rearing children, the industry has spoiled the kids rotten. The phrase "spare the rod and spoil the child" aptly describes the old disciplinary method of not punishing children when they are caught doing something wrong. As a matter of fact you will hear tales from the industry that doctors literally ASK for anything under the sun - from cars to trips to furniture to laptops to mobile phones to sponsoring their annual dues or convention fees to driving them to and from the airport or picking up their children to school or asking med reps for personal "favors" in exchange for keeping a "close relationship" with the rep in particular and the pharmaceutical company in general. But that's because they allow it and that's because the industry is so deeply mired in this traditional exchange "gift" that the marketing people have not changed the old "tactics" of selling a product.

I tell my students that a good drug, sells itself. A bad drug, needs a gift to go with the bag.

Some of my friends who practice in the United States once asked me how some of my colleagues here are in several conventions in the U.S. or Europe or Asia in a year. When I asked them how they know, they tell me that they read it as "shoutouts" with matching pictures of various tourist destinations from some of our colleagues almost every other month! Some of them even post the pictures on Facebook with the signage of the drug product they were asked to pose and promote.

One of the biggest contributors to sponsorship as an indirect form of bribery are the various organizational societies themselves. Touted as pillars of the medical circle, some of them violate ethical boundaries by demanding from pharmaceutical companies sponsorships in conventions which they collect convention fees and some threaten companies of boycott if they do not "contribute" to the success of said conventions. When the pharmaceutical company agrees to sponsor an event like a convention, the society must maintain its unbiased position by ensuring that the sponsors do not in any form pose bias in the promotion of its company's products by unduly providing more exposure than the other sponsors with lesser financial means. If the society cannot police itself at the get go, how will it expect its members to follow suit?

The National Pediatric Infectious Diseases Seminar (NPIDS) sponsored by the Baylor College of Medicine in Houston spearheaded by Infectious Disease pillars Drs. George McCracken and John Nelson had discontinued their program after almost a quarter of a century of providing unbiased CME programs because they decided to adhere to more ethical standards in the conduct of the seminar. Because industry did not want to sponsor events where there would be less exposure to their products, the pharmaceutical companies threatened to pull out sponsorships if the organizers refused to give them more exposure. Because the cost of running the program without the aid of the industry was a tall order and prohibitive, the organizers decided that it was time to end the program rather than give in to the coercion of the industry. I used to attend this seminar for over 10 years until it closed down several years ago. It was a great loss but I admired the organizers for taking a stand.

The issue on conflicts of interest are not solely the problem of doctors. Each professional field is mired in its own conflict, but the medical field is the only one wherein a second person or more persons are affected by the decision made by the primary person whom that conflict is borne upon - a decision that can affect life, cost/benefit outcome in limited or scarce resources scenario, and burden of treatment or diagnostic procedure when the latter is not required.

During a meeting with one of the pharmaceutical companies, they had expressed exasperation at the attitude of some doctors whom they could not provide "gifts" to. Some of the doctors were either angry or in denial or were bargaining (agreeing to sponsorships for local conventions instead of foreign ones) and I was shocked that some even had the temerity to reply, "paano na ngayon?"

Truth be told, the doctors are one of the highest paid professionals - locally or abroad. Let's face it, our patients know that. They see how grandiose some can be - toting a Hermes or LV or Prada, driving an Audi or Porsche or Pajero, living in posh villages, wearing signature clothes with matching shoes, belts and bags and bling, dining in 5-star hotels or expensive restaurants. The mere fact that we flash around all these largesse and yet ask pharmaceutical companies for "gifts" in any form leaves a bad taste in the mouth.

I am not saying that we don't accept a gift. When a gift is given, it should not expect anything in return. After all, if it is a sincere gesture, it should not expect payback. If the gift provided is part of an exchange deal, then it should not be accepted. It is unethical to demand anything from a company. What the industry provides or gives us is a privilege and not a RIGHT!

Today's changing landscape in the pharmaceutical industry should be a reason why there needs to be a paradigm change on the Filipino physician's role with the industry. There needs to be a concerted effort at preserving the dignity of each of us in spite of the pressure of some sectors of the industry putting a carrot in front of the rabbit to make the rabbit hop!

After 10-15 years of studying to be the most distinguished profession in the world, we cannot let conflicts of interest destroy our integrity. At the end of the day, our patients should benefit from our judgement. They pay our professional fees, put food on our table, a house over our heads, send our children to good schools. They deserve nothing less than the best standard of care without undue influence from the pharmaceutical industry.

The top 5 text messages that drove me crazy!

So I get text messages from mothers who have issues or concerns or queries about their kids health.

While some of them deserve immediate medical attention, most of them are the mundane or stupid (excuse my comment).

I selectively picked the most stupid and irritating and annoying. There are times that I don't even want to answer the text message. But my conscience gets the better of me.

So you judge for yourself which should be the top irritating text message from parents (I saved them then decided to delete them after I blogged). The message in parentheses are just my wishful thoughts which I wanted to text back but did not.:

1. 930PM
M (mom): Si baby nag thu-thumb suck. Bakit kaya?
R (reply): Ewan. Baka gutom.
M: Tinatanggal ko pero umiiyak pag inaalis ko ang thumb niya.
R: Huwag mo ng tanggalin.
M: Di ba masama mag-thumb suck?
R: Bigyan mo na lang ng gatas.
M: Na-i-istress ako sa pag thumb suck niya doc.
(AKO DIN, NA-I-STRESS SA PAG TEXT MO)
R: Dalhin mo na lang sa clinic bukas at paliwanag ko sa yo.
M: Next month na lang pag check up niya. Ano kaya puede ko gawin in the meantime?
(SAPAKIN MO ANAK MO)
R: Wala. Ikaw na lang mag-suck ng thumb niya.

2. 130AM
M: Pasensiya na kayo magtatanong lang. Iyak ng iyak si baby. Natataranta kami dito sa bahay. Nagagalit na si lola at kanina pa umiiyak anak ko. Bakit kaya siya umiiyak? May kabag ba? Ok ba ang acete de mansanilya?
R: Baka gutom o basa. Paki tingin.
M: Napadede ko na pero pagkatapos ng dede eh umiiyak pa din.
R: Pakidala na lang sa clinic mamayang hapon.
M: Naku eh baka naman puede magreseta muna kayo ng gamot.
R: Para sa?
M: Para tumigil ang pagiyak niya.
(LAGYAN MO NG UNAN ANG MUKHA TIGNAN NATIN KUNG DI TUMAHIMIK YAN)
R: Dalhin niyo sa emergency room.
M: Ngayon?
(NEXT YEAR)
R: Yes. Ask the resident to check the baby.
M: Wala pa asawa ko. Walang magdadala sa amin.
(AND I SUPPOSE MAY BIBILI DIN NG GAMOT. TALAGA NAMAN)
R: When your husband comes home take the baby to the hospital.

3. 1125PM
M: Elvis, 3 years old, has fever and cough for 5 days. What to give?
(DIOS MIO. 5 DAYS NA MAY SAKIT AND YOU DECIDE TO TEXT CLOSE TO MIDNIGHT?)
R: Paracetamol. Bring to the clinic tomorrow.
M: May exam siya bukas sa school.
(OMG! 3 YEARS OLD MAY EXAM? ANO YAN COLLEGE NA? NAMPUCHA NAMAN)
R: No school muna. Bring to clinic tomorrow.
M: Naku, may honor pa naman siya. Di siya puede mag-absent.
R: No school! Bring to clinic tomorrow.
M: Puede yung nabigay mong antibiotic last year?
(HOMICIDAL ANG NANAY NA TOH!)
R: No. Bring to clinic tomorrow.
M: Kawawa naman anak ko.
(TALAGANG KAWAWA. TANGA YUNG NANAY KASI)

4. 3AM
M: Doc, 10 x na nagtatae at 5 x na sumuka si baby kahapon. What to do?
R: Bring to the ER
M: Walang gamot?
R: Bring to the ER so the baby can get assessed.
M: Meron akong Ercefuryl. Gamot ng aking pamangkin. Puede ba yon?
R: Bring to the ER. If he keeps having diarrhea and continues to vomit, he will get dehydrated.
M: Kasi baka panis na yung gatas.
(AND WHO PREPARED THE MILK? AKO BA? SUSMARYOSEP)
R: Can't tell unless you take the patient to the ER. Have the resident assess him and they will call me.
M: Sige doc, observe ko muna baka mawala.
(ANAK NG TIPAKLONG TALAGA. GRRRRRRRR)

5. 2AM
M: Hi Doc. Ask lang ako kasi may nakapa akong bukol sa puwet ng anak ko (7 years old). Anong puedeng ipahid?
R: Wala. Bring to the clinic later.
M: Kasi katabi niya si lola at nagaaala si nanay baka cancer daw.
(CANCER? BAKA PIGSA LANG YAN. AT ANONG GINAGAWA NG NANAY MO NANGANGAPA SA ANAK MO NG MADALING ARAW? PEDOPHILE YATA YANG MATANDANG YAN)
R: I don't think so. Baka pigsa lang.
M: Di makatulog si nanay. Nagpapatext sa inyo.
(BIGYAN NG VALIUM YANG NANAY MO)
R: Bring to clinic later. Kung cancer yan eh hindi ako nagrereseta ng chemotherapy sa text!
M: Ganun? Nakakatakot naman.
(OO. NAKAKATAKOT KAYO MAGING MAGULANG)
R: Wala yan. Bring to clinic later for check up.

These are but some of the weird text messages I got over the week. Nothing is more stressful than having to answer them "nicely". Seriously, I think these people think that we're text buddies and that I don't sleep. Geez! Some people have got to get a life. But if you happen to be a pediatrician who really likes entertaining these loonies, let me know. I would be more than happy to transfer these patients to you.

Miracles

It was a Sunday. One of those days where you didn't want to go to work, but had to.

I had just made rounds with four critically ill patients and had come home past lunch. A little over an hour, I received a call from a colleague of mine if I wouldn't mind seeing a referral. "No I wouldn't." After a quick lunch I broke my Sunday rest and gave in to the call of duty.

He was an 11 year old boy transferred from a provincial hospital. I will not talk about the diagnosis or how the doctors there managed him, but when I entered the critical care area, he was dyspneic and oxygen saturations were between 85-89%. He was very ill looking and probably would need intubation in awhile. The chest x-rays were not compatible with the initial diagnosis on transfer and I was worried. The parents probably did not recognize the gravity of the situation, but I stayed on for 2 hours assessing him and decided a management plan. I just didn't like the gut feeling that things weren't going to go well with him.

True enough, in about 2 hours he was eventually intubated and transferred to the ICU. [I know that most of those that read my blog were my medical students. I will leave the grand rounds to where it should be.] What transpired in the next 48 hours was heart breaking. He clinically deteriorated in 24 hours and the chest x-rays showed signs of ARDS (adult or acute respiratory distress syndrome). The ventilatory set-up was at its maximum. For those who have managed ARDS patients, you know that the outcome is grim. Compounding the fact is that the family has already maximized their insurance coverage in just 24 hours at the intensive care. Financial problems are added burden in times of confusion.

His condition from guarded to critical had turned for the worse. I told the attending that I would talk to the mother.

Believe me when I say that in my 27 years as a physician, this is the part where they don't teach us how to deal with this in medical school. How do you say to a mother who is barely making sense out of everything at the moment, with her son intubated and probably at the brink of death that their family will need to brace with reality? The outcome for patients with ARDS is 1 in every 10. With ventilatory set-up that high, chances of pulmonary complications are high as well.

When I was discussing the situation with the mother, her mind was completely in chaos. Here she was, listening to what I wanted to tell her, but at the same time not being able to comprehend why this was happening to her boy. I am sure that his 11 years rushed into her head like a movie that needed to be compressed in 1 hour. She was angry. She was in denial. She was massaging his reed thin legs and asking him why he was going to leave her already. Even when I put my arm around her shoulder, she was just pouring out her grief and I could not help but suck in some air so I could hold back my own tears.

I don't think she understood what I said. I told her that we were already giving everything we could to take care of the infection. But I did not think that this was just an infection we were battling. I did not want to discuss any mumbo jumbo jargon which she probably wouldn't understand further. I told her that I was going to try something. The drug I was going to give is controversial in the management of ARDS. But there are positive results with some patients. In my mind, I was grasping at straws. In the next 10 minutes I needed to summon all my remaining powers and decipher and balance all the evidence-based literatures I could recall on the role of steroids in ARDS, in patients that were septic. I asked permission from the attending and she consented. My parting words to the mother was that "we are doing the best we can at the moment. We are trying him on a medication and there is no guarantee that this will work. But let's pray that it does because at the moment, this is our best option. We will do everything to make him better. I need you to be strong now." [I think I was talking to myself in that last sentence].

FLASHBACK. I never wanted to be a doctor. This is why I have a mathematics degree. But because it was a compromise between my dad and I, I reluctantly went to med school. Many events have transpired since I graduated from med school. In my chosen specialty and subspecialty, I had to deal with the dramas of life and death. And the latter has never been easy. It's always the reason why I get flashbacks...

On my way home, I decided to pass by the chapel. Said a little prayer for the patient and his parents. Knelt before God and asked Him that if there are miracles that truly happen, all I ask is a small miracle in today. Beyond all the fame and fortune He has given me, I begged Him for a miracle. And I made a pact with God - that if the boy survived, I would waive my professional fee just to see him alive.

The following day I missed making rounds early. The attending had seen him and I received a text message from her. The patient was doing much better and it was like he was rapidly recovering. The ventilatory set-up was much lower now and that he was more awake. When I made rounds that afternoon, after a whole morning of meetings and conference calls, the mother's face had a different aura. She was holding on to her husband and they were grateful as I was explaining that it looked like he was going to make it. That the drugs were working. That their son's condition from seriously ill to critical had become guarded. That if he continued to improve, he probably would make it.

This time, they grasped the situation. They began to discuss the finances they had incurred. I took the mom's hand and told her that when the patient is stable enough, we can discuss this. I told her also the pact I made with God. I was not going to collect a single centavo from them as long as their son survived.

In a few days the boy had been extubated and was transferred to the ward. When the boy was transferred to the ward, he gave me a letter he wrote thanking me for taking care of him. And of waiving the professional fee. The mom was profusely thanking me for the generosity.

I told her that it was not generosity on my part but on the part of God. You see, I was skeptical on the outcome as well. I needed divine intervention and her son is alive because God hears prayers. I was merely an instrument of the miracle that came their way. And if God is able to grant him another chance at life, who was I to collect from them at this time of need? Compassion is never taught. It is learned.

In return, I told the boy, the miracle of life provides him an opportunity to pay this forward. It's probably why he is still alive today.

I blog about this today because I know that most of my readers were my students in medical school. Many of them have provided kind comments on how well I taught and how well they learned from me. There is no formal class that teaches compassion for our fellow men. That teaches us to respect the dignity of life. That teaches us how to deal with death and the dying. But the medical profession is a noble one. That we are given the opportunity to make life or death matter with our fellow men is God's gift to us. And while my patient will remain anonymous to all my readers, he will always be a firm reminder to me of the gift from God called a miracle.

I was awed at the miracle that day. I knew that God was behind it all.

Miracles do happen, even in this day and age of Facebook and Tweeter and iPads. It is within us all. Deep within the hearts of every human being. If only we look for them...and believe...

[photo from Mike Greenberg]

The health of our nation

Last Saturday, Dr. Emmanuel Johann Obana, was interviewed in the Mindanao Agenda.

The latter is an investigative TV program of GMA network in Davao City. Dr. Obana is one of a handful of idealistic doctors in the Philippine government's "Doctors to the Barrio" program.

In the interview, Reporter John Paul Saniel showed how Doc Eman tried to divide a bottle of paracetamol among several kids or how he used one overly used thermometer for practically all patients, or how difficult it was in grabbing a banca (water boat) to see patients that were difficult to reach.

It was in Doc Eman that I flashbacks on my days as training officer for pediatrics of a government hospital (Ospital ng Maynila) and a private hospital (UST Hospital).

My years in training the residents in pediatrics was blood, sweat and tears. It was not the measly pay that the local government provided (P2,400/month and you were required 8 visits a months), or the fact that you had to wait 3 months to get paid (or 6 months on some occasions), or being castigated by some hot shot councilor because the patient's parents were complaining about why we were asking them to buy medicines (answer - because the hospital does not carry it stupid!)...

Yup. Those were the years when I shared my teaching skills with my residents and took the time, patience and sighhhh....even money. But it was hard for some government big time assholes to see the light at the end of the tunnel. To them, even the plight of health care in the Philippines was (and should I say - IS) just a show. The media frenzy is the their big turn on. These shit heads have crap on their shoulders. I hated them - not for their guts, but for their brainless behavior.

I once interviewed a prospective candidate applying for residency in pediatrics. I asked her why she wanted to pursue pediatric training, considering that she is a city health officer (in one of the big cities in Metro Manila) already. She said that the Lina Law on the devolution of the local government had made her mayor lose significant IQ points. In short, he turned from dumb to dumbest overnight. (He's a public official - it was a curse he was to inherit.) He told the local health officials that their pay would be scaled down because NO ONE can get a pay more than his pay! Sounds logical right? Wrong! It's stupid.

We are not mayors. We are doctors.

We cure people and we work more hours toiling to see patients get better.

In our professional practice, we do not steal.

I was appointed to head the pharmacy of the government hospital. On my first day on the job, I was told that there was going to be good news. I am being given P3M to purchase drugs for the 400 bed capacity hospital.

Then the bad news. I will need to spend that money for the purchase of drugs for the whole fiscal year. Watdfuk!?!?!

I did my math. It meant P250,000 in medicines per month. Assuming that there will only be 400 patients for the whole month, (which is the thinking of Councilor Stupid), this would mean P625.00 for medicines for each patient. Presuming that he will be admitted for the whole month, that would mean medicines worth P20.83 per day. Sanamagan!?!?!?! Only in the Philippines!!!

That same year, they repainted the whole hospital, changed the glass panes of the windows (which were still quite new), bought new air conditioners for some offices, painted lines in the parking slots, upgraded the medical directors office - all to the tune of P50M.

The following year, I resigned from my position in the Pharmacy and as residency training officer and as consultant in pediatrics. I needed to keep my sanity and did not want to die an angry man early in life because some asshole politician forgot to clean his sh*t! And I'm not going to clean it for him.

In the report of poor flung to the barrios doctor in Caraga, the reporter noted that Caraga Mayor Alice Mori had several stacks of government-issued medicine supplies in her possession. And nope, it was not located in the health center nor the municipalities. It was in her house. When interviewed, Mayor Mori claimed that the medicines in her house will be used for medical missions. (The election is near and it is time to hoard for political campaigns?) The mayor refused the reporter's request for video footage on the drugs because she said that it might be used as propaganda by the political opposition (well, I guess this is the opposition's opportunity to bash the mayor).

As reported by Carlos Isagani T. Zarate in the Daily Inquirer, "before the TV program on the interview of Doc Eman was over, the good doctor had already said a mouthful that not only described his frustrations but even aptly indicted the skewed priorities of the government's health program. Doc Eman is one of only two 'doctors to the barrios' assigned in far-flung areas of Southern Mindanao..." Doc Eman hails from a poor family in Cavite.

It's people like him that actually go back to basic grass roots of trying to pass goodness forward.

"Unfortunately, last Wednesday - before Mindanao Agenda was shown on local TV - Doc Eman was pulled out by the Department of Health from Caraga, Davao Oriental. He received death threats via text messages on his mobile phone two days after Saniel did an interview on him and Mayor Mori."

In a country so much in dire need not only of spiritual healing, even those who tend to the living bodies are not spared by the politics of desperation and greed. There is no remedy to this. Even in death...

Private Practice - As real as it gets

Not since ER or Grey's Anatomy have I enjoyed a medical drama series called Private Practice.

In the Philippines, it shows on Star World (cable channel) at 9PM on Thursday evenings right after American Idol's 9th Season.

The series which started September 2007 in the US is a spin-off of Grey's Anatomy and features Dr. Addison Montgomery (Kate Walsh) as she leaves Seattle Grace Hospital to jon a private practice firm based in Los Angeles.

The physicians are private practitioners based in LA and the setting is a private clinic. But the lives of both the doctors and families and patients that are intertwined in the series is the most heart wrenching medical drama that I have seen. It is not some Doogie Howser where a young physician is a genius at bay, nor is it like House where the doctor is the central theme of the story.

Rather, the story evolves around both the medical and timely, ethical and legal issues surrounding the lives and decisions that doctors, like us, have to make in the practice of medicine.

It's as surreal as it gets and is on it's third season (in the US or if you can get pirated DVDs in the Philippines, you'd be up-to-date on this).

If you're a doctor, you're bound to be engrossed in the ethical dilemma physicians face. It's actually a good teaching material for an ethics class for students in the medical school. If you're a patient, you'll understand the crossroads doctors face when you see us for consult.

If you haven't seen it yet, you should. It's not just drama. It's as real as it gets.

The practice

I had a referral the other day. A 14 year old boy diagnosed last January 2009 to have severe aplastic anemia. He has been in and out of the hospital in the last 2 months. His last hospitalization was a few days ago. He was directly admitted to the Pediatric Intensive Care Unit because of difficulty of breathing. Managed as a case of sepsis with pneumonia and put on several high-power antibiotics.

Then I got the call for an infectious disease consult.

The story is not about the consult. It's about how badly I felt after seeing the boy.

He's 14. And the family is not well off. I can understand and feel the burden of a serious disease and its toll not only on the family's life, but on how the young man feels.

There's a burden of hopelessness that lurks in my spirit and yet I know I need to draw strength from the greatest healer, Jesus Christ, so that I can do everything in my knowledge in the practice of medicine in providing the best care to the boy. What is most draining and depressing is the fact that I feel helpless to some degree. I am at battle with a disease on a helpless patient whose immune system seems to just look like it wants to give in.

Not everything in the field of medicine is life-saving. Half, perhaps is due to the physician who heals. The other half, today, I leave to God, the divine healer. While the boy strives with every breath left, and the family looks for means to make him survive, I am left with hope and should not give up on him. Not yet.