Monday, August 31, 2009

Random Don'ts

Some admonitions to myself:

Don't break someone's heart just because somebody else broke yours.

Don't believe you're ugly just because you know you aren't pretty at all. Ugly and not pretty are two very different things.

Don't believe your trip was spoiled just because your schedule and itinerary didn't turn out as planned. Adventures are never planned.

Don't believe you're lost just because you don't know where you're heading.

Don't fall in love with someone just because he's interested in you. You might be a mere specimen to study, or an adventure to complete, or a puzzle to solve.

Don't lose your best friends just because you loved them.

Don't drive away people who love you because they already know too much.

Don't be afraid to appear vulnerable. But don't be vulnerable.

Don't be afraid to live your life alone. You won't.

Don't pity yourself when you have dinners alone. Others dream of time for themselves.

Don't be afraid of saying sorry. But never say you're sorry when you don't mean it.

Don't forget to say thank you. You may forget why but say thank you anyway.

Don't accept something as right simply because everybody else says so.

Don't be afraid to look someone in the eye no matter how beautiful he is or how deep those eyes are.

Don't pity yourself because somebody broke your heart.

Hitch Hiker's Guide

I wonder why they call this a holiday, when just like any other warm day, you spend your time at the side of the road, waving your clenched hand with the thumb's-up sign, with the intention of catching a ride that would eventually take you somewhere. Your hastily written but carefully planned cardboard sign propped up by the side of your weary feet reads - "ANYWHERE" - a place you never intended to travel to, much less arrive at.

Even then, nobody trusts you enough to pick you up. Not even a single dusty, cramped space at the back of a truck, where you could have relished the journey in the company and comfort of livestock or all sorts of household gibberish. Anywhere. Just manage to get somewhere.

But all you see is the endless road. An infinite horizon stretching out ahead, indistinct images becoming even more blurred, shadowy lines and whorls of senseless matter at the back of your eyes. You sit down by the side of the road exhausted, drained.

What is life. What is living. Even anywhere has to be somewhere. There has to be a way to get there. Maybe tomorrow. If you live til tomorrow. Maybe you wake up and discover that the place you've been standing on is somebody else's somewhere. And you never really had to go anywhere. Because where you are is where you're supposed to be.

Tuesday, August 18, 2009

After 21 Years

Hi everyone. This is a post for all the disgruntled souls out there.

I came across this article from PJIM while I was doing my research protocol. It's a speech by Dr. Dans some 21 years ago. Hope you'll have the time to read it, and somehow get some spirit-boost from it.

We can look at the state of things this way: it's sad because it seems that after 20 years, nothing much has really changed. PGH, in all its drudgery and imperfections, is still pretty much the same. But it's also uplifting since this is proof that it's possible to be passionate about a cause and still remain on fire after 20 years. Idealism, after all, may transcend age.=)

Phil. J. Internal Medicine, 26: 65-67, March-April, 1988


Antonio L. Dans, M.D.**

Dr. Yolando Sulit, members of the executive committee, Dr. Ernesto Domingo, parents, fellows, residents, friends, good evening.

Crossroads are very important times in our lives when we stop whatever it is we're doing just to think. We look back at how much ground we've covered. We look around at what we've reached. We shake hands, bid farewell to old friends, then we go on in different directions, until the next crossroads, or until our sojourn ends.

Graduation is but one of the crossroads of life. But tonight's graduation has several problems. For one thing, our parents are probably beginning to wonder why we have to graduate so often more times in fact, than most of normal people. Unless there are objections, our average age is 30. We have been to approximately 12 to 14 graduations and still, many of us are either partially or totally dependent on our parents for support. The problem is very common, but it is easily overcome by their kind understanding.

More than that however, there is a bigger problem, a more painful one that all internists must face, especially after graduating. The problem is the irrelevance of Internal Medicine in the Philippine situation. The issue is not new, and in fact, it was the subject of a speech delivered by the Honorable Secretary of Social Service and Development, Dr. Mita Pardo de Tavera, when she was guest in last year's graduation ceremonies.

The irrelevance of Internal Medicine was a strange theme for a speech, considering the circumstances under which it was delivered. But her arguments were strong and convincing and full of painful truths, which we must face up to the present time. The problem is a depressing one, how indeed can Internal Medicine be relevant in a country where 90% of the population live below the poverty line, and probably cannot afford to consult at all. How can this specialty, which is dependent on western technology and medications, be relevant in a country whose major problem is an already enormous and malignant foreign debt?

The cost of living is going up, while life itself is becoming cheap. Filipinos are killing Filipinos, for money, for religious beliefs, and for political affiliation. Even our own soldiers war among themselves, and last week, a former cabinet member and a respected patriot, died of a profound frustration. The EDSA revolution, it seems, has produced no drastic changes in the situation, and the future of our children remains guarded and uncertain. In the final analysis, when our very existence as a nation is in danger then, how indeed can this gathering be relevant at all?

Secretary Pardo de Tavera's message was clear as it was painful and true. The incidence of disease in our country is only a product of deeper seated problems. By becoming specialists in the treatment of disease, we are merely treating symptoms of underlying social, economic, and cultural ills.

It was a terrible message to give a group of graduating internists and despite her apologies, a number of us resented her frankness. Her message stung for a few minutes, or a few hours, a few days at the most, being drowned eventually in the ups and downs of life in the Philippine General Hospital. Tonight as we look back at the years that passed, we ponder the irrelevance of the road we have taken.

Yes we learned of diseases that most physicians never see in a lifetime - footnotes in medical literature like - Castleman's disease, Noonan's syndrome, Refsum's disease, and Gardner 's syndrome. We also learned of common maladies and their therapy. But aside from these clinical lessons, we also learned a lot about the Filipino people, the majority of them, the 90% who live below the poverty line. We became close to them, and we learned from their hardships, their joys, their miseries, their aspirations and their frustrations. In this sense they became our teachers, and we were their students in life.

We all know Carmelita Ramos, a patient with chronic lung diseases. Aling Carmelita was a permanent fixture of PGH, entirely dependent on oxygen and our samples of bronchodilators and steroids. We will always remember her and her 14 year old daughter with whom she had to share her hospital meals. We will always remember the times when she could smile and breathe enough to actually say thank you. Her daughters' cries of agony filled ward 1 whsn she died this year, for she had lost the only person she ever loved. Those cries will be heard in our minds for years.

Encarnacion Gondra (Cystic Fibrosis), Flor Urabe (Chronic Renal Disease), Maribel Chavez (Takayasu's Aortitis), Vivian Magday (Systemic Lupus Erythematosus). The clinical lessons will always remain in our minds but our hearts will be filled with the stories of their lives; the halls of our wards will echo with their cries of anguish, their sighs of relief, and occasional laughter; our floors will be stained with their suffering, their blood and their tears. Yes, we understand that their woes are low priority for policy makers who are trying to get to the root of the problem. But the solutions are nowhere near in sight, and if we call these people's concerns irrelevant, then life itself must be meaningless and irrelevant.

The years in PGH have changed our perception of Dr. Pardo de Tavera's speech. Tonight it is no longer clear whether she was hurling an accusation, or a challenge. Irrelevance was never a problem inherent in Internal Medicine. Rather it has been a problem of the Internist himself. To be available or not, to the poorest of the poor; to be dependent or not on unavailable technology - these are decisions we faced daily in PGH; these are decisions we must make when we leave.

To be sure, the hospital has always taught us relevance, and it has taught us well. To diagnose by acumen and not by a battery of unneeded tests; to know when to treat and when merely to console; to first do no harm. These are lessons about relevance, and though we learned them in a strange environment, we learned them nevertheless. And yes, it is a strange environment. The country's premiere teaching hospital has World War II vintage equipment – that is strange. We often have to pay for own patients' medications - that is strange. Half the resident staff has no salary and still eat off their parents hands - that is not only strange, that is miserable.

Alas, the lessons in PGH by far outweigh the misery. And among its lessons, the lesson of relevance is both the simplest and the most fascinating. Think about it. The hospital doesn't run on equipment, for there is hardly any, and it certainly doesn't run on money. This hospital runs on the hearts and minds of the men and women who have chosen the art of healing, and healing well. It runs on patriotism and love for God and fellowman. The day these ideals become irrelevant, will be the day our dreams and aspirations end. On that day, the Philippine General Hospital will cease to exist.

It really is a strange hospital, as strange as it is dear. It is just partly a reality, and mostly it is a dream; we are proud to have been part of it, even if it was just for one brief shining moment. To those who follow us, we wish you strength and pride in your work.

On behalf of Badine, Benita, Beth, Don, Ed, Elmer, Joven, Raymond, Sullian, and 38 other graduating residents and fellows, we would like to thank our revered consultants for giving us the chance to be part of PGH, and for unselfishly sharing with us their wisdom and expertise. We would also like to thank our dear parents for the understanding they have shown and for allowing us to extend our dependence. To all our other friends in this room, we thank you for your support and your kindness. Most of all we would like to thank the Lord for His forgiveness and His love and His guidance. We pray for our parents, our patients, our hospital, our people and our country . . . That He may deliver us from irrelevance.

Until the next crossroads, thank you and goodnight.

* Speech dellvered during the Graduatlon Ceremonies for Internal Medicine Residents of the Philippine General Hospital on December 14, 1987

** Chief Resident. Department of Medicine, College of Medicine , Philippine General Hospital , University of the Philippines Manila

Stumbling upon this old masterpiece had a major impact on me. Finding it was serendipitous, almost impossibly and absurdly occurring at the perfect time and scenario. The best thing about it is the fact that Dr. D actually gave this talk BEFORE he went into Cardio! Perhaps my decision to train as a fellow in PGH Cardiology despite not having the ambition to be a cardiologist is right after all.

Kung kaya ni Sir, kaya ko rin siguro.

I pray that 20 years from now, my students will also have the same reaction as I did. My fear is that they'll read about what I've been ranting about during my youth and ask, "what happened?"

I'll end this post by sharing a part of an email from my good friend, beer buddy and dear IM residency batchmate. This is PGH fellowship in a nutshell, without the existential angst, or the passionate and youthful idealism. Just plain, everyday PGH life in unembellished, unexaggerated tones. And why despite all the ugliness and backbreaking, uncompensated labor, everything is worth it...

In here, we’re 30 y.o. with no money. But we have sinigang sa miso, dirt-cheap pirated DVDs, patients who speak your native tongue, families to go home to on weekends and leaders who eat like royalty. It’s a circus here, but it’s my country. Today, I’ve been thanked by a wife for treating her husband who died without receiving any drug; went through one masterals class by copying the assignment of my co-fellow; had lunch at Rodic’s for P60 and learned that i earned several $$ from my clinical trial! Everything is unpredictable here, but this everything is home.

All quoted works posted with permission from the original writers (Dr. AMLD and Dr. PST). My heart is bursting with gratitude. =)

Sunday, August 16, 2009

No Hero

Few weeks ago, I've been complaining about how today's newspapers always contain trash that they have become trash themselves. Fate however, always enjoys surprises. During the rare times that you pick up the paper, you read about certain names and faces you would have wanted to forget.

Today, my Sunday morning started with text messages from several people. "You're in the paper." "Check out Inquirer." "You have a picture in Inquirer page8". Thinking about the First Gentleman scholarship program for specialists which has received a bit of newspaper space several times for the past month and with my name or at best my face the size of a nail receiving a few inches of precious newspaper space, I shrugged and concluded, "Ahh, after the 1 million peso dinner in New York, the president probably wants to tell the world they're spending good money for a good cause, at my expense."

I was wrong. Lo and behold, the story was in the front page, and my picture was a huge one. Here's a link to that story. The on-line version has no pictures but this is the best available.

My point is I don't deserve this. Melanie's story is real and there are hundreds of people behind the success. All I did was do my job. During my last conversation with my good friend J, I whined and complained about having to do all those things. I almost cried because I was so tired. And when my friend asked me, "So why do all those? What's so special about that patient?" I just said, "I guess I have no choice. The matter is already in my hands. I can't say 'no' anymore."

So when I saw my face on the Sunday Inquirer, I couldn't be proud at all. If my friend J reads that story, he would have laughed. He would have recalled how I fought with Melanie and her mom and how I dreaded having to reply to text messages from them in the wee hours of morning. He would have known the hesitation, the agony, the exhaustion behind that smile. He would have known I'm not a good Samaritan at all.

As for me, how can I bask in pride over a job well-done and national publicity while the real heroes continue to do their tasks quietly. If all the hard work of our PGH consultants, fellows, residents and even students get recognized, we would have volumes and volumes of books about them. Our profession, our strategic postion in the scheme of things makes it inevitable for us to save lives, and lose some too.

Seldom do we get into the papers for doing our jobs. I guess it just so happened that today, I just did. But I'm no hero. I was just doing my job.

Tuesday, August 11, 2009

Talking about the weather

If there's one thing more unpredictable than my mind, it's the weather these days. I'd say it has a female temperament. It doesn't seem to know what it wants. One moment it's warm, the next it's stormy. One day it's humid, the next day it's rainy.

Today is hot as hell. It's sweltering summer heat right smack in the middle of August. It's a virtual oven in the hospital. The stench of disease becomes more pronounced, tempers
are flaring, minds become suddenly blank. Despite the heat, I'm getting brain freeze.

Suddenly I realized it's this time of the year when I'm supposed to be on vacation. Exactly two years ago, I was lost in the middle of the road to Mt. Apo, with very dear friends. Exactly one year ago, I was lost in a wilderness called Guiuan, Samar, on my first real solitary backpacking adventure. Now, I'm stuck in a frenzied, hellish hospital, with nothing in my head. I've lost the good friend I brought home to my folks exactly two years ago because I was stupid. When just a year ago, I was full of exciting adventures and the prospect of spending time with myself in a very strange place seemed rewarding, now I'm stuck in a corner immobile, complaining about the heat, with nothing better to write about than the weather.

Indeed, the only thing I can think of is this freakin' weather. Pathetic thoughts for such a pathetic state. I hope the state of my fate will change and get better like the weather too.

Monday, August 10, 2009

Too bad

A few hours ago, a junior resident, with a huge smile on her face and a glimmer in her eyes, walked up to me and said, "Ma'am we saw you before, walking with a man in Robinson's. We were so intrigued we stared at you until you completely disappeared. Uyy ma'am, sino sya?"

I was writing on a chart of a toxic new patient, so instinctively and with a smile as huge as hers, I replied, "Oh, so you saw us. That was my very good friend." "Really, ma'am? Everybody in show business says that." "Honestly, he's a very good friend. I've gotten drunk with him, traveled with him, even brought him home to my parents in the province already." "OK, ma'am."

I think I convinced her.

I kept on writing on my chart. Focus. Work. Patient is dying. Arrhythmia, hypotension, crackles, systolic failure. Re-entry, ischemia, defibrillate, myocardial infarction, heart failure. Damn. All heart. I have to run away. Stop working and just brood.

Too much for amnesia. It wouldn't come if you want it to, just when you want it to. Too bad, to not have a chance to explain, to elaborate. Too bad, to have to say anything at all.

Back to earth, "Ma'am what do we do about her?" "Oh, just keep on cardioverting. Nothing much we can do about the scars anymore. She'll have arrhythmias until she dies. So cardiovert again and again. Cardiovert and pray."

Too bad. Sometimes our worst patients have better prognosis than we do.

Wednesday, August 5, 2009

Signs of the Times

When many of the icons of our generation have died or are dying, this could only mean one thing - we are not getting any younger anymore. This is the age when we've stopped counting. Somebody asks how old we are and we pause before we blurt out the number of years we've been alive. Sometimes we even actually do simple arithmetic. Hmmm, 2009 minus 1980, that's...

Oh yeah. We can't stop time from moving forward. We look at the mirror and there are wrinkles under our eyes and blemishes on our skin. No amount of anti-aging cream can reverse them anymore. Sometimes we become short of breath after running the same distance we used to run effortlessly when we were younger. Sometimes, we wake up with aching backs and knees and fingers. Our blood pressures are rising. There are extra flabs of fat on our arms and tummies that we can no longer claim to be baby fat. Facebook friends and egroup discussions are all about weddings and babies and home improvement. Our colleagues are discussing baby bottles, house mortgages, unreliable yayas and the rising tuition fees in kindergarten schools.

For those of use who are still stuck in extended adolescence, still grappling with issues on intimacy and isolation, struggling with a meager salary, feeding on solitary fastfood meals at the end of a long and busy day, the signs of the times can be alarming and depressing. The world is getting older. Time is running out, and it's not announcing its passing subtly anymore. Alarm signals are being turned on - a tolling bell, an irritating beep of a computer running on low battery, a red light flashing on and off. And we watch them and endure their persistent warning with mouths gaping wide and eyes frozen in fear.

Michael Jackson, whose music we danced to when we were kids, is dead. Cory Aquino, the reason why we wore those yellow shirts while we sat on our dads' shoulders as they were all waving that thumb and pointing finger signal that seemed ridiculous during that time, is to be buried today. Ely Buendia has had two MIs. Nobody uses OHPs and transparencies in class anymore. Everyone around you is either having babies, getting married, settling down, or admitting they're gay.

While you're still alone, stuck in your eternal solitary state, still not getting enough of your life. You still have no one to talk to at the end of the day. You still wonder what is there to live for and why. And when you wake up the next day, you notice the signs of the times, realize how the world is moving so fast, pity your old and solitary self only for a moment, shrug, laugh, hope, and move on with your life anyway.