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Monthly Archives: November 2012

My Academic Journey: A Struggle (Conclusion)

During my first month of internship, I rotated first in the Department of Medicine. It was during this time that our dean, who happened to be the department head of Pathology also got hospitalized. She is a fierce opinionated lady you wouldn’t want to cross paths with, she was very intimidating. I was not assigned to her during her admission but due to fear of everyone, I was the one sent to insert intravenous line for her. I took it as a chance to build rapport with her and perhaps earn “pogi points” as she had known my interest too to train with her. But I was mistaken as she realized that while I was inseerting her IV line, I would be better off as a clinician rather than an academician. Later, months after her discharge, she sent me a feeler that at first slighted me, but later on made me thank her for realizing which discipline I ought to be in.

So I got it that after obtaining my license, I’d rather go to branch of medicine that would have hands on for patients. I had 4 options then. Medicine, Surgery, Obstetrics and Gynecology, and Pediatrics. If I were to go to internal medicine, my patients would be adult and it has been my observation that adults usually are stubborn patients (but I was not wrong as I still maintain such observation up to this date). Take for example an infection: even if the advice is to complete 1 week of antibiotics, as soon as they feel better on the third day of the treatment regimen, they voluntarily stop and don’t follow-up any further. Being a goal-oriented person, it would frustrate me if I don’t see concrete resolution of my patients’ problems. If I were to be a surgeon, I don’t think I have the knee-jerk reflex to react on emergency operating room conditions. I think I have a good manual skills but I didn’t think it was wise for me to be in this department. If obstetrics and gynecology, though most gynecologist abroad are males, the same does not hold true locally, and I might not be able to have a good practice after all. So I was left with pediatrics. I have seen how parents were obliged to complete their children’s treatment regimens, how results usually were appreciated and how most parents complied with instructions. (I am not saying right now that pediatrics was my last option, it was just that this was how I justified my choice of specialization. In fact, I only applied in one department, Pediatrics.) Unfortunately though, I had to wait for available item at my alma mater so it took me a year after passing the board exam to start my residency training. I don’t know, I didn’t consider going away and train in other institutions. Perhaps because I would want to be familiar at the place where I would be having my practice, that’s why. Or maybe, I didn’t want to be away from my parents.

When I applied already for residency training, the outgoing chairman of Pediatrics didn’t personally like me. In fact, it was during the time when I applied there were 4 aspects of evaluation — academic standing, actual examination, pre-residency performance and emotional quotient, for the very first time. These weren’t the same criteria used to screen previous residents. Meanwhile, while waiting for the call if I got the slo or not, I didn’t want to be idle. I applied as school physician in one of the universities in Baguio where I was accepted amongst other applicants, even if they knew I was waiting for my call to start training and I could resign anytime. Two months into my work, the new department head (who had been fighting for me to be accepted into training) of pediatrics called me and start my training if still interested. I tendered my resignation at the school after accomplishing the annual physical examination of the students. (I thought if I were to leave soonest, at least I would be able to accomplish even just a small deed.)

When I was already starting my residency training in Pediatrics, I felt harrassed by threats of recommendation for my termination. I may not have been a very brilliant freshie resident and was having difficulty adjusting to the individualities of several consultants. My performance may not have met their expectations thats why I kept on earning their ire. It was always a tense-filled day since day 1. But slowly, I believed I was getting better (who else doesnt believe they’re improving huh?). I just had to accept the fact that I cannot please everybody. It was hurting to hear those negative remarks though… but that was the reality in my field… and I just had to swallow them.

Immediately after my residency, I just tried my luck in applying for fellowship training in neonatology. There were no neonatologists in our department during my residency training and I wondered whether or not what we were doing with those prematures were the right thing. I chose UST Hospital upon the recommendation of a more senior resident who started fellowship too on neurology at the same hospital. This time, the struggle was on another field, finances. UST Hospital back then do not give salaries to fellowship trainees, unlike the residents. Fellows had to find sponsors who’ll finance their training. I had to find one too. It was difficult. The stipend was a lump sum of 6 months, but given late, about three months late. There were times when I had to borrow money from my younger sisters who were already working then. My father already retired from work and is merely relying on his pension for his monthly sustenance. Sometimes, I had to borrow from friends. I even applied to teach in a medical transcription school to augment my finances but they wont accept me because I had to be at the hospital during regular office hours, conflict of schedule. What made my training lighter was that all of my mentors were accommodating and approachable, despite their being a national figure in their own subspecialties. I never had difficulty adjusting. They never made me feel I was a stranger. They made me feel I was one of them. Three years passed, finally I graduated.

I wanted to go back home because life in the province was simpler than the complicated lifestyle in Manila. Moreover, I wanted to share back the knowledge I gathered, a “pay-it-forward” act on my part — to my alma mater, to my sponsors during my studies and to my community.

It has been 5 years now since I started my private practice and yes, this is my story. I want to make it big in my practice so I can earn my keep and start a foundation or continue the legacy of my benefactor during my high school years. (I hope you found some inspiration somewhere as you read through my journey.)

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Posted by on November 26, 2012 in Personal

 

My Academic Journey: A Struggle (2nd Part)

When I reached college, I was 15 years old by then (feeling inferior as I came from what I perceived was a lowly school). Equipped with the study habits that I developed in my high school years, I just went on with same study habit in college… come what may. Philippines was under daylight savings time then (1 hour advance). Unfortunately, only 2 months after I started my college life, there was a student protest against tuition fee increase. On July 16, 1990, classes were suspended in the morning. At around 4 pm, the historic earthquake struck the city causing massive devastation of almost all susceptible and vulnerable infrastructures. Classes was suspended indefinitely and resumed 2 months after. While boredom was killing me during that long break, I went to check my workbooks and tried doing my drawings in advance. At the end of the first semester, I never really expected it, but I ended in the dean’s list and academic scholars. (Academic scholars are 5 selected students from the dean’s list who can have refund of their semestral tuitions, whether half or full.) I was ecstatic as I never expected that a simple and baduy probinsiyano, who had limited exposure to the world would end up in that list. This boosted my self-confidence and helped me earned respect from my batchmates, especially from students who graduated from the city.

I was consistent in the list for 8 semesters of my course, sometimes being the top. I gained popularity I guess, having been on most important social, extracurricular clubs, sometimes an officer at that. I also had the taste of student politics as I was the mayor of my batch for three successive years, then ending the governor of my college (of Natural Sciences) on my senior year though I must admit, I wasnt that much accomplished as a student leader. Yeah, I too had some stretch of nerves drafting resolutions (so now, I’m not that totally ignorant how it is done). What was absurd though in my college back then was that we had a fixed maximum grade for prelims (93), midterms (95) and finals (99). I dont know the rationale for this that I heard was that no student would be able to earn such very high remarks at the very beginning of the semester. (Whatever… with a capital “W.”) I was able to graduate cum laude (few point and I would have been a magna cum laude. No I’m not bitter).

So now that I earned a bachelor’s degree, I was really eyeing to be a physician… but there was trouble… my father told me we couldn’t afford it. There are 4 of us siblings, and we were all in college simultaneously. The youngest herself was able to obtain a scholarship and that was quite a relief. Now, I was having problem as I will be having big expenses for my medical schooling. I could not fathom how stressful for my mother to budget for our school expenses, apartment rental and our monthly utilities and household expenses. Luckily, there was a very generous benefactor who willingly sponsored my schooling (for whom I will be very grateful in my lifetime. Now, that part of the problem was solved. I had been a straight student, never shifted in my course. I didn’t want to stop, work, before resuming studies). Yes, I was quite selfish back then with regards this aspect.

Guess many are wondering why a doctor? I also opted to be an engineer and thirdly a teacher. (But I am a virgo, ruled by the planet mercury. Whatever superstitions go with it, it says that people in my group would do best in public service, health care included. Well, I just learned about thisafter I graduated from med school.) My first experience of playing doctor was when I was in my elementary days, 3rd grade to be exact. I then had a classmate who had a chronic oozing would at her shin. My teacher commissioned me to do the treatment daily until it heals. I remembered she told me to apply some yellow-colored ointment. From then on, I got inspired, thinking of helping people who are sick. What a wonderful feat that would be.

 
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Posted by on November 26, 2012 in Personal

 

My Academic Journey: A Struggle – Part I

I had been wanting to write how I ended up in this profession and career as a medical practitioner, not to essay my difficulties in my struggle, but at least to provide some inspiration or motivation to those who find it interesting to read…

I am the eldest of four siblings, and I come from a poor family. Stories have been told how families try so much to make ends meet, we were not spared from such. My mom was a dedicated housewife and housekeeper, my dad struggled from jobs to jobs until he was able to find a permanent employment with a generous company, of whom I am thankful as it enabled the four of us finish college degrees.

During my “early age years” mom said we used to own a television (the box type, black & white) but I can’t even recall what shows I had watched. We also had a phonograph (do you even know this existed and how it looks like? LOL). Mom said there was one record that became my favorite. I could recognize it, even if they will cover the title of the song, I would still know that such was my favorite record. I happened also to memorize quite a few songs fully, and the stores near the apartment we lived would bribe me with chocolates just for a song. Eventually my mom and my aunt would end up eating my chocolate “salaries.” Our neighbors would even “kidnap” me then “display” me at their store, singing to the amusement of their clients.

During my early childhood years, we had to move to the mountains (my mom’s town), where life became so difficult. Sometimes, we had to barter to have something at the table. (Come to think of it, I never had a birthday party back then. It was that hard). There was only one school nearby where we lived and I was so lucky because it was about a stone away so I never had to walk kilometers unlike my other classmates / schoolmates. There were only 6 teachers in that school, one per grade level. Preschool was not an “in” thing then, and we had none where I studied. At 5 years of age, my mom noticed that I could already easily follow her instructions, read some words and get bored easily, so she decided to let me join the first grade classes, as a “visitor.” But even if I was the youngest in the class, and I was not officially enrolled, I happened to top them all. A condition was then given for me by the head teacher, that if I turn 6 by October, then I will be officially admitted and enrolled as grade 1. Well, I turned 6 by August 30th, so that did push through. By the end of the school year, I was at the top of my batch.

My life then was indeed a struggle. We didn’t wear fancy uniforms unlike every student now, even those enrolled in public schools. Sometimes, our clothes were worn out already, with holes than can accept a fist. We didn’t have shoes, just slippers. I can even recall one time, when I had no decent clothes to wear at school, I had to borrow the jogging pants of my younger brother (I was smaller than him). When he noticed me wearing it during the flag ceremony, he came and tried to tug it. That time, my father was also trying his best to provide for us. He was into gardening and small scale mining at the same time, but it wasn’t enough at all. When I was on my 3rd grade, he decided now to join a company, which eventually provided a slight relief from our damning condition. Well, I ended up always at the top of my class every commencement exercises.

When I was on my 4th grade, we had to move to another place, my father’s town this time. My father then regularly sent  money for us as he had to stay in Manila for his new found job. At this time, we were now able to buy a transistor radio which kept us abreast with the world at least. Back then, there was an existing policy, that a transferee, even if he is academically excelling, can never be given the first honors at the end of the school year. But my teacher did not heed to such, so again I was given the first honors at my 4th grade, then consistently, until I graduated valedictorian. Well it wasn’t a big deal to be valedictorian from the school where I came from as there were only a few of us, merely one section, graduating.

I was lucky, that during the time I was studying, there was and still is a generous family, who was willing to take 5 scholars per batch, based on academic standing (plus another 5 relatives) for high school and college years. Even accommodation at the high school was provided for free. I was lucky then to be chosen as one of those scholars and so I spared my parents from spending for my tuition and dormitory fee those years.

My high school was few barangay away from my home so I had to stay at the dormitory and can go home during weekends as most of us do. I was 11 years old on my first year, and I was away from home. I was used to being cooked food by my mom, now I was forced to live independently, with my other dorm mates of course. I had few friends who would do the cooking and laundry for me. I was lucky and grateful of that fact.

When I was in high school, I was no longer at the top of the class but luckily I was still in the top 10. Well, I was the youngest in the batch once again. There were some clubs I joined in, I was also in the school paper, and became the editor-in-chief of our school paper for two years. (Oh I could still remember, our first school paper was in stencil print, until our advisers decided to have it done by a printing press on the next issues). I was winning my extracurricular activities – intramurals, literary festivals, town fiesta literary-musical contests… but I was never athletic. I remember when I joined 4 categories during one fiesta, a member of the quiz show, duet, extemporaneous speech, and oration — I/we got all the gold medals in those categories.

During our 4th year, we were to take the national college entrance examinations (NCEE as we call it then). Luckily, me and some classmates were registered by our principal to avail some government educational grants/scholarships. I was then able to be one of the Selected Ethnic Group Educational Assistance Program (SEGEAP) grantee. Having this grant, on top of the scholarship from the Laguinia Anton Foundation, I decided to give up on the LAF, so that the funds my benefactor would supposedly spend on me would be channelled to other incoming scholars instead, while I go on with the SEGEAP.

 
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Posted by on November 20, 2012 in Personal

 

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Resourcefulness in Saving Babies’ Lives

In rural places where sophisticated technology, medicine are scarce if not available, how do physicians like me deal with a baby with a life threatening medical condition — congenital adrenal hyperplasia?

In my place of practice, with about 250 thousand population as of the latest, there is 1 government tertiary (pediatric residency training) hospital and 3 private hospitals (but one pediatric residency training hospital) that could possibly admit cases such as CAH. We do not have pediatric endocrinologist, and the nearest one is in Manila. There are 3 adult endocrinologists though.

At time that we see babies with the above condition, our training as neonatologist is our first armamentarium especially when our babies are in crisis/es, then a proper communication with our pediatric endocrinologists in Manila for further evaluation and management. It would be best if our patients have all the resources to have all necessary tests done, the medications bought. Unfortunately, not all Filipinos are in the same social stratum.

A baby who is already a month old came to my office for second opinion. Baby has ambiguous genitalia,  small for age and showed wrinkling of the skin (sign of failure to thrive), with a serum electrolyte test result (done weeks ago) and a confirmatory result for congenital adrenal hyperplasia. Mother wanted to know what are her options, and if this condition can be reversed. (It is so hard to tell a very definitive answer for these type of questions as sometimes, patients tend to misquote you when they go to another doctor if they are unsatisfied with your answers, or answer them satisfactorily but those weren’t the answers they were wanting to hear.)

One of the problem of congenital adrenal hyperplasia, aside from low circulating cortisol in the body system, is the loss of sodium. (They usually go together). If the sodium goes below critical level, it can trigger seizures that cannot be controlled by anti-epileptic drugs, until the sodium deficit has been corrected. This was my immediate concern. So I had to check first the sodium level of the baby and true enough, it was very low, near the critical level for seizures.

So what will a “probinsiyano” or rural physician do in this scenario? The best and ideal approach was to admit the baby and do necessary correction of the sodium deficit. But the mother refuses. Even if I strongly disagree with the mother bringing the baby home, I cannot force her. Thus, I had to be resourceful and creative on how to treat baby at home.

With regards the sodium deficit, this is usually computed (based on a formula that we, especially neonatologists should bear in mind). Next, derive the maintenance dose of sodium in 24 hours, which is often between 2 to 4 mEqs/kg/day. (If you are dealing with a baby who has deficit, then better use the maximum, which is 4mEqs/kg). Sodium correction however should not be done rapidly, it should be done in 48 hours, at a steady rate (and hence the requisite for a hospital admission).

I was able to compute baby’s sodium deficit and maintenance. Baby is on formula feeding to begin with. I asked the mother what is the average milk consumption for a day and that is where I based my computation. I was able to derive how much sodium is provided by the milk to the baby and it is just the same as the maintenance requirement. So now, my problem is how to deliver/administer the deficit.

There are sodium tablets that could be divided into papertabs and then you can incorporate that to the milk intake of the baby. (Of course, the taste of the milk will be altered — and that might again cause refusal of baby to feed, but then there’s no other way that I can administer the medication as mother refuses baby’s hospitalization). Unfortunately, there are no sodium tablets available locally. So the next alternative for me is to use the ampules or vials of NaCl solution available in the pharmacy (2.5mEqs/mL). With my computation, I got how many mL of the solution is needed per day, divide it into number of feedings per day. After 48 hours, I asked the mother to have the serum electrolyte repeated. Lo and behold, it went normal… So am I done with the baby’s problem? No… because the salt-losing part of the disorder is permanent, unless corrected by medications… which they cant afford yet as of the moment.

I had to maintain the baby on the available steroid and continue the sodium supplementation until the day when parents are able to save for the expenses baby will incur. A month has passed by already, and the baby’s sodium level has been maintained within acceptable level, and baby has been gaining weight as well. Mom checks baby’s sodium on a weekly basis… for now.. I really wish they will be able to raise funds for this…

(Disclaimer: this method of correcting sodium deficit has not been documented by a randomized controlled trial. But for now, it is the only available option I had for this patient. I credit my mentor Dr. Emilio A. Hernandez for teaching me this technique while I was under his tutelage as a neonatology fellow).

 

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