Doctors Protect Doctors

Grades are just numbers. In med school, it mattered however, for one to get in. It mattered for a student to be promoted from one level to another. It mattered to be accepted in residency training. It mattered. Sad to say however that spewing medical informations does not make a good doctor. A patient will seldom remember the medical terms you say nor care about them. They will remember however how it felt like talking to you during those weak times. They will remember the sincerity. You do not have to hold their hands. In med school and in training, it is even discouraged for fear of breaching objectivity. You touch a patient with gloved hands. That reminds them that you are there as a professional. But touching doesn’t have to happen. Communication is all they needed. And the truth. When you enter med school, there is a standard question asked to all the aspiring doctors. If I remember it right, it goes like “Why do you want to be a doctor?”. And answers seem like those in beauty contests. I forgot my answer, but I think it isn’t something my interviewer is used to hearing. I may have said something odd because his look seemed to say, “this one needs a neuro psych evaluation stat”. The world of medicine is already made up of people far from regular. And out there, I still seem to stand out. How odd can I get? In practice, the oddness became full blown. I don't dress right. I look like a kid. I give unexpected answers. I fight the norm. I challenge the standard, even if it meant standing alone. My mind have ways of making the acceptable seem mundane. “If it’s been done before, why can’t we make it better?” There was something about me that scared the standard bearers, the orthodox, the sane. I walk into a lecture hall full of expectant medical students, wearing jeans, black sweatshirt, and sneakers. But I do not just talk. I do not just deliver. I challenge. These aspiring doctors do not need an image. They need mentors. They need a starting point. And to begin, one should be willing to take on a challenge among many others to come, as they go deeper into the forest of medical practice. “Why do you want to be a doctor?” “To heal the world” is so not original. “To help the sick” is so generic and poorly thought off. “To find myself…”, this one is a goner. Not a step further. :) I do not know why I wanted to be a doctor. All I know was that, I was pulled in to it by a force so strong, I had no choice but to follow. The challenge however is, would you be willing to shed off your original skin, and don on the medical cloak? Are you willing to give up a big chuck of a normal life to be a mutant like the rest of us. Are you willing to be a racehorse in a trackless world? As a doctor, you will always be catching up on something. Because never again will your life be just yours.

Would I want my children to be doctors? Is like asking, “do I want my kids to be soldiers?”. Not if my opinion even mattered. Medicine is not something you choose to do just because a parent is a doctor. There is never a “doctor gene” to make it easier. No doctor is ever born. A doctor is made from broken glasses, from caffeine-laden system, from derogatory remarks, from frustrations, sweat, tears, and curses under your breath. The grand presentation that a lay person sees of a doctor in white, is nothing but an image projected of a person who survived a battleground. What one does not see is the layer after layer of scars, finely hidden by the profession’s cloak. Would I want my children scarred? Not if I can help it. If I can just pave an easier road for the little ones, I would. Just as my parents wanted to put pads on my walls to make sure life handled me with care. But how one chooses his path on this world is something no parent can ever forsee. Not even me. But if I had the power to choose, I’d rather they make a name in an industry less stained with madness. A doctor is like a racehorse in a world without racetracts. A profession without absolutes. A science that evolves faster than human knowledge can ever contain in a lifetime. In medicine, a standard protocol is often considered basic, a reference point, because no person is ever the same, what work for one, does not necessarily work for everyone. So the term “atypical” is often most used in the medical world. To become obsolete is every doctor’s worst fear. The Professional Regulatory Commision had assembled a point system requirement for Continous Medical Education among physicians renewing medical license. This is to make sure that every practicing physician has updated medical knowledge. Like a racehorse keeping up with something as changeable as change. And the fastest among us remain still a few years away.

Sometimes, a person’s aggressive environment after a while becomes his comfortable niche. Because it is predictable and somewhat familiar. Like autism in its grandest state. A doctor sometimes evolve from regular and normal, to autistic madness. Like a soldier trained in the roughest terrains, appearing like a lost soul in the civilized peaceful world. Fellowship followed residency. Obsession with training has nothing to do with professional growth, and more to do with being a scaredy cat to change. The steady chaos of the hospital was comforting. Although most will never understand where comfort is when stress hounds in every walls. I am utterly afraid of the idea of starting on my own. Although finally being launched as one of the few in my line of specialty seem like sweet triumph and boundless freedom, after donning on my grand hat as IDS fellow, I was like “You mean I’m done? But..but...but…”. Though learning was limitless in the area of infectious diseases, I am now expected to begin specialty practice. And so to begin I did. And it was among the scariest moment of my life. I have always carried the name of a hospital. And to finally carry and promote my name was somewhat foreign and frightening. Maybe I am one of the few blessed with enough resources to go through all the training in one smooth swipe, I never really believed that patients would come looking for me when I no longer belong within the protective wings of the prestigious hospitals. Faith in myself had never been a great virtue of mine. Starting a practice was expensive. And to be in training for so long, no doctor is expected to have accumulated millions to afford hospital bonds. And so we go to our parents, if they are still alive, or beg on the streets. Parents who continued to support us throughout those years we spent on training. And all those years, they were growing old. I was blessed with parents who had me when they were very young, who continued to work even in old age, and who were just too happy to have me as living proof that medicine is never absolute, My father is a doctor, a fellow in the field of Infectious gynecology. And he understood the need for specialty training. What he wasn’t aware of was the reason I went through it in the first place. Fear is just as powerful an enemy as regret.

Humans are the most resilient creatures ever created, with our ability to adapt to the environment where we exist in, no matter how unfavorable it is to normal human living condition. Mutation however comes into play one way or the other, as nature’s way of fortifying survival. For many years, a doctor embraces the chaotic, often aggressive hospital world, and such exposure either creates strength in character or post traumatic stress disorder. :) My first few months away from the hospital, was something like flashback episodes of a warzone. I’d often wake up with a start in the middle of the night disoriented. Loud voices would make my heart gallop like it always does when commotions meant an emergency or worst, a “code”. I also found it a struggle to return to the social circle. Of course, this is mostly due to the fact that I have been forgotten, or worst, presumed dead. Well, I have never as alive as when I was in the hospital, when there was no time for self. Being outside my fast paced routine, I was faced with so much empty time to think about me. It was a scary period.

What I often forget when I was still on training was how sick I was. I have carried the illness of so many people upon my shoulder that I'd often forget that I wasn't healthy either. I rejected the idea of telling my seniors about my illness, and I hated being treated differently. But several times, I did collapsed while attending to a patient, that I'd wonder where the patient went. "Hi floor. We meet again". My doctors would often remind me that IM training isn't for someone like me. It's too stressful. I can opt to try something easier like Dermatology. But I am not the derma kind. I dont have the skin of one nor their fashion sense. I am not saying that IM doctors are ugly. I am just saying that I dont have the guts to be a dermatologist. "Rest Joei, rest. Huh? Are you talking to me?" The world would have gone to an end and we'd still be too preoccupied with hospital works and training to give a damn. I'd often wonder why it's so crowded inside the hospital when there is so much space outside of it. And why is the hospital administrators fussing about what we are wearing when when we don't even have the luxury of time to take a decent bath? We are so concentrated on the patient's files that we forget our own birthdays. That we forget that brushing our teeth should be done at least twice in a day, according to social norms. There were so many things we forgot while we focused on honing our skills. Most of it had something to do with taking care of ourselves, since we can not give what we do not have.

Sometimes, while in residency, we forget that there is a whole bigger world outside the hospital. There are birthdays, and Christmas days, and New Years. We often forget that there are tons of people missing us. We forget the world, and sometimes, the world forgets us.

After passing the Physician's Licensure Examination, I started Residency Training. Others deferred Residency because they opted to earn after being a student for so long. Residents by the way already have tenures and are considered “In House Physicians on Training”. But precisely due to the "on training status", resident physicians are usually given very minimal income. Not enough to buy the books needed for the training, more so afford the hospital mandated formal attire. Most residents also do not get free parking from the hospital, so instead of paying, most opt to risk parking their cars on side streets. So you see, residency training must also be afforded by the family of the doctor. This is often the reason why most would defer it in favor of moonlighting jobs or drop the idea of specialty training altogether. Some enter Residency at such advanced age that the training becomes too much of an attack to the pride. Also, being too far gone from school makes it harder to recall the most basic skill like going through history taking and physical examination, which often comes naturally to someone who has just finished medical internship. It is also tragic for an old doctor going back to training again after spending long years in corporate setting to mislabel a Hyoid Bone as "baby's mandible", or to forget the algorithm of the cranial nerves, and how to test them. Residency is of course a tough obstacle course, even among the most intellectually gifted, and the most resilient individuals. One must have a strong hold of who they are (something I never had). Residency training has a way of washing off all your sense of self that most would come out no longer capable of remembering who they were before they got in. They say, if it’s easy it isn't a training. And a training for those who would eventually balance life and death on the palm of their hands is of course the toughest professional training there would ever be. Have you seen a joggler on a unicycle, juggling 12 balls all at the same time, while eating and spewing fire, and throwing jokes at the amazed crowd? Well, a resident physician on training is somewhat like that. Only, his audience will not be amazed at all. A resident doctor works for 36 hours a day in the hospital. And while a resident works, he needs to prepare case reports, read on all his case admissions for the next day's endorsement, do the charts, attend case conferences and grand rounds. That is over and above running the wards, seeing patients in the ER, ICU and OPD. A resident is also expected to teach and supervise medical clerks and interns, communicate with consultants, and counsel patients and families. Sometimes, with a resident's workload, eating and sleeping become a privilege.

There are a lot of things in private medical practice that are not learned during residency training. Medical Economics is one of them. Doctors are often made to believe that the profession is noble and service oriented that they forget to tackle somehow the business side of the profession. But of course there is the money making side for crying out loud! Doctors have to make money just as much as any other person. They need to be able to support themselves for continuing medical studies that cost so much, and give their families a decent life. But often, a doctor is faced with huge financial dilemma after residency training and regular (though minimal) monthly salaries stop coming in. A doctor with all the mandated training credentials from accredited medical societies can not just present themselves to their hospital of choice and practice there. He or she must first be able to afford the cost of stocks.” Right to Practice” in a huge tertiary hospital cost Millions of Pesos. So, to be able to rotate in a hospital, there are doctor who accept free teaching duties in training institutions to be given the privilege to get shifts. Of course, doctors with money will just buy the "rights" and are able to get their names as accredited physicians in big and prestigious hospitals. No other qualifications needed except specialty accreditation and lots and lots of money. So a doctor from expensive hospitals do not necessarily mean better as compared to doctors in smaller hospitals. They just happen to come from rich families. Of course I am not diminishing the skills and knowledge if these doctors. I am just saying that the hospital where they practice is not a qualifier in choosing the better doctor. A lot of doctors can not afford a practice of their own even after passing all the government and society mandated qualifying exams. So, they become Company Doctors or HMO salaried physicians. Right now, an Advocacy for Filipino doctors who are under salary status have been actively campaigning for a lowly standardized pay of (sigh) P200 per hour net for General Practitioners. But it is still a long, and tedious road to thread.

Do not laugh, but psychiatry was one of my toughest rotation as a Junior Intern. The patients scared the hell out of me. Being the lucky one that I am, I was posted at the Male axis during the day, and acute unit (Axis II) at night. Sufficing to say, in the male axis, you will witness an uncomfortable amount of masturbation. The doctor’s table is strategically situated in the center of a semi circled, jail-like wards where the most aggressive male patients were locked in. Again, I am describing a government owned psychiatric hospital. The private ones are of course better in terms of accommodation. And they were never referred to as psychiatric wards. They are often called “basement or detox wards. Going back, in my table, in the middle of this nightmarish semi circle, I often wear rain gear, and my umbrella is always open just in case a patient decides to aim his squirts directly at me. Witnessing an awful lot of masturbation is enough thank you. I dreaded night duty in the asylum. The admission area is located very near our sleeping quarters, and a lock on the door is of course absent since JIs need to be able to come and go. Often, a new patient would escape the orderlies escorting them to their respective Axis, and the common detour would be the JI’s quarters. I also hated doing vital signs monitoring in Axis II, obviously since I would be too near an acutely insane, possibly dangerous mentally ill person. The orderlies stand on guard usually, but there are times when they sleep on the job and would take too long to unlock the door in spite of my panicky call. In the psychiatric world, one sees the bold contrast between normalcy and insanity. But do you know that more than half of the patients in the government asylum are not really mentally ill? Insanity became their ticket to free food and lodging. I am often left to wonder how many in the normal world actually belonged in this asylum. I am sure there are more broken people pretending to be whole than those people inside the loony ward pretending to be insane.

Before one becomes a doctor, he or she first becomes a “dumb guard”. Before one becomes the key entity, he must first learn how it is to be a nobody. A doctor goes thru a process of learning while his character is transformed from the humblest beginning. Every time you see a medical clerk or an intern scampering after a group of doctors during bedside rounds either pushing a cart full of medical charts, or staggering inside your ward like a zombie in the wee hours of the night to get your vitals, you have to remember that even the most prestigious and well paid doctor went through the same humbling experience. Before one can even treat the broken, he himself must be pounded to the ground. For intelligence comes naturally. But a doctor’s character must go through fire to be molded to just the right shape to handle the degree of responsibility he or she will be given in future practice. Compassion is ideal, but burdensome in reality. A doctor wrestles with death and suffering at a daily basis, and often, emotions could be hindering. We keep it under our pillows at night as we succumb to restless slumber. But to bring it with us in our daily battles with the sick and the dying is like tying a boulder around our necks. We need to have just enough apathy in us to stay objective, and to survive the medical battleground still relatively sane.

What happened after my first Episiorrhaphy wasn’t something I myself expected. A Surgery resident came to “assist” me. We explored the incision. He asked me to be the one to take it out myself. And then he asked me to stitch her up. I think I made a pretty good job because she was discharged the next day together with her baby. The succeeding episiorrhaphy jobs by me had been uneventful and I learned to utilize my manpower, no matter how overbearing they may be. I am still the doctor and the one in command. Their job is to assist me and not the other way around. The surgery resident also taught me a good lesson about righting a mistake. No matter the consequences to the doctor, the welfare of a patient comes first. A doctor is never expected to be infallible. And so to ask help from a colleague who has more experience must never be deemed a sign of inadequacy. The circle helps each other. And to learn, one has to make many mistakes, and learn from it. Unlike other professions, Medicine learn from each other’s experiences. The mistake of one becomes the direction for other doctors. That is Medicine. Or at least, that is how it should be. A doctor is often likened to a mechanic. We fix human machinery. But unlike a mechanic who tries to figure out the problem while a machine is shut down, a doctor works on a breathing, live, and dynamic human who can not by all mean be rebooted. That by itself makes the profession uniquely different. Of course not all doctors seem to find mentoring a part of their skin. There are more bullies within the medical circle than there are in alleys of a poor neighborhood. There are more professional jealousy among us than there is in any other profession. So often, you see an SCon publicly shaming a JCon, who will find it within his right to shame residents, and so on and so forth. It is what the circle calls “The Right Of Entry”. And public shamings happen not just during bedside rounds. It happens during Case Audits, And Grand Conferences. It seem like the doctor who can spew more derogatory remark on a colleague qualifies him or her as the best in the field of medicine. But shaming happens within us. You hit on a doctor outside the medical circle and the entire profession fights back. Again, that is another characteristic unique to the medical community. Only us have the right to bully one another.

Another notorious “scream” unit in a hospital was the Labour room. My Obstetric rotation was somewhere in the middle of my Senior Year in Medicine. Aside from the perpetual smell of Lochia that is often enough to dampen one’s appetite for days, one common thing I observed among women in labour was Halitosis. Of course this is largely due to stress and pain. But again, being a clerk, I am often posted on the level of a patient’s face, coaching, monitoring contraction and fetal heart rate, and the like. “ Ha! Ha! Ha!, push!” “ you’re doing good. One more!” “ Ha! Ha! Ha! Push!”. By the time I have assisted more than five NSDs, I am almost out of my mind. There is nothing more wonderful however, than when you are finally allowed to deliver a baby into the world yourself. There is nothing more magnificent and fulfilling than to pull a baby out from the birth canal and deliver him to the waiting pedia to be resuscitated and cleaned. Of course that’s how it should be. But with 10 more patients on “fully” (full cervical dilatation), everything is in fast forward. No time for musing in slow- mo. Otherwise, these mothers would start delivering outside the sterile area and the newborn would go to sepsis watch for a week instead of going home the next day. So fast forward it is. Because my family name was well known in the field of Obstetrics and Gynecology, I was often given high priority on procedural hands on. As if my Dad had actually taught me Episiorrhaphy since toddlerhood. So my first take on hands on episiorrhaphy went like this: Resident was paged. Emergency CS on OR#5, and all the residents were already inside the OR. The interns were busy at the ER. “Joei, you close her up.”, my OB resident said. “Wa - what??!” But just like that, she was gone. And so the little me took the grand position between the lady’s thigh. If I were just not too nervous, I could do this. The old nurse assisting me rudely said “ Hey, you want me to do it?!”. “ NO!” I said almost as rudely. The hell with these old nurses. So to stitch I did. I did not even learn to stitch my own socks for crying out loud. And the episiotomy cut was lateral and away from the anus. That’s how training hospitals do it as compared to what midwives do. That differentiates the doctors from those who are not. The problem with the lateral cut was that it distorts the anatomy of the female genitalia. And if you do not have a picture of the internal anatomy in your head, you will end up with either a skewed vagina or a closed one. So, muscle to fats to fascia to skin I go. This connects here. That connects there. Bleeders ligated. So far so good. I got the hang of it. Until I ran out of suture. And instead of calling for a nurse, I stood up and got me a new fresh one. When I am ready to start another round of stitching, my old needle was gone. “Oh oh…” I was beyond panic. I was horrified. Either tell my resident I lost my needle somewhere in the poor woman’s pussy, or close her up needle and all, and pray she won’t develop abscess and go into septic shock while I am still here. I told my resident.

The Burn Ward smelled exactly as it is, named, of burnt flesh. Patients here are either charred beyond recognition, with the whites of their flesh peeking out or hanging loose. They are usually bandaged from head to foot. Most are conscious, and some are in coma state. Those who are awake would be screaming their lungs out, for no amount of anesthesia can numb their pain completely, without limiting their pulmonary function.This is a “scream” ward. As the lowest mammal on training, I am often fascinated by the trauma unit. It is actually a branch of Orthopedic surgery, but burn encroaches on both these specialties. Anyway, a burn patient is of course co managed by different specialties: General Surgery, Medicine, and Trauma. As a clerk, you go berserk dealing with all three of them. The only thing I ever did in the burn ward was debride, dress, debride. There is a huge bath tub to soak the patient in. Remove the old dressing. Debride the wound of dead tissue, put antibiotic ointment and zinc oxide, and dress. This seem simple enough except that most patients are bigger than me, with craters all over their bodies like over baked cakes, usually due to electric burns. And while I do my job, most of them would try to take a swing at me. They will be screaming curses, and if such could actually kill, I wouldn’t have made it out alive on my first day. Onother thing about rotating in the Burn Unit was that, the smell lingers long after you have showered. It’s like the stench of burnt flesh clung to the hair on your nostrils, and wouldn’t let go no matter what. Of course during your rotation, you are expected to learn how to diagnose 1st, 2nd, and 3rd degree burn. That was fairly easy. But I did learn to hide boxes of gauze and huge containers of burn ointment for me to use on the patients the next day without waiting for delivery of supply to come. I learned to listen to patient’s stories beyond the scream of condemnation. I learned that pain is almost tangible. Almost as tangible as the dead tissues I try to debride. I learned that the more a burnt flesh bleeds, the better would be its chances to heal. Their scars afterwards would be worst than their actual wounds. A different kind of pain would follow. And it would be the kind of pain no amount of morphine could numb.

Two hours before endorsement of duties to the incoming would be spent memorizing the cases and the new lab results that just came in: “This is a case of Miliary TB blah blah blah, with current Arterial Blood Gas of blah blah blah.” Memorizing patient’s files happen while duties to posts occur. This is a few hours before you go to the daily Bull Out session (endorsement conference) with the senior residents and consultants. You stand up in front of a conference room full of nicely bathed, properly fed, and well slept doctors on their well ironed white smock gowns. You on the other hand is expected to know all the details of last night’s patients, have read about your cases according to Harrison, ( remember that cases goes up to a hundred in government hospitals), and would still be sane enough to answer questions from consultants, when you can’t barely stand, more so make out their faces because your sleep deprived eyes are threatening to close any minute. Actually, that almost dead status after 24 hours duty is grace from heaven. No matter how many insulting, derogatory remarks thrown at you henceforth, it does not get absorbed by your senses. You have lapsed into ambulatory coma state.

been. To have a healthy life outside this dungeon seem so far fetched as of the moment

The thing is, Latin is dead. So, the medical language only meant something within the medical circle. Being in constant communication with patients who are of course mostly lay people does not go without a challenge among doctors trained for years to “speak in tongues”. Translating the medical jargons to a language that is understandable to normal (non medical) people is tougher to.most doctors than learning the latin jargons in the first place. This narrowed down to a significant level the number of effective clinicians. Most doctors prefered to be isolated into the lonely, but more familiar arena of the scientific world.

I was never lucky with the game of chance. If I were to play Russian Roulette, I would have 99.9% chance of blowing off my head. In draw lots, I always have that 90% probability that my name would be picked for less favorable circumstances, and 99.9% chance that my name would not be picked for highly aimed after rewards without effort. And so I am either in the TB ward, The labour watch unit, or the Burn Unit. That’s how lucky I have always been. While others were doing bedside vital signs monitoring at Q4, I am doing Q1. While others are sneaking some sleep, I am on close labour watch on a “Primie”. While others are preparing to go home, I am still waiting for the delivery of the fucking government issued gauze to debride the wounds of at least 10 severely burned patients. I hated Vital Signs monitoring, precisely because it requires very little cerebral function. It’s mechanical, tok tok tok tok, 140/100. Refer. Inhale exhale, 90 cpm. Refer. tok tok tok tok, 100 beats per min. Normal. And by the time I get to the last bed, the 50th, I’d be 30 mins late on bed #1. And so it goes until morning comes. Of course, this routine Q1 monitoring gets disrupted when I get to a bed and there is no tok tok tok. Zero vitals! CODE RED!!!! And I’d sprint towards the dilapidated cart with a missing 3rd leg, pretending to be a life saving E-Cart. By the time the rest of the doctors get to my post, I’d have replaced the ventilator to a manual ambu bag, had infused around 10cc Epinephrine, and had already done a series of pumps, a sorry imitation of chest compression. I’d be brazenly removed from my humiliating post, on top of a dying patient, by a resident, and proper resuscitation would begin.