Healthcare Blog of Dr. Remo Aguilar

Lesser Surgeons?

in Medicine/Orthopedics by

I’m amazed at how surgeons in provinces surpass the seemingly insurmountable odds besetting their practice. I’ve heard of horrifying stories regarding provincial practice during my training, that I sometimes wince at the thought that me too shall join their ranks soon when I get back to my hometown.  Then I got the first hand “feel” of what its to be like a surgeon from the provinces.

In my first year of practice I remember managing one patient who sustained multiple closed fractures of the ankle and that of the leg. On treatment appraisal I found out the guy can afford an operative procedure for the (bimalleolar) ankle fracture but not that of the leg fracture. I was in a dilemma at that time since current evidence only supports good overall functional results if both fractures will be treated operatively at the same time. Treating the two fractures differently or separately will result to a less than good outcome the review further noted. I racked my brains out for a middle ground solution. I can find none more than speculative statistics. I presented this dilemma to the patient and let him decide based on the ‘literature” and statistics I was explaining. I was dumbfounded with what he told me after my lengthy explanation. “Do what you think is best doc”.

Not only that.  I  told the patient that because we don’t have intra-op x-rays in that institution, it’s either we risk infection bringing out the patient to the x-ray room during operation to check for fracture reduction or just feel out reduction and accept whatever comes out after surgery. His only answer was “do what you think is best doc”.

Inside OR, there were so many other things that are less than ideal and often “damning’ to surgeons. I’m pushed to use a manual drill because we don’t have a sterilizer fit for my power drill. No pneumatic torniquets. No reduction clamps nor suitable retractors. And did I say before we don’t have a c-arm or an intra-operative xray machine? None of the nurse assists is comfortable with my orthopedic instruments. If this surgery turned horribly wrong, I wouldn’t be surprised. So I made sure the patient knew exactly what are our risk and he too wouldn’t be surprised if this surgery go bonkers.

I don’t know how the patient’s surgery went well despite these never ending list of “have nots. He went through the surgery knowing all of these and it went well, save for the surgeons’ anxiety and stress. I couldn’t sleep before and after the surgery knowing the odds we’re getting through. Frankly, I’m scared more than the patient but choice is something limited for us during those times. The need outweighs the risk.

Nowadays, I stil encounter a few of these have nots in most of my ORs, and I’m just as scared as before. I always talk these oddities to my patients and secure their approval before performing any surgery on them under these situations. This doesn’t lessen my anxiety and stress level though. It just pushes me beyond my comfort zone trying out new things “unorthodox”  that are anchored on a logical framework I’m taught during training. Ultimately, need is such an impetus for innovation.

So I wonder, does these insurmountable odds make us- the”provincial” cutters, less of a surgeon?


Dr. Remo-tito Aguilar co-founded #HealthXPh. A board certified orthopedic surgeon, he is previously Chief of Clinics at St. Louis Hospital in Tacurong City and a consultant in Orthopedics at the Southern Philippines Medical Center in Davao City. Dr. Aguilar is a healthcare social media evangelist and writes his medical musings at The Cast & Curious (


  1. Not just in the province, this also happens in the metro. In the Metro Manila hospital where I work, it is common for surgeons to do ORs with only nurses or midwives for assists, sometimes fresh graduates. Most orthos have to bring their own instruments, because only the very basic ones are provided by the hospital. Also, I think training hospitals provide better surgical care than their counterpart.

  2. anakat yes to some extent I agree..Indeed some training institutions is better equipped than some other institutions. From where I trained, I always whine at what we don't have in the OR.But here in provinces, I consider my training institutions logistics as already luxurious. Imagine the very basic intra op xrays…you can die of stress anxiety from thinking about the ramifications of a wrong procedure done simply because you don't have an intra-op xray to check it…

  3. wow, doc remo, i recently joined the ranks too…it never crossed my mind that i will, because i am a true manilena. i am somewhere in the heart of luzon right now, and though i am aware (and have had experiences) of the difficulties of practicing surgery outside the city, iba pa rin yung ikaw na ang surgeon. it's not like i cannot nail using a kuntscher or do partial hip arthroplasty using an austin-moore, but i guess we studied what the ideal treatment should be, during our training. why i moved, that is another story *smile* but the so-called "lesser surgeons" are actually big in heart and gall 🙂

  4. @Gigi, yes if you are the surgeon, stress levels are higher than what we thought it will be, even for supposed to be simplier surgeries. THE FUNNY THING IS we still brave heaven and hell despite the surmounting odds and risk were taking. Cardiomegaly and gallstones indeed…

  5. make do with what you have and pray that the px's relatives is in non -combative mode, and pray hard! buhay doctor sa pinas!

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