Cast & Curious

Tag: education

  • Why I threw a patient’s ‘counsel’ out of my clinic

    Patients with a bantay or 'counsel' photo taken from this site (http://www.umc.org)

    It’s not uncommon to see a patient or a patient’s relative bringing along some unrelated individual as “counsel” in your clinic. This counsel is unique among my Filipino patients and such counsel’s role has baffled me ever since I started my medical career. Roles, that to my knowledge broadly range from just plain ambulatory assistant or worst, to a nagging and combative counsel to the patient. I have tolerated such roles before because at times they can be very helpful in educating patients and relatives who haven’t had any time to convene a family meeting on their health issues at hand. But a recent bad experience with a ‘counsel’ pushed me to institute a policy of “no non related guardians allowed” inside my clinic.

    My patient was a 10 year old girl who sustained a supracondylar fracture from falling over a park statue where she was playing with her cousins. The kid was brought to my clinic after 3 days, on a makeshift splint and after 3 sessions with a known bone setter in the area. The elbow is already grayish blue in color and is still swollen. The kid is wrenching in pain but  I can still feel the pulses and there are no signs of compartment syndrome. The mom brought with her a “counsel” after the bone setter allegedly ordered an xray. In my setting here, even if we’re already an urbanize city with a tertiary level hospital at that , bone setters are primarily the first one being sought by patients or their relatives when dealing with fractures. It’s even very common to hear bone setters manipulating fractures and ordering x-rays! Anyway, what bugged me that time was the way this ‘counsel’ is disrupting my talk with the patient’s mom.

    I was explaining the diagnosis and the treatment options to the mom, baring that a surgery is already needed in her daughters case. I could employ a conservative treatment (if cost is prohibitive to the parents) but the results, which I explained carefully to the mom, would be unacceptable and costly in the end. The ‘counsel” is impolite in drawing attention of the mom, and whispering barely audibles that as I can figure out was a urging the mom not to have the surgery done and bring back the patient to the bone setter. The mother was very much bothered and was in fact becoming inattentive to me because of the constant nudging of this counsel.  As it grew frustrating to me, I looked straight to the counsel’s eye but politely asked the mom what is this counsel’s relation to the patient or the mom. She was a neighbor, the mom told me. She was also the one who brought the kid to the bone setter for manipulation twice! I asked the mom again politely of course, to ask the counsel to leave the clinic now and just wait outside. I also urged the mother to call a family meeting and talk with her husband the treatment options I laidout for the patient.

    Well, that didn’t happen. The counsel refused to leave and worst, she kept on annoyingly nagging the patient’s mom.  This prompted me to talk directly at the counsel, ask her that if she doesn’t stop disrupting our conversation, she’d answer for all the complications her constant nagging has brought to the patient’s condition. And she’d be thrown off the clinic’s premises for good!

    Then there was this an uneasy silence. Everyone in the clinic knew that my usual cool composure got blown by this annoying ‘counsel’. Everyone was silent for at least 3 minutes. When the counsel was escorted out of the clinic, I apologized to the patient’s mom, not for throwing out the counsel, but for the disruption in our conversation. She just smiled and from that moment on. I know I won another loyal patron.

  • Reviving the physician’s administrative function

    Right. I almost forgot. The medical staff do have “dual” functions.

    The medical staff has a dual and overlapping management system- the administrative which involves the activities of a medico-administrative character, and professional, which concerns of the clinical aspects of its functions.

    The physician is typically absorbed with the clinical aspects of his profession and rarely bother with administrative functions unless he or she is managing a large group practice or a hospital. Private, solo practice large reduces the physician’s administrative function to bare minimum.

    This may not be necessarily true in a practice that involves a tertiary institution.

    This realization struck me as I was tasked an administrative position of setting up clinical services for a tertiary level health care facility. While defining clinical functions is not a “breeze”, setting up additional administrative functions for the involved physician is like “walking into a storm”. Again, this is seemingly related to physician’s preference to clinical functions rather than the administrative part. In reality, most physicians shy away from ANY administrative functions at all.  I now understood why physician administrators grow (or lose) gray hairs by the hundreds each day.

    physician as administrator
    physician as an administrator, what gives?

    The reason?  My personal observation is this: As a physician, we were trained mainly on the clinical aspects of our profession. The few that got some training on the administrative skills probably got stuck in such functions. This compartmentalization of functions seem to enhance productivity on either of such functions but not on both. We were trained to specialize. Even solo, private practice seem to support this observation. The other reason is that physicians are generally slow to adapt to any change. Our comfort zone is just to comfortable to let go suddenly.  Thus, physicians tiptoes and are slow to adapt to administrative changes intended to improved  health care delivery.

    This is where I am looking for ways to get viral and enthusiastic response from the medical staff. This dual function of hospital based physicians are intertwined and complementary. Defining such functions is necessary for providing top notch health care service and the smooth operations of the health care institution. I’m not just saying this because I’m now part of a hospital administration. As I’ve said before,  have I recognized administrative functions before in a solo practice, my practice would have been smoother and productive.

    In your practice, do you really care about administrative functions at all?

  • Balancing Act: Community and tertiary care orthopedic practice

    Barely five years into a private medical-surgical practice, some people got interested how I’m “doing” with my “kind” of orthopedic practice.  Orthopedic practice refers to an orthopedic surgeon’s working environment, the plethora of patients or cases he handles, the time, effort and money he or she invests on it as well the returns (monetary or otherwise) he gets from this professional career. This is rather a simplistic definition, one that is based on a business model, but roughly what approximates a “medical-surgical practice” in the real Philippine health care settings. This definition is further muddled by “subtypes” of an orthopedic practice as well as the mix and match attitude by most orthopedic surgeons practicing in this country.

    Before I’d shed light on my kind of orthopedics, let me describe what I think is the two extremes in orthopedic practice- the community type, generalist orthopedic practice  and the super specialist tertiary level academic orthopedics.

    A community type of orthopedic practice usually caters to patients with general orthopedics (osteomyelitis) and extremity trauma (fractures) problems and usually the first line of orthopedic care in the provinces. These patients are commonly admitted to a non specialist, primary to secondary level, health care institutions found within the surgeon’s community or area of practice. Academic orthopedics on the other hand,  is basically a tertiary, level I trauma care practice that deals with, specialized or complicated orthopedic problems (e.g. arthroplasty or spine cases) that requires super specialist institutions with supporting facilities (ICUs) . Such specialist type of orthopedic practice is usually coupled with training residents in the orthopedic specialty. Some hospitals add admitting and/or administrative privileges to the surgeon.

    The contrast between these two types of orthopedic practice is probably  apparent in the  amount of time and effort an orthopedic surgeon “invest” on each cases .  A super specialist academic orthopedics is generally thought to be more time, effort and learning  intensive, compared to a community type of orthopedics.  It is also perceived that specialist care are more lucrative, pay and prestige wise.  Of course there will be exceptions to this observation, as the delineation between “learning” in the country side versus the urban centers is gradually grayed by the advent of fast information and the internet. But for our purposes here, let me just simplify definitions to differentiate between the two.

    Why am I differentiating between these two types of practices?  Theoretically speaking, somewhere between these two practices is the middle ground which is for me, the logically desirable type of practice –time, effort and income wise.  Thus, a balanced orthopedic practice (in my opinion) is one that  involves continuous learning and at the same time, offers a “relaxed” environment that caters more to delivering quality orthopedic care in a community setting.

    Many surgeons believe such “balanced orthopedic practice” is not easy “find” , difficult to live with, or is unsustainable. The inherent affinity of the orthopedic practice to orthopedic implants and gadgetry as well as to a tertiary level health care institutions is believed to be the primary reason for such negative perception . While many many orthopedic surgeons still conglomerate on urbanized cities and tertiary level care institutions because of  this logistics necessity, a trend towards community type of orthopedic practice is picking up pace because of improved information technology and delivery of much needed orthopedic implants.

    One former mentor asked me if I’m happy with this dual type of orthopedic practice. I answered ” yes” although I qualified it immediately by saying “.. with some necessary lifestyle and living adjustments” . Personally, I find it natural that this two sub types of practice  complement each other. A community practice without continuous learning is boring. Likewise, teaching orthopedics without actually doing what you teach is too good to be true. Somewhere between these two “extreme” sphere of practices lies a compromise that I felt, will produce the balancing act.

    “But what about lifestyle modifications as you said?” I for one, chose this balancing act, because it fits my lifestyle. Compared to an urban, high volume, city practice, I certainly preferred the relatively relaxed working environment of a community practice. On the other hand, I cannot let go of the many opportunities for learning that these big academic institutions could give. Besides, I love teaching. Teaching could have  been my career if not for the ‘healer” awakening I got in college. Like one mentor said ,  “there’s no better way of learning than to help others learn“.

    Well, a community type of practice will rarely make you rich, but I’m pretty sure you’d be able to put food (or a house and a car perhaps along with some other perks) in your family’s table. A simple living will surely come handy in surviving this dual type of orthopedic practice. But it does pay well in the amount and quality of time you spent with your love ones! I guess it all boils down to what fits your lifestyle and your priorities. Mine just happened to be where I wanted to be years before I became a doctor.

    So which one do you prefer then, the community type of practice? the academe?or both?

  • A Perspective on Non-Compliant Patients and the Contractual Doctor-Patient Relationship

    I have long been an advocate of a no refusal, admit all patients policy for physicians . Any physician is bound by his Hippocratic oath and the law to treat any patient (within the bounds of his skill and expertise) whatever the circumstances of that patient will be. The physician also has the social responsibility of reporting any patient (to proper authorities)  that  may pose danger to any other person or to the society for which the patient belongs.

    Lately however,  I’ve noticed a few non-compliant patients pushing limits of our patience and  resources. My case in point.

    A thirty something male patient brought to the ER (allegedly from another hospital) for a 2 day old gun shot wound. The GSW entry point is at the postero-medial portion of his right leg, with no exit wound noted. He has a comminuted fracture on the middle part his tibia. On examination, the bullet  slug is palpable on the  postero-lateral side of his knee. I noted a wide area of contused skin from the leg, extending to the lateral posterior of his right thigh. Patient is febrile and have an elevated BP. We immediately started IV antibiotics and  scheduled the patient for an emergency debridement and external fixation of the fracture.  Surgery went well and while the skin contusion did grew to a alarming size, the patient eventually recovered and was on his recovery 5 days  after surgery.  The patient ran away from the hospital without proper discharge procedure and without paying his bills. As we learned later, all patient’s data and circumstances were dubious and the patient is nowhere to be found.  My worst fear is the danger of this patient contracting osteomyletis if ever his fracture isn’t followed up carefully.

    If he ever goes back to any hospital, and if you are the physician, what would you do?

    The dilemma is much more difficult in government hospitals. In the Philippines, government hospitals are funded by people’s taxes. Funding that are at less than optimal and is finite. Government physicians sometimes sees patients, that for some reason,are rarely compliant. Most often these patient’s’ non compliance results to complications and prolonged treatment. Prolonged treatment siphons physician and hospital resources that could have been allocated to other patients. This is where the decision making abilities of a physician enters and is very crucial. It can actually make or break his career because litigation and malpractice suits isn’t easy to come by.

    My take on this? I’d still treat the patient according to what his medical problem requires and to what treatment the patients consents to. But I’m going to document it very carefully and protect myself with detailed consents and waivers. I will also get the opinions of  appropriate legal or social services department. Sometimes, its more with communicating with the patient and convincing them of their most beneficial treatment option. This is not easy. But aren’t we surgeons and doctors now if our job is easy?

    I may sound like crap but again, the simple fact remains the same. We are the physicians, the very persons privileged to touch and care for sick people. When we treat patients, we (and the hospital) enter a ‘contract” with that patient. Contract that to an extent, requires both the doctor and the patient to work for the wellness of the patient, for so long as that treatment is not detrimental to others. It all boils down to both parties being aware of their responsibilities in this contract. If one violates this contract, that ceases the existence of the contract and therefore, ceases the doctor- patient relationship.

    If you are a physician in this situation, what would you do? If, you are a patient, what do you think should the physician do?

  • Where’s health and education now Mr. President?

    I had mixed feelings after reading the text of  your recent State of the Nation Address (SONA) Mr. President.

    On one part, I got excited when you detailed some of what many of  your countryman (which you gracefully called your Boss) knew years ago- corruption is rampant among many of the government agencies. That however, is old story to us Mr. President. My eardrums has thickened hearing all those  exposes that ended up in the waste can for “lack of evidence” and so many legalese gobbledygook. Put the corrupt officials behind bars and recover the peoples money and we will be all excited and happy. Including my eardrums.

    The other part of me had this bad feeling about what might happen to your other priorities mentioned in your campaign. Your tone on corruption is very much aligned with your campaign tag line, but you spoke less on health and education. Where are they now in your priorities Mr. President?

    Yes, the statistics on Philhealth coverage is confusing. But so is our health care system. You mentioned correcting the coverage statistics and expanding Philhealth coverage  to every Pinoy. It sounds good on our ears but personally Mr. President, its not enough to heal the woes of our health care system. Many of your Boss, cannot survive Philippines with Philhealth coverage alone.

    And education? I can barely make anything of what you mentioned, yet. Frankly,I spent half of my lifetime in school and yet I barely can put food in my table. That’s why i doubt prolonging  years in school actually translate to a quality life.

    I understand you’re trying to paint a picture of a negative starting point for your term. (Give thanks to the previous administration by the way, they made that painting an easy task for you with all those nauseating scandals). But that is the same reason we put you in charge now Mr. President. We believe you can be a good president even if you start from a negative starting point. We believe you can save us,  your boss,  from lingering in the kamote fields.

    You asked for our support. If you noticed, there are many uprisings we supported in one way or another-rebellions, coups, edsa and even green revolutions. The people have shown their support to the presidency in so many times already. The people rallied to support so many crusaders but most of them failed us in many respect. Look at us now, we’re back to square negative. Maybe its high time you give us results already. You are the president. You weave power enough to do all of these reforms. Results is all we’re after now.

    In all of this Mr. President, my prayers is with still with you. Give back health and education to the people .  Make them your priorities. And give us results.

    You cannot fail us. We forbid you.