RemoMD Rebuild

Tag: Training

  • No where to go but up!

    (I wrote this article while savoring the brutality of starting a practice and endless whining of a slow start.)

    My struggle has always been between filling up my empty stomach or satisfying my impoverished brain. To the millions of hungry Filipinos like me, this our “class struggle”-an unarmed, non-violent but similarly aggressive perspective of seeing past our choices of everyday life.

    To a proletarian who have gone to the bottom lowest of the pits, the best assurance one can get whenever you start a career or something is an old adage that says “you can go nowhere but up” or something to that effect. Like a messianic prophecy, I fanatically held on to this belief since high school days . The capitalist notion of incentive-driven success vis a vis hard work is as ironic as it is baffling to everyone in this “stomach” struggle. Yet, I survived half of my lifetime living in such altruistic ironies that neither my myopic deconstruction of choices nor the risky jumps I made could explain the extraordinary luck I had ending up being a physician.

    The dream of donning a white blazer and treating a patient is as fascinating as it is exciting. I am so entwined with that dream I forgot I have neither the financial capabilities nor the intellectual giftedness needed to attain such lofty dreams. I went into this profession simply because I wanted to prove to myself (and to my less encouraging social caste) what everyone in my bunghole has failed to do before me- don the white blazer with the least expense I can- financially and intellectually that is. Everyone think it was suicide in the making. I thought I have nothing to loose. I don’t have anything to loose anyway.


    That dream however grew into a vision, thanks to my alma mater. I practically crawled and bled to finish top of the line education for a career not everyone in my caste will experience- not even in their dreams. Fifteen years of Hippocratic studying did wizen my outlook about this noble profession. But it also shattered some idyllic notions I once have about doctors’ blissful life. More importantly, it brought my bourgeois upbringing to its knees and gave me the awakening of my comfortable life. My mission is never confined to the personal and financial self gratification kind of success. Because if it is that myopic, I could have never gotten this far.

    I have all the necessary ingredients for a successful medical practice. Ingredients that when “cooked” rightfully, would lead me into the much coveted goal in life that is termed success. Such “ingredients” are big words indeed, taught in bold letters, eaten in gastronomic amounts and digested in herculean way. It’s funny after that word found its way into the neurons of my brain, I have been deluded of a blissful life outside the academe, akin to the Renaissance Man. Little did I know about the truth that lay ahead in real medical life that is called “the Practice“


    Starting an upstream professional career is never an easy thing for the not so typical surgeon wannabe like me. I neither possess the inherited practice most other surgeons nor the coffers to buy a new one. Most people believe though, that having trained in one of the best medical schools in the country prepared me for one of the most formidable foe of the real life physician practice- an empty stomach.

    Of course being out of the academe and starting your own practice has its exciting advantages. The thought of having to take control of one’s time and spend it according to what you want is exhilarating. I can spend more time with what I want most, or with my loved ones I neglected when I was still studying. Gone are the Sundays where you have to read and prepare for pre-ops instead of having to eat dinner with family. I see non emergency patients on a scheduled time I myself created. Most of all, I have time to take care of my body while taking care of patients as well. I can eat full meals in a day and exercise regularly to maintain a sound and fit body. It is ironic that while we take care of patients 24/7 in a hospital, I lost tract of my own health in the process.

    I am into the practice of my profession for just barely two months, and it’s neither the blissful stride I once dreamed nor the catastrophic frustration I’m so afraid of before. Somewhere in between these extremes is the horrible spectrum of uncertainty where my minute practice existence resides. I wish my practice was as dramatic as the scenes in ER and Grey’s Anatomy or as wacky as unnerving as House’s one liner ass kicking. Nonetheless, the uncertainty gave me ample excuse to whine and be cynical about everything I get my hands on. Blame it on inexperience surgeon wannabe that is me. Everyone says that staring a career is shitty enough to make or break your soul. My soul has undergone so many breaks it neither can feel any shattering this practice has to offer nor enough time to recover form constant battery of changing lucks past choices.

    I bet it’s easier to just look at it as the paradigms of opposites. The definitions of success (and failure) in ones’ professional practice defined by simplistic phrases like-great clinic practice, successful surgeries, acknowledged researches, magnanimous services to patients and yes, professional fees enough to buy what we need. In essence, the very opposite of such adjectives and superlatives defines failure . Of course almost everyone believes that such simple dichotomous definitions don’t exist in reality. The theory of relativity seems to apply even in the psychology of success.

    So it seems. But that, I have yet to uncover.

    (Photo credits: All photos were taken from Deviant ART, my favorite repository of artistic shots.)

  • Orthopedic Logbook re-examines patient when he is in doubt!

    “I think it’s Septic Arthritis.”

    Twenty six years old male farmer with a history of fall from level ground, landing on his buttocks, able to stand up and walk immediately after without pain. The next day he felt excruciating pain in his swollen left hip, was unable to move his L thigh nor ambulate. He was brought to a bone setter who “massage” his L thigh but patient wasn’t relieved of the pain at all. In severe pain and febrile the next day, he was brought to the hospital immediately.

    “It looks like septic arthritis to me.”

    He was referred to a surgeon instead, who took x-rays and showed a less than 5% compression deformity of L5 . His differential count showed leucocytosis with lymphocytic predominance. He was started on Cefuroxime IV and pain meds. Four days after patient still has fever spikes and increasing trend of leucocytosis with lymphocytic predominance. Unable to move his swollen L hip and thigh he was referred to me.

    “I’m leaning towards reactive synovitis or septic hip here, bacterial or otherwise”.

    Short of doing formal arthrocentesis, I asked for an ultrasound of the hip-looking for water filled masses or pus filled joint. There was none according to radiologist. The white cell count is still increasing with lymphocytic predominance. I started the patient on Metronidazole and re -examined the patient carefully. He was afebrile for 2 days and noted an improvement in L hip range of motion. But there was still L hip pain and is unable to walk. The white cell count is still increasing. Lymphocytosis?Mature lymphocytes? Let’s call in an internist (we don’t have infectious disease specialist here nor a hema-oncologist)! See if it’s a possible lymphoproliferative thing!

    “I still think its septic arthritis, but I have no hard evidence yet”

    Instead, the IM gave more pain relievers and suggested patient be seen by a neurologist for a radiculopathy 2 herniated disc. The neurologist agrees triumphantly and advised more pain meds and bed rest. Sighed. Febrile, 26/male with L hip pain and elevated white cell count? Radiculopathy? I re-examined the patient. I courteously asked the patient if they can afford a CT scan of the hip and then asked the Radiologist to make the cuts up to the lumbar area and “peek” at possible herniated disc.

    “I’m still convinced this is septic arthritis L hip”.

    “No lumbar disc herniation nor radiculopathy. The L hip and anterior musculature is enlarged and fluid filled much more than the right. No fractures. Septic Arthritis highly considered”. Double sighed. Tomorrow I have to open up this patient’s hip joint, drain it’s pus, wash it carefully and apply traction. I gave enough time for guess making here.

    So when In doubt, go back and re-examine your patient!

  • Department of Orthopedics, Davao Medical Center: Answering the call to excellence in orthopedic training and services in Mindanao

    Just recently, The Department of Orthopedics at Davao Medical Center went under the sharp scrutiny of the esteemed Philippine Board of Orthopedics (PBO), for the department’s yearly accreditation as an orthopedic training institution. This process of evaluation and accreditation have very important goals namely;

    1. to determine if the institution is capable of training aspiring orthopedic surgeons in the area or
    2. was it successful in training current orthopedic residents and render orthopedic service to the region that is at at par with the board’s standards and the orthopedic profession in general.

    Being a newbie to this institution (and as an attending at that) it was also an opportune moment for me know my DMC Orthopedics family and learn how I maybe of help to them in the light of the staff’s main thrusts and the boards recommendations . No, I am not with the board, but I am happy I will benefit from their efforts and recommendations.

    The “board” is probably the best “external evaluator” of orthopedic training institutions within the national orthopedic community. Not only because the board are the ones who accredit training programs but because they are also in the best position to oobjectively assess our training program and give recommendations for its improvement. The board consist of elected and well respected orthopedic fellows from different training institutions around the country. Their collective experience simply equate to the “third eye” for any orthopedic training program.

    The Department of Orthopedics is probably one of the best department here in Davao Medical Center, if we base our assessment on the latest P.I.A.D. conducted by the DMC administration. PIAD was a patient satisfaction survey of all the DMC departments, in terms of services, facilities, personnel among others. The Department passed this evaluation with flying colors (100% mostly) and garnered probably one of the highest “grade” according to patients surveyed, if not the highest. This form of an “internal” evaluation has boosted the moral of the Orthopedic (consultants and residents), medical and allied medical support staff, and gave us greater resolve to improve more of our services and training capabilities.

    There is no doubt that in the DMC orthopedic community, talents and innovative ideas abound. The department graduates has been 100% passers on the Orthopedic Diplomate Exams since it started. It’s current residents also landing in the top of their batches in the in service training exams. On the national level, DMC ortho is probably at par with other training institutions, if not better. And we are just beginning to think globally and interact with foreign orthopedic community.

    But like any government training institution, challenges to DMC Orthopedics’ existence and goals are enormous if not astronomic. We are perpetually lacking in funds to support our services, maintain our facilities and equipments, conduct innovative research and support healthcare delivery to our patients. This is where the staff’s devotion to providing top notch service, despite odds, become utterly heroic. One third of the consultant staff are voluntary, meaning they don’t have plantilla items and thus don’t get salaries despite seeing patients and breaking brains to render services. Our resident staff is dwindling every year (might be again, brain drain or pocket drain whichever applies) and the MD to patient ratio is bloating, which I peg somewhere between 1:50. Our allied medical support staff like the nurses so often changes we barely have time to train a permanent younger one.

    Despite these odds, our department shines. Keeps us, the staff, smiling at the end of a tiring day. Thanks to the unwavering devotion of both the orthopedic and the non orthopedic support staff. We have so many goals to achieve, and so many ways of achieving it, but only one thing in mind(as our chairman will say)- give top notch patient care and train top notch residents. . We see a future in all these hardships. Maybe, the Orthopedics Department is after all, bound for greater heights.

  • Streamlining our OPD services (Orthopedics)

    We’re streamlining our Orthopedic outpatient services. And this is all to strengthen our out services especially to the indigent ones. The proposal will try to achieve the following

    1. Provide a better, quality and cost efficient outpatient service for patients.
    2. Better case documentation and improved follow up of patients.
    3. Improve our residents’ training program with better documentation of cases and outpatient follow up.
    4. De congest the outpatient department with unnecessary follow up and costly diagnostic procedures such as x-rays.

    Hopefully, this will alleviate some of the service concern of our patients.

  • Training Perspectives Part I: Dummies guide to surviving an Orthopedic pre-operative case conference

    It’s never a pleasant experience for me, as an attending, to see a resident tremble in front of the consultant staff, his pre- op case vanishing in room air and his morale at the level of the floor mat. I was in the same undesirable instances before, as any resident would be, not a long time ago. Often, the deja vu, nauseates my academic appetite. Ironically some of the best lessons I learned in my training came from such spectacular display of “enlightenment”.

    I am in the opposite sitting arrangement now, as an attending, throwing the same bullish questions I lovingly evade before. But then again, if you are a resident and you accept your status as it is, this might be the best way of freeing yourself from such lowly self esteem!

    A word of caution though. This is not Us, The attending vs You The Residents sort of set up. As Someonetc said, were all in these together. Nethier you or us nor the patients should lose. We all learn from it.

    The common question from the frustrated resident is “How will I ever satisfy this ever critical attending? I’m always wrong to him!”So our residents will ask me, “how can I ever avoid such hell questions during pre-op?” In the short time I’ve been an attending (and the long time hibernation as a resident) these are the “attributes” I look for and emphasize during rounds and pre-op. In this particular order.

    1. Present the case for your patient. Know your patient, examine him well, take care of him, and decide according to his realities and situation. Put him in the top of your indication list. Err on his side. Overdo things for his welfare. I cannot emphasize more. Nothing irritates us more when the patient is not on your number one list or if you forgo the patient’s welfare just because you were busy with something else.It is always wrong to reason out that way!
    2. Never lie or bluff your way out. We will be sending you to vacationland for good or force you to jump-off training. Believe me.
    3. It’s the decision making process that I look in more. The logic behind why you do the labs, why did you decide to do the the surgery or not. This separates you from as a scientist and surgeon to a technician. Treatment protocols may vary, gold standard of treatment will change in the future, but logic and decision making attributes remain the same.
    4. Read for your case. Read voraciously what is relevant to your patient and case at hand. Hit your ortho books but new relevant studies will always grab our interest. Never come unprepared to the pre -op. No patient (not even you as a resident) would want a surgeon who doesn’t know what hes doing, to operate on him
    5. Accept mistakes and make good at your promise to do well next time. The attending will always remember the next time.
    6. Talk to your attending or consultant after the conference (and the patient) to make sure you got what they advised you.Its always a mark of a dignified resident to clarify his lessons and make sure he understands them well.

    Again, we’re all in these together, you residents, us the consultant staff and the patients. I still believe no consultant is in there to personally destroy a residents career. Most of us are there to help you learn, learn the right way for you“-free of charge. Perhaps, thats the best assurance you can get from us.