Professional Documents
Culture Documents
Reynaldo O. Joson, MD
2013
120
Preface
Introduction
12
14
Epiloque
98
Appendices
1
2
3
4
5
6
100
105
101
102
111
117
119
118
No.
2004
2004
2004
Title
Reporter
Page
Needle Evaluation of
Breast Mass over Outright
Open Excision-Biopsy
Holistic Surgeon
Reynaldo O.
Joson, MD
93
Hazel Z.
Turingan, MD
14
Jose Mario
Amado M.
Pingul, MD
17
2004
4
5
Janix M. de
Guzman, MD
Maria Cecilia T.
Leyson, MD
44
2004
Coincidence of
Unfortunate Events
Facing Death
2005
Unaccounted Sponge
Jeffy G. Guerra,
MD
89
2005
Grumpy Granny
Rommel Q. De
Leon, MD
74
2005
Nolan O.
Aludino, MD
24
2006
Man of Honor
Roderick S.
Mujer, MD
26
2006
10
Benjamin C.
Deveza, MD
21
2007
11
Harvey A.
Balucating, MD
40
2007
12
55
2008
13
Jonathan R.
Malabanan, MD
70
61
Appendix 6
Year
No.
2008
14
Explaining a
Colleagues Differing
Diagnosis
Edelweis
Z. Velasquez, MD
82
2009
15
First Time
Robelle J. Peralta,
MD
58
2009
16
Informed Consentfor
Real
Michael Angelo L.
Suaz, MD
78
2010
17
Medical Certificate
Extension
Alma Jawali
Lucero, MD
94
2011
18
Better Facilities or
Patients Trust
Ariel T. Celzo,
MD
51
2011
19
Calmness and
Flexibility
Rembo M. Aguda,
MD
76
2012
20
A Senior Worthy of
Emulation
Sheena Shayne P.
Siapno, MD
47
2012
21
Onofree L.
OConnor, MD
32
2012
22
Helping an Indigent
Patient through IPHP
(Indigent Patient Help
Program)
Conflicting Results of
Clinical and
Diagnostic
Examinations
John Lloyd F.
Fonte, MD
85
Being a Patients
Relative
Caring for an
Abandoned Patient
Jenny Vi. H. de
Castro, MD
Lucas Riel B.
Bersamin, MD
65
A Patient of Honor
Reynaldo O.
Joson, MD
30
2013
23
2013
24
2013
25
Title
Reporter
Page
36
117
understanding.
The Medical Anecdotal Reports also reminds each surgery resident the
ultimate goals of the department: A Live Patient, Minimized Complications,
No Disability, No Lawsuits. These goals I believe are not just noble
aspirations but goals that all surgeons in training and in practice should
strive for.
I believe that at the end of each ones 5 year residency training in the
OMMC Department of Surgery, these Medical Anecdotal Reports would
remind us how much we have learned along the way in terms of being a
competent surgeon, reinforcing professionalism and ethical values, and of
the importance of recognizing each and every person as a human being.
Page
14
17
21
24
26
32
30
36
40
44
116
47
51
Appendix 5
Page
55
70
76
58
61
65
74
78
82
85
89
93
94
115
also learning. That was when I realized that MAR is not just a mere storytelling but a learning experience not only for us surgeons of this institution
but for medical interns too. Often times, Dr. Rey Joson would say that
every patient is unique and many times we learn something from them.
This learning should not go to waste and can be utilized in creating
policies for the department, including guidelines in clinical diagnosis and
treatment.
Medical Anecdotal Reports are important to remind us that patients are
there not only to be cured, but to share in our experience as doctors. By
getting to know our patients, we know not only their illness, but also their
story, their lives, and we use all of these to improve in our work as
surgeons. Medical Anecdotal Reports are what remains of our patients, the
memories they leave behind even after they have been cured. It just goes
to show that even if our patients return back to their normal lives, we have
taken and kept a part of them. Through Medical Anecdotal Reports, we
have obtained something from them which can be used not only to reflect
on our performance as surgeons, but also to improve on how we can cure
future patients. Indeed, Medical Anecdotal Reports are a simple yet
meaningful way of knowing our patients and learning from our patients by
reliving our experience as their doctors.
Preface
In April 2004, I started a project which I named Medical Anecdotal Reports
or MAR for short, in the Department of Surgery (Surg) of Ospital ng
Maynila Medical Center (OMMC) [OMMCSurg]. The MAR was an
additional innovative teaching-learning activity that I had designed for the
Department during my term as Chairman from 2001 to 2009. The MAR
was operationally defined as a brief written report on an actual medical event
that involves an actual patient seen by a surgical resident or trainee. The
medical observation must have an impact on the surgical resident as a
physician in terms of insight gained and which he/she thinks is worth sharing
with colleagues as this may help improve patient care and may be useful for
the knowledge management system of the Department. In essence, the MAR
is a reflection paper and writing it is a reflective learning activity for the
surgical residents or trainees.
From April 2004 to June 2013 (the time of this writing), the objectives,
policies and implementing instructions on the MAR have been continually
refined. Below are key information on the MAR.
As to objectives, the MAR is primarily a learning activity in the
development of holistic, professional, and compassionate physicians among
the surgical residents of OMMCSurg. The second objective is to enhance
the residents English writing skills. The third objective is to reinforce the
Departments knowledge management system through the issues raised and
resolutions made in the MAR activity.
As to policies and implementing instructions on the MAR, each resident is
required to write and present one MAR a month, except in January and
December, the respite period. A template is used for the writing and
presentation of the MAR which consists essentially of a one-page paper with
narration followed by insight and categorization of the latter into physical,
professional /ethical, and psychosocial domain. For every presentation of a
MAR, at least 2 residents are required to react with a consultant moderating
and facilitating discussion. Feedback and discussion cover both the contents
and the technical writing of the MAR. At the conclusion of each MAR
presentation and discussion, resolutions are made on measures to be adopted
by the Department staff in enhancing the development of holistic,
professional, and compassionate physicians as well as in improving the
system of care, not only of the Department but also of the entire hospital.
(Note: The history of the MAR can be seen in the following website:
114
(https://sites.google.com/site/medicalanecdotalreports/history-of-mar-inommc-surgery).
Since after presenting a formative evaluation paper on the MAR project in
the 4th Asia-Pacific Conference on Problem-based Learning in Health
Sciences in September of 2004 with the findings of usefulness of the MAR
in improving trainees competency in biopsychosocial management of
patients, I have been wanting to publish the MARs into a book. I feel a
book on MAR will be appreciated by both medical and non-medical
readers, not only because of the uniqueness of the MAR as a training
method for physicians but also because of the extremely valuable
competencies (holism, professionalism, and compassion) it is developing.
These competencies are being constantly sought by patients and medical
teachers alike from their physicians and physician-students respectively.
Meanwhile that a book publication has not yet been done, the MARs have
been posted in several websites since 2004 by both the surgical residents
and myself. In 2005, I asked the help of Dr. Elvie Razon, who spent
clinical clerkship in OMMC and who was known to be a good writer, to
edit the 2004 MARs. Thereafter, Dr. Nolan Aludino, a surgical resident,
created a website (http://omsurg-mar.tripod.com) and posted the MARs
edited by Dr. Razon and also the MARs written by the surgical residents in
2005 and 2006. After 2006, the MARs have been scattered in the online
General Surgery Journal of the individual residents.
As mentioned earlier, I have been wanting to publish the MARs into a book
since 2004. However, I was bogged down by the search of a good design.
I have been looking for a design that will approximate the key processes
involved in making and presenting the MAR by the surgical residents, that
is, presence of an insight-triggering event followed by reflection and
writing of insight and then feedback and discussion by readers and
listeners. In addition, I have been looking for a way in how to make the
MARs useful to the readers, both medical and non-medical. Initially, I
thought of just a compilation of the MARs with editing of the grammar and
syntax. This was essentially what happened to the 2004 MARs. I wanted
to go beyond that. For the past 9 years, I have been experimenting on the
design. I used websites to simulate the book. Honestly, I was having difficulty deciding on the design.
Finally, in June 2013, 7 months prior to my compulsory retirement from
OMMC on January 31, 2014, I decided to have the following action plans
to have a book on the MARs published:
Appendix 5
Feedback on the MAR by Surgical Residents in 2012
Onofree L.OConnor, MD. (Year Level 3 in 2012)
As medical practitioners, we should be constantly reminded not to treat
patients just as mere cases, as operative procedures we tally and keep track
of, or as numbers to complete a census. The dangerous side of being a
doctor is forgetting that patients are human beings. As humans, we impart
experience and through that experience, we touch other peoples lives. As
surgeons, we touch our patients lives by healing them, by curing their
physical illness, by using our knowledge and hard-earned skill to restore
their bodies to their best possible condition. When we look at it this way, it
seems that our patients have the better end of the deal. However, what we
dont see is that we as doctors also gain something from them, just as much
as they get something from us. Aside from honing our skill, these patients
touch our lives just as much as they have touched ours. They give us an
opportunity to learn, to improve in our craft, but also to remind us that we
are human, that we have emotions, and are capable of compassion. Every
patient is different, and every patient brings something new and contributes
to our experience as surgeons. Medical anecdotal reports are an avenue for
collecting these experiences with our patients and putting them to good use.
By presenting them, we learn from them, and by learning from them, we
improve as healers and agents of the medical field.
A Medical Anecdotal Report (MAR) is defined by the Updated Policies and
Procedures on Medical Anecdotal Reports (Dr. Joson, 2012) as a brief
report on a medically-related event encountered by the reporter which
brought a significant impact to the reporter, that is worth sharing with his/
her colleagues for the promotion of good patient care. It is further
systematically classified whether the insight gained is Physical, involving
the processes of diagnosis and treatment of a medical condition;
Professional/ Ethical, involving the handling of the patient; or Psychosocial,
involving empathy for the patients medical condition.
During my first year as resident surgeon, I regard the MAR as just small
sharing of personal experience with a special patient to our fellow resident.
However as I coursed through my residency, making more MAR every
year, I then realized that we are reporting more than just an experience, but
113
112
10
Appendix 5
Feedback on the MAR by Surgical Residents in 2012
Sheena Shayne P. Siapno, MD (Year Level 1 in 2012)
On September-October 2009, I was a rotating junior intern of the
Department of Surgery in Ospital ng Maynila Medical Center. It was then
that I first heard about the MAR. I often hear this, uttered by the
residents. Curious as I am, I asked what the MAR stands for. That
resident answered, Medical Anecdotal Report. My inquiry stopped there
and no further questions was asked.
Then on September 2011, I had my pre-residency in this department. Now,
I just did not hear about the MAR, I was now able to listen to residents
presenting their MAR. I did not fully understand what the MAR was for. I
just knew that they shared their own anecdotes, and their learnings from
such. However, these anecdotes opened the surgeons day-to-day activities
to the listeners/readers. It showed how they were able to deal with their
patients and colleagues in the hospital or in other places where they were
able to encounter them.
Come November of last year, we were able to experience writing our own
MAR. Before I became a part of this department, I thought that writing the
MAR was that easy - think about an experience and put it into writing. But,
when the time came that I was doing it, it was not superficial as thinking
about an event in your hospital life. It was picking the experience which
had the impact in you and at the same time, you know that it was worth
sharing. It was more than superficial-digging deep into your emotions
regarding that experience and how it taught you some lessons.
The Medical Anecdotal Report (MAR) is unique to the Department of
Surgery. The history of which, is unknown to me, but enough to say that it
started in 2004. It has become a part of the Departments weekly activities,
wherein during our conferences, assigned residents present a written report
on medical events which they experienced. These experiences are those
which have an impact on them as physicians, and from which, arises
insights that they were able to realize. These insights are then categorized
into physical, professional/ethical and psychosocial. (Details of
categorization is stated in PROJECT: MEDICAL ANECDOTAL REPORT
111
Appendix 4
Feedback on the MAR by 15 Surgical Residents in 2006
110
11
Introduction
Appendix 4
There are two ways of going through the MARs. One is by year of
reporting of the MARs, chronologically from 2004 to 2013. Second is by
issues and topics (not titles of MARs) that I, as author of this book,
identified and discussed in the TPORs portion of the MARs of the surgical
residents and also in my own 2 MARs. (See the two sets of Table of MARs
in the first few pages of this book.)
The Table of MARs by issues and topics will be useful to readers who
want to look for information on specific topics upon opening of the book.
It will also be useful for readers who will use the book as a take-off point
for group discussion on specific topics. Based on the issues and topics
discussed, I categorized the MARs into 3 groups, namely, Making of a
Holistic Physician, Making of a Compassionate Physician, and Making of a
Professional Physician. This will not only help the readers identify the
theme of each MAR; it also gave me a better basis (I think) for the
sequence of presentation of the 25 MARs in this book.
In the Appendices, I included the following for historical value:
1.
2.
12
109
Appendix 4
Feedback on the MAR by 15 Surgical Residents in 2006
What do you like most in OMMC Surgery MAR and why?
It gives us the opportunity to express our actual experiences in managing
and interacting to our patients. This is a good training ground for us to
develop our physician-patient relationship. It is also nice that we are
required to report it thru e-mail and thru actual presentation. This way
others may learn and vice-versa the reporter also learns from them based
on their comments.
The narration of the experience of the surgeon.
The thinking process, wherein you are looking at your experience as a
whole, not just the good side but also the bad side and learning from it.
It helps me express my thoughts and emotions as well as enriched my
vocabulary in writing narrations about patients and their management.
Learning what others are thinking that they usually fail to share.
Learning from the success stories of others as well as from others
mistakes (not to commit them), MAR opens the eye to a number of
perspectives on a similar scenario, mostly from the reactions from the
audience after presenting a MAR.
The thing I like most about MAR is that it is an avenue to for me and for
the other MAR writers to share our experiences which would otherwise
not be considered as informative in other for a. It breaks down barriers in
such a way that we can share emotions felt, the feelings involved in being
a doctor. Through this form of sharing, other persons will learn from our
experiences. What would otherwise be a personal or intimate lesson
becomes a lesson shared for others to digest.
As the saying goes experience is our best teacher. MAR gives us the
opportunity to make a reflection of our own experiences in dealing with
our patient and everybody in the hospital. Then we learn in the process.
3.
4.
5.
It is through this project that we, residents are able to share our
experiences that eventually become venue for self growth, personal and
training wise. Moreover, MAR developed our English and literary writing
skills.
108
13
Appendix 4
NARRATION:
Reactions to 29 Statements
Last 2003, I operated on a patient with breast cancer stage III-A. I learned
that she has a strong family history of breast cancer. Two siblings have
the same disease and one already passed away. For a long time, she was
in denial about her condition, refusing to accept that she was also
afflicted with breast cancer like her sisters.
With her sisters conditions, she was very knowledgeable about breast
cancer. When she decided to have her operation done, her resistance
dissolved and she complied with utmost obedience to treatment. She
underwent chemotherapy for six months after the operation with diligent
follow-up. For a year, I was in touch with her and her daughters.
Three months ago, she came back with bone pains and a bony elevation
on the head of her left clavicle. Chest x-ray and bone scan were both
negative. Two months later, she returned with pulmonary and bone
metastases that were earlier undetected. She was then referred to a
surgical oncologist and was again put on chemotherapy.
She and her daughters still came to visit me and update me regarding her
condition. Later, one of her daughters came back and told me about her
deteriorating condition. I told her to get her mothers affairs in order as
she may not have the luxury of time. I told her to make the best out of her
mothers remaining days.
A few weeks ago, I received a message from her that her mother expired
with the whole family on her side. Again, the patients daughters came to
visit me and expressed their gratitude for giving their mother the care and
concern they felt I gave not just as a doctor but also just like a real
daughter to their mother, as well.
INSIGHT:
Although we were taught in medical school to empathize with our
patients and maintain a certain degree of detachment as doctors,
sometimes we transcend the delineation between a doctor-patient
14
15
15
15
14
107
15
15
15
15
15
relationship and a human relationship where strong bonds are formed and
no restrictions are made.
Appendix 4
Feedback on the MAR by 15 Surgical Residents in 2006
Reactions to 29 Statements
Key: SA Strongly agree; A Agree; UnC Uncertain; D Disagree; SD
Strongly Disagree
Statements on OMMC Surgery Medical Anecdotal
SA A Un D SD
Reporting (MAR)
C
The insights and learning acquired through MAR can
15
supplement or complement the guidelines derived
from conventional evidence-medicine methodology in
patient care.
MAR-initiated practice guidelines such as how to deal 15
with indigent patients, irrational patients,
conflict in management with medical colleagues, etc.
can facilitate training of residents in developing their
relational competency and in their day-to-day
management of patients.
MAR is a form of narrative medicine defined as
15
medicine practiced with narrative competence and
marked with an understanding of these highly
complex narrative situations among doctors,
patients, colleagues, and the public. (Dr. Rita Charon
of Columbian University)
Through the sharing of MAR, I can help my
15
colleagues improve on their patient care.
Through the MAR, I have improved on my patient
care as a whole.
15
14
106
2.
3.
4.
15
14
For terminal patients who undergo the process of denial, anger, guilt and
eventually, acceptance in the course of their illness, surgeons must realize
where their role as a doctor ends and where their role as a friend begins.
15
Appendix 4
Feedback on the MAR by 15 Surgical Residents in 2006
Reactions to 29 Statements
Key: SA Strongly agree; A Agree; UnC Uncertain; D Disagree; SD
Strongly Disagree
Statements on OMMC Surgery Medical Anecdotal
SA A Un D SD
Reporting (MAR)
C
The MAR is a form of learning through reflection.
15
Through the MAR, I can reflect on significant insights 15
derived from patient encounters, acquire learning, and
share them with my colleagues.
Through the MAR, I was able to experience and fully
15
grasp the concept of learning through reflection.
Through the MAR, I have developed the habit to put
14
1
importance on all aspects of physician-patient
biopsychosocial interaction and to analyze them for
insights and my continuous learning.
Since 2001, when I became the Chairman of the Department of Surgery of
Ospital ng Maynila Medical Center, I have been putting emphasis on the
development of a holistic physician among the surgical residents. This is
one of the objectives of the Medical Anecdotal Reports (MAR).
In this MAR, one can see several elements of a holistic physician
performed by Dr. Turingan. She was treating her patient comprehensively
with surgery and chemotherapy. She was not only treating her patient but
was also managing the patients family. She was serving not only as a
biopsychosocial health counselor for her patient but also as a life coach.
Link to Reporters Original MAR:
http://medicalanecdotalreportsvol1.wordpress.com/2013/06/19/
hzturingans-mar-04-3-wholistic-surgeon
16
15
15
105
15
14
15
15
Appendix 3
External Anecdotal Feedback on the MAR in 2005
Convey to Dr. Guerra that I was impressed and liked very much his
anecdote Beyond Hospital Walls. It is very true that good patient care
transcends hospital walls!! His article coincides perfectly with what I have
always been teaching my students and residents on the ethical values of
personalized patient care. Unfortunately, today, as I saw it in our own
PGH, patient care by some of our doctors has become too mechanical and
the human touch is LOST. I hope more residents will read Dr. Guerras
article and again. Kudos to you for stimulating your residents to come up
with much needed and thought provoking anecdotes like Dr. Guerras.
Antonio Limson, MD
General Surgeon
March 1, 2005
I appreciate very much the anecdote submitted by Dr. R. Chan. It
distinctly shows her unprejudiced attention to details and true compassion
and concern for a patient whether a law breaker or any ordinary patient. I
am extremely hopeful that there will be more doctors like her. May her
tribe increase. My hats off to her. KUDOS to Dr. R. Chan!
Antonio Limson, MD
General Surgeon
May 23, 2005
Thank you for writing to us. Your short e-mail surely tells us that there are
certainly a lot of heroes in the medical profession working quietly to
promote and retain the special values of caring and compassion. I visited
the link that you shared with us, and based on the project write-up, I am
confident, you must have touched a lot of physicians and their patients in
some inspiring way through the insights gained from the reports.
Susan EBL Enriquez
National Coordinator Joy of Caring Advocacy, Biomedis, Inc.
2005
104
17
BELIEVE = that this can be done. We can break this bad tradition, a
vision that someday, no Filipino child will not have to face the agony of a
painful circumcision, of being laughed or ridiculed upon.
PERSIST = keep the campaign going, even after residency, at home,
with friends, anywhere. Certain groups may laugh at the thought for
now. We ourselves may be laughed at by even entertaining the idea. But
we have to move on, make a firm stand, or to stand up again if we fall.
ACCOUNTABILITY = we are responsible for each other, reinforcing
and encouraging each other.
The Philippines have many bad traditions. To break these will take
several generations to change but everything must start from within, from
each Filipino.
Each of us has a bad habit, the question is: do we want to break it or not.
If there is a bad habit a person wants to break, follow these steps:
identify, have discipline, believe, persist, and ask for help. And it does
not happen overnight.
ROJOSONs INSIGHT (TPORs):
How can physicians help promote good traditions and habits and
break bad traditions and habits in the Philippines?
Tradition as defined in Merriam-Webster Dictionary is a way of thinking,
behaving or doing something that has been used by the people in a
particular group, family, society, etc., for a long time. Habit is defined in
Merriam-Webster Dictionary as a usual way of behaving; something that
a person does often in a regular or repeated way.
Tradition and habit are almost similar. This is the reason why Dr. Pingul
considered them together. Both have something in common - a regular
performance of a certain behavior. They differ in that in tradition, the
regular behavior is seen or done in or by a group of people whereas in
habit, it is in seen or done in or by an individual. The moment a group of
individuals in a certain locality are doing something as a habit, that habit
may turn out to be a tradition.
Appendix 3
External Anecdotal Feedback on the MAR in 2005
I could not help but feel for the emotional burden that Dr Hazel went
through, to say the least. Because she was only a first year resident then, she
had to follow what was the order. I will not make any criticisms of the
hospital and departmental policy but I believe we should always respect and
uphold ones basic right to refuse a procedure, most of all in death. If we
allow patients to refuse blood transfusions because of their religious beliefs
even if this may mean the demise of our patients, then we must respect
ones religious belief when it comes to, the least of all, an autopsy. If this
was already a Stage IV Gastric CA, would the autopsy have contributed
much to how we would manage a similar case in the future? Or was the
procedure an academic exercise? The pain of losing a loved one was too
heavy a burden to carry for the husband. I also understand why he did what
he did.
The anecdotes on the ileal perforation and Dr. Turingans advanced breast
ca, again focus on personalized and complete patient care and religious
follow up care. This is what we have been trying to teach our residents, and
I hope more and more people will read these articles. Why not compile all
of these anecdotes and make a book. It will serve a lot for young surgeons.
The message of Dr. B. Devesa on family affairs is very timely. DONT
FORGET YOUR FAMILY, even how busy you are. Marc is becoming
guilty of this, he sees us only once in three weeks, claiming hes always tied
up with work. I believe no matter how engaged one is in work, one will
always find the time for certain obligations, like the family!!. Commend
your residents for their excellent and timely contributions.
Antonio Limson, MD
General Surgeon
March 1, 2005
Tradition and habit may be good or bad. They are considered bad
if they are not desirable for one reason or another. On the other hand,
18
103
Appendix 3
External Anecdotal Feedback on the MAR in 2005
I am touched by your efforts to make your residents so aware of their deeper
emotional reactions to the complex situations they are in and the wonderful
people they come in contact with. More so to find beauty in the midst of
destruction, misery and suffering. The practice of medicine, surgical and
non surgical, is a dangerous ground for doctors as it is a field that can make
one feel so powerful, dominant, critical and insensitive to self and others. I
feel embarrassed that you the surgeon has done a sensitivity program
while I have not done my bit to contribute to make our work more humane
and meaningful to others but more so to ourselves. You are an inspiration.
Thank you. You deserve the accolades and recognition.
Connie Salazar-Aleta, MD
Psychiatrist
Feb 16. 2005
Hi! I rarely open my email. Just got to read your anecdotal reports. Kudos!
Its something even we in the field of Psychiatry dont even do. I might just
do that with the psych residents. Thanks for the heart & the inspiration.
Laureen Conanan, MD
Psychiatrist
April 25, 2005
Thank you, Sir, for allowing us to hear the anecdotal reports of your
residents. It gives us also opportunities to re-live our surgical residency
days, to say the least. May we have the kind of humane and compassionate
doctors and surgeons that you are trying to mold, I hopefully wish, fill up
our world.
Randy Abdullah, MD
March 25, 2005
I read the interesting and touching Anecdote of Dr. Rommel de Leon. I
admire his patience and understanding and the incident reminded me of my
days as a young PGH resident assigned to the ER. I met the same
MAKULIT individuals, and yes, parents, too, I just cant recall if I then
demonstrated the same degree of patience as Rommel. Tell him I salute him
and I have to admire you for stimulating your residents to share their
experiences, pleasant or otherwise, or on tragic occasions like the Tsunami
Story of one of your residents, sorry I cant recall his name.
Antonio Limson, MD
General Surgeon
Feb 23, 2005
102
they are considered good if they are considered desirable for one reason
or another. Desirable is in terms of being worthy of doing or should be
done as it is pleasing; useful; beneficial; valid; cost-effective; etc.
Undesirable is in terms of not worthy of doing or should not be done as
it is not pleasing; not useful; harmful; not valid; not cost-effective; etc.
In the health arena, there are good and bad traditions and habits. There
are good traditions and habits that need to be promoted and sustained.
There are bad traditions and habits that need to be broken down and
changed.
Examples of good traditions and habits in the health arena are the
following:
1. Being a compassionate physician.
2. Establish rapport with patients and relatives during medical
management.
3. Washing hands before seeing a patient.
4. Eating balanced diet.
5. Doing exercises regularly.
Examples of bad traditions and habits in the health arena are the
following:
1. Doing routine circumcision in males without medical
indications.
2. Swallowing santol seeds.
3. Routinely taking synthetic vitamins.
4. Routinely administering antibiotics for all types of
operations including clean ones.
5. Applying antibiotic powder in open wounds.
How can physicians help promote good traditions and habits and
break bad traditions and habits in the Philippines?
First of all, they have to identify which are good and which are bad
traditions and habits in the Philippines.
They have to do an in-depth analysis of concerned traditions and habits in
terms of benefit, risk, cost, and availability factors. They have to analyze
the pros and cons. They have to check the effectiveness and usefulness of
a behavior or practice and the risk of side-effects and harm. After which,
they make a decision.
19
Once there is a decision, the physicians should do advocacy work for those
to be promoted and sustained and those to be broken down and changed.
The most practical strategy in doing advocacy work is continuous
education.
My current personal practice is to do the continuous education through the
Internet and social media. Below are some of my advocacies in terms of
breaking down bad traditions and habits.
1. No to routine circumcision (https://xtulepinoy.wordpress.com)
2. Beware of santol seed swallowing (http://santolseed.tripod.com)
3. Advocacy against unnecessary operations, procedures, and health
practices (http://x-unnec-med-practice.tripod.com)
Link to Reporters Original MAR:
http://medicalanecdotalreportsvol1.wordpress.com/2013/10/09/jmpingulsmar-04-02-breaking-bad-traditions-and-breaking-bad-habits
20
Appendix 2
Department of Surgery
Ospital ng Maynila Medical Center
List of Surgical Resident Staff who have written MARs
from 2004 to 2013
Hazel Z. Turingan, MD
Marlou O. Padua, MD
Redomir P. Roque, MD
Rubi Ann Claire D. Chan, MD
Derrick Chua, MD
Janix M. De Guzman, MD
Maria Cecilia T. Leyson, MD
Oliver S. Leyson, MD
Jose Mario Amado M. Pingul, MD
Nolan O. Aludino, MD
Martin Joseph S. Cabahug, MD
Rommel Q. De Leon, MD
Roderick S. Mujer, MD
Jeffy Guerra, MD
Trisha Daughterty Medina, MD
Benjamin C. Deveza, MD
Harvey Balacuting, MD
Edwin Estonilo, MD
Roberto Gonzales, MD
Michelle Galang, MD
Jonathan Malabanan, MD
Michael Angelo Sunaz, MD
Edelweiz Velasquez, MD
Allan Gabriel, MD
101
Appendix 1
Medical Anecdotal Reporting as a Teaching-Learning Activity in a
Clinical Department in the Philippines
Nolan Aludino, MD
Reynaldo O. Joson, MD, MHPEd, MS Surg.
(Presented in the 4th Asia-Pacific Conference on Problem-based Learning
in Health Sciences in September of 2004)
Abstract
Up to this time, medical anecdotal reporting is used solely in research
methodology discussion and is usually frowned upon when invoked in
patient management. This paper reports on the use of medical anecdotal
reporting (MAR) as a teaching-learning activity in the Department of
Surgery of Ospital ng Maynila Medical Center. MAR is operationally
defined as a brief written report on an actual medical event that involves
an actual patient seen by a trainee. The medical observation must have an
impact on the trainee in terms of insight gained and which the reporter
thinks is worth sharing with colleagues. The insight may come in three
forms, namely: a discovery; a stimulus for investigation and research; and
a reinforcement or validation of previously held philosophy and principles.
Each clinical trainee was required to submit at least one brief MAR a
month, posted in the Departments group email and trainees online
journal and presented in the Departments conference. Formative
evaluation of the MAR showed that it could be used as an evaluation tool
by the faculty as well as a meaningful learning activity by the trainees.
Through the MAR, the trainees gained insights or learning through
reflection and analysis of the event. They experienced all aspects of
physician-patient biopsychosocial interaction. They were given
opportunities to be expressive and to polish their written communication
skills. Through the MAR, the faculty was able to observe and evaluate the
cognitive and affective levels of competency of the trainees.
The full paper can be seen in:
https://sites.google.com/site/medicalanecdotalreports/mar-as-a-teachinglearning-activity-in-ommc-surgery
100
21
I thought I have seen enough until I saw that patient. It was a learning
experience for me. I realized that in our profession, there is always
something new and interesting to learn about. I would say that this is one of
them. We must constantly have that zest for knowledge because in
medicine.. ITS NEVER ENOUGH. It is always a continuous learning
process.
ROJOSONs INSIGHT (TPORs):
Is there such a thing as enough in the learning of medicine?
Medicine is a profession that has no finite amount of contents, knowledge
and skill that have to be learned by the practitioner. There are several
reasons for this. First, the field of medicine is so vast. Second, there are still
a lot of uncertainties in the science. Third, it is an inexact science. This
means that in medicine, exact explanation of causes of diseases, concise
diagnosis and absolute predictability of outcome of treatment are difficult, if
not impossible! Fourth, the mindset and behaviour of human beings greatly
influence the type and extent of diseases and injuries that patients will
present to physicians. With infinite number of mindset and behaviour in the
human population, one would expect a corresponding infinite number of
types and different extents of diseases and injuries in medical practice.
In the MAR of Dr. Deveza, although the circumstance leading to the skin of
the patients penis accidentally being caught by the zipper of his pant was
not divulged, for certain, a behaviour caused this unusual medical event,
uncommonly seen in medical practice. Thus, something new for Dr.
Deveza.
For all the reasons cited above, there could be more, there is no such thing as
enough in the learning of medicine! As an offshoot of it is never
enough, learning medicine is a lifetime continuous learning. It ends only
when the physician has decided not to become a learned physician
anymore or when death or unwanted disability forces him to stop.
Postscript:
Self-directed learning is the habit that must be acquired and possessed by all
physicians who are required to do lifetime continuous learning in order to
maintain their professional competency.
22
99
Epilogue
As mentioned in the Preface, I started actively developing this book in June
2013 using a framework that approximates the key processes of Medical
Anecdotal Report. By today, October 29, 2013, five months after, I am
done with appending my insights or thoughts, perceptions, opinions and
recommendations (TPORs) to 23 Medical Anecdotal Reports (MARs)
written by the surgical residents of OMMC Surg. In my original plan, as
seen in the Preface, I said I will put 15 to 20 MARs per volume. I decided
to put in 25, at least in this first volume, as there are still a lot of MARs to
cover, over 1400 MARs written from 2004 to 2013. In subsequent
volumes, I hope I can maintain the number of MARs at 25 per publication.
98
23
I honestly do not remember the day that I saw the patient nor the
circumstances surrounding my working impression at that time. There
may or there may not have been a palpable breast mass. I may have
overlooked something obvious.
My encounter with this patient shows that I still have much to learn. Each
and every patient we see is a learning experience. We must make the most
out of each patient seen. Treat them as best as we can and thank them for
allowing us to learn from them.
ROJOSONs INSIGHT (TPORs):
What is the benefit of learning medicine the hard way? What is the
reality in learning medicine? Can learning medicine the hard way be
avoided?
24
97
Dr. Nolan Aludino entitled his MAR as Learning the Hard Way. This
phrase means learning something by experience, especially by an
unpleasant experience. In the context of his MAR, Dr. Aludino was
referring to learning medicine by an unpleasant experience, in this case,
having a patient confronting him for allegedly missing a breast mass or
early breast cancer in his physical examination.
96
25
26
95
INSIGHT:
Sometimes, we find ourselves hesitant to help strangers, most of the time,
thinking that they are taking advantages of us. Human nature protects us
from being pawed upon by our scheming race that is survival of the
fittest. We often belie our conviction towards our first impression,
without much consideration that our initial judgment maybe wrong. The
father has shown me that humankind the epitome of the word, still
exists. We have helped each other in our own ways. I have helped him in
monetary kind and he has helped me opened up my trust and better
understanding of the people around me. He has brought honor to himself
by paying me back, and indirectly honored me by helping him.
These people showed me that no matter how tough life could be, with
passion and genuine concern as the main drive, everything could be
smoothened out and resolved. We should remember that a physician does
not care solely for the physically ill, but also to heal the emotionally
crippled.
ROJOSONs INSIGHT (TPORs):
INSIGHT:
This is not an isolated case. We encountered a lot of these patients coming to
us asking for extension of their medical certificate. Depending on the
patients condition, an extension on the duration of illness could be given.
Caring is our business and this is one way of showing our care and helping
our patients, but in this case I dont think I will be fair to the employer and to
SSS who will pay this patient if I tolerate this kind of act.
94
27
Postscript:
28
93
3.
92
In the MAR of Dr. Mujer, after making sure that his act of compassion
will not fall into the wrong hands, he decided to give it wholeheartedly
without expecting a payback. However, he was surprised to get a payback
of the money he lent. This MAR shows that there are true indigent
patients, and more than that, there are indigent patients with great sense of
gratitude and even honor.
I have a MAR in 2013 with the same theme as that of Dr. Mujer. I titled it
A Patient of Honor to parallel Dr. Mujers Man of Honor. I suggest
this as further reading. Here is the link:
http://medicalanecdotalreportsvol1.wordpress.com/2013/10/03/rojosonsmar-patient-of-honor/
The MAR is also published in this book.
Link to Reporters Original MAR:
http://medicalanecdotalreportsvol1.wordpress.com/2013/10/02/rjmujersmar-06-04-man-of-honor/
29
1.
NARRATION:
In one of my clinic days in July 2013, when I was just initiating a
conversation with a female patient seated across my desk, I got a very
extraordinary answer to my usual opening consultation question of what
can I do for you? The answers that I have been accustomed to hearing are
health concerns such as pain here and there; mass here and there; goiter;
gallbladder stones; etc. The extraordinary answer that I got ran like this in
English, Doctor, I am here to pay my balance on your professional fee. I
was very much surprised and at the same time amused at what I heard. My
instant response was to look at the patient very closely and tried to recall
who she was; what medical services I had given her and when; and the
circumstances behind the balance she was mentioning in the professional
fee. Unable to recall, I asked and got the necessary information from her.
Eighteen (18) years ago in 1997, LMJ Clemente was 16 years old when I
operated on her thyroid nodule in the Philippine General Hospital. I
assumed she had a balance on my professional fee which I had let it passed
and had totally forgotten until that one day in July 2013, when she came
back to my clinic to settle. When she initially asked me how much she owed
me, I told her honestly, I dont know as I could not remember anything
anymore regarding my professional fee. She then mentioned the amount that
she owed me.
LMJ Clemente is now 34 years old, working and earning. Obviously,
during the past 18 years, she had not forgotten me and she had a resolve to
settle her balance in my professional fee. A week later, she emailed these
notes to me: This is LMJ Clemente, your patient long time ago. I had my
check up last week and paid my remaining balance. Thank you so much,
doc, for saving my life. Pasensya na po at natagalan before ako nakabalik
at nakapagbayad ng remaining balance. Muli, maraming salamat po. (Sorry
for the long delay in my return and paying the balance. Again, thank you
very much.)
INSIGHT:
The following have been my policies and procedures on professional fees
30
2.
91
INSIGHT:
Unlike other professions, the practice of medicine, particularly surgery, has
no room for errors of judgement or decision making. The fragility of human
life is such that it leaves very little room for miscalculations. One
miscalculated move might lead to a complicated case, a medicolegal case or
ultimately, a dead patient.
As to my case, I was so lucky that early in my practice, I was exposed and
reminded to be more cautious in my operations. I suggest that, as much as
possible avoid putting sponges under the peritoneum while closing it.
Secondly, always remind the circulating nurse to have the sponges, needles
and instruments counted prior to abdominal closure as well as prior to
unscrubbing. Thirdly, lets get back to the practice of using 16x16 inch
sponges, instead of 8x16 inch ones for abdominal surgery.
90
31
NARRATION:
I was at the Outpatient Department (OPD) when a 31-year-old male
brought me a referral letter from a fellow doctor in Cavite. The patient was
referred for evaluation of an anterior neck mass. After taking my history
and physical examination, my assessment was that the mass was 5 cm in its
largest diameter, solid, firm, no redness, non-tender, located on the right
anterior of the neck and which moved with swallowing. Afterwards, the
patient handed to me his laboratory examinations that included an
ultrasound (non-invasive procedure that involves exposing part of the body
to high-frequency sound waves to produce pictures of the inside of the
body) and a fine needle aspiration biopsy (FNAB - a diagnostic procedure
used to investigate superficial lumps or masses using a thin, hollow needle
that is inserted into the mass for sampling of cells) which revealed a benign
colloid condition.
Immediately, I referred the patient to our chief resident and informed him
of my consideration of a colloid adenomatous nodule (CAN: benign, noncancerous growth of thyroid tissue). We then explained to the patient the
need for surgery. We also explained both the benefits and risks of surgery.
The patient understood our explanations. However, he informed us that he
was not financially capable for his operation and he asked me for help. He
further narrated that he was previously employed as a regular employee
about a year ago in a restaurant, but because of his condition, he was
advised to stop on his job. After we heard his story, we told him that we
might be able to help him with our Indigent Patient Help Program (a
program of the Ospital ng Maynila Medical Center Department of Surgery
that provides health care support needs such as free surgical supplies and
anaesthetics to indigent patients). The patient was very happy hearing the
good news. After his medical and anaesthesiology evaluation, the patient
was then scheduled for thyroid surgery. We immediately prepared the
surgical and anaesthetic needs of our patient and we were glad that a group
of doctors helped us by providing financial support for the anaesthetic
needs of our patient. The patient underwent the operation and was
discharged on the third post-operative day.
32
89
INSIGHT:
Summarizing Points:
1. The problem-solver and decision-maker in situations where
the clinical and laboratory diagnoses do not jibe is the
physician-clinician.
2. Several recommendations are offered on how to reconcile
conflicting clinical and laboratory diagnoses and these
basically consist of review, repeat, and performance of
another diagnostic procedure if necessary.
3. A deciding factor in accepting a laboratory diagnosis which
does not jibe with the clinical diagnosis is to determine
whether the data from the interview and physical examination
can support the laboratory diagnosis.
Here are my TPORs on Indigent Patient Incidents which by and large have
been the driving factors for the Indigent Patient Help Program of OMMC
Department of Surgery:
88
Here in our institution, we often attend to patients who are not financially
capable of supporting their health needs. Luckily, our department created a
program that helps support indigent patients to undergo surgical procedures
despite their financial incapability. Through this program, we once again
were able to make a change in another persons life, the patient mentioned
in the narration. We were able to bring back the patients hope to get back
to his previous career.
ROJOSONs INSIGHT (TPORs):
What is the Indigent Patient Help Program of the Department of Surgery
of Ospital ng Maynila Medical Center?
1.
2.
33
3.
4.
5.
2.
3.
34
87
should also be kept in mind that though helpful, some of these procedures,
e.g. ultrasonography, are operator-dependent. Therefore, we should always
correlate the results of the diagnostic procedures to the clinical findings.
As my teacher in medical school once told us, we should treat the patient,
not the labs (laboratory results).
ROJOSONs INSIGHT (TPORs):
What to do when clinical and laboratory diagnoses do not jibe with each
other?
There are three terms or phrases in the MAR of Dr. Fonte that I feel I
should make clarifications and operational definitions on to facilitate my
TPORs.
Results of clinical examinations refers to the assessment or diagnosis
made by a physician-clinician based on the data he/she obtained after
conducting an interview (or history, by medical parlance) and doing a
physical examination on the patient. (Physician-clinicians are those
physicians who are primarily and directly involved in the management of
the patients, those who call the shots.) I will use clinical diagnosis to
refer to results of clinical examinations.
Results of diagnostic examinations refers to the assessment or diagnosis
that is derived from the performance of a procedure other than a physical
examination. The results are usually in the forms of the numerical values
generated by machines or the interpretations of physician-diagnosticians.
Dr. Fonte also used the phrase paraclinical diagnostic procedures. This
is the same as diagnostic examinations. Examples of paraclinical
diagnostic procedures are blood tests, urine tests, x-rays, ultrasound
studies, etc. I will use laboratory diagnosis to refer to results of the
diagnostic examinations.
Conflicting results mean the clinical diagnosis and the laboratory
diagnosis do not jibe with each other.
In the course of management of patients, physician-clinicians frequently
encounter situations wherein the clinical diagnosis and laboratory
diagnosis do not jibe. What should the physician-clinicians do in such a
situation? Here are my general recommendations:
1.
86
35
NARRATION:
NARRATION:
A 49-year-old male was brought to our emergency room due to a stab wound
on the 6th intercostal space, left anterior axillary line. His vital signs were
normal and stable, and he was not in respiratory distress. On auscultation,
there was a slightly decreased breath sound on the base of the ipsilateral lung
field. Given these findings, we did chest radiography. It revealed
hemothorax for which a closed tube thoracostomy was done. We were able
to evacuate 400 ml of blood. After an hour, there was no further drainage of
blood noted on the thoracostomy bottle. We thought we already addressed
all of the patients problems. But an hour later, the patient started
complaining of abdominal pain. Physical examination revealed a slightly
distended abdomen with tenderness on the upper quadrants. We requested
for a Focused Abdominal Sonography for Trauma (FAST). The sonologist
interpreted it as a normal sonogram. As much as we wanted to believe that
the patient had a non-surgical abdomen based on the result of the FAST,
clinical judgment got the better of us. We decided to operate on the patient.
True enough, there were diaphragmatic injury, gastric perforation and
hemoperitoneum. The said problems were adequately addressed, and after
about a week of hospitalization the patient was discharged.
INSIGHT:
One day, I was asked by a nurse in the ward: Why do you do it? I looked
away for a moment and answered with a light voice: Kawawa naman
siya. (He is pitiful.) The nurses and the medical clerks then gave me a look
36
85
The other dos and donts are given by Dr. Velasquez in her beautiful down
-to-earth insight.
(Note: Dr. Velasquez was a second-year surgical resident in 2008 when she
wrote this MAR. With her MAR, I appreciated her early learning on how
to use professionalism, ethics, and humility to respond to a situation in
which there is differing clinical diagnosis from another physician.)
Link to Reporters Original MAR:
http://medicalanecdotalreportsvol1.wordpress.com/2013/10/01/
ezvelasquezs-mar-08-01-explaining-a-colleagues-differing-diagnosis/
84
37
38
83
82
39
NARRATION:
INSIGHT:
40
81
Among the patients whom I gave my personal number to, I was able to see
the advantages in this particular patient.
1.
3.
2.
Over the past 2 years, since June 2011, when I established my Facebook, I
publicized my cellphone number. I have patients as friends in my
Facebook.
80
41
Just like anything in life, there are pros and cons; advantages and
42
patient and his relatives these things that they expressed how they finally
understood why the procedure had to be done and some would even have
second thoughts about the consent they gave after having heard the risks
involved. In the latter situation, I would give them time to talk it over again
among themselves and most, if not all of the time, they would decide to go
on with the procedure because it has been made clear to them as to why it
has to be done.
Most of the time, these procedures go on smoothly and the patient or the
patients relatives never fail to show their gratitude even long after the
procedure has been done and I just happen to come across them around the
hospital during their follow-ups. However, there are also times when
complications like bleeding arise. But in such cases, I am not met with any
hostility from the patients relatives since they have been primed as to what
could happen.
ROJOSONs INSIGHT (TPORs):
What is informed consent in medical management? How should an
informed consent be secured so that it fulfills the legal requirements?
Dr. Sunaz appreciated the importance of an informed consent in this MAR.
What is informed consent in medical management?
It is a formal consent of a patient or his legal guardian to a medical
procedure after the nature, benefits, risks and costs are explained by a
physician. For the informed consent to be valid and effective, the
explanation must be complete and clearly understood and there must be a
formal attestation of consent to the medical procedure by the patient or his
guardian. The consent can be done through a manual signature, thumb mark
or other legally accepted means.
An informed consent prior to a medical procedure is one of the universal
rights of patients. Thus, an informed consent must be secured before a
medical procedure is done.
What are the advantages of a properly done informed consent? With the
medical procedure properly explained and understood and the patient
consenting, the risk of misunderstanding that could lead to
79
Just as she was saying these, I figured out who she was talking about and I
immediately recognized her face. She was the mother of a 23-year-old male
patient referred to our department for chest tube thoracostomy (inserting a
tube into a chest cavity) due pneumothorax (air in the chest cavity). My
junior and I did the procedure the night before after explaining its
indications as well as the risks involved. It was only then that the patient
and his relatives seemed to realize why the procedure was needed and what
dangers would be involved. Thank God the procedure was uneventful and
the patient eventually recovered and was sent home.
INSIGHT:
In all my years as a surgery resident, Ive received numerous referrals from
other departments for certain surgical bedside procedures. Some of these
referrals are follow-ups and I am usually informed that the materials needed
and the consent for the procedure have already been secured.
Instead of immediately performing the procedure because consent has
already been secured, I take time to again talk to the patient and the
patients relatives and explain to the them the indications for the procedure
as well as the risks involved. This has been a habit Ive tried to instill on my
juniors whenever they accompany me during such procedures.
There were many instances wherein it was only after explaining to the
78
43
44
and quickly adjust to people and situations. But sometimes, we tend to lose
our patience especially to annoying patients and /or their relatives.
Therefore, it is a good practice to always be calm and professional when
talking to people even if they are annoying to avoid further conflict. Also,
our profession warrants us to always be the bigger man and understand the
relatives concern for her patient. Therefore being doctors, we should always
keep our cool and be professional as possible.
ROJOSONs INSIGHT (TPORs):
What should physicians do when they encounter patients and relatives who
have different expectations on what they should be doing?
An issue that I picked up from the Dr. Agudas MAR is what to do when
physicians encounter patients and relatives who have different, not to say,
unreasonable expectations of what they should be doing, especially, in
emergency situations and in the emergency room. There is a tendency for
physicians to be annoyed by such patients and relatives. So, what should
they do?
The following are my TPORs (thoughts, perceptions, opinions, and
recommendations) on this challenge:
1.
2.
3.
4.
5.
77
76
an active bleeding on upper lobe of the left lung, we clamped the left
hilum. Then, we did an intrathoracic cardiac massage.
Despite everything, he succumbed to death right on the operating table
due to transected left pulmonary vessels and bronchus. The hardest part,
thereafter, was informing the relatives that patient died on the day of his
birthday.
INSIGHT:
Life in the emergency room is full of action, suspense, drama, and
sometimes comes in a package. I had the chance to be in this situation
and the experience overwhelmed me. Given the option, I will not like to
be put in the same position again. But do we really have the choice?
Instead of avoiding what we cannot avoid, it is better to be prepared.
Keep always in mind the ABCs of emergency and trauma. Decisionmaking plays a big difference. It either makes or breaks. Know when to
seek help.
Equally important, be wary of the relatives or somebody concerned and
find time to talk. Even a short conversation matters and they will surely
appreciate it. I know it is kind of hard for a surgeon coming out in the
operating room to tell the relatives sorry, thats the best that we can do
but I had to do it.
With that, I invoke the prayer of St. Francis, grant that I may not so
much seek to be consoled as to console.
ROJOSONs INSIGHT (TPORs):
To console or to be consoled?
Dr. Janix de Guzmans titled his MAR as Coincidence. I changed it to
Coincidence of Unfortunate Events. Coincidence is defined as a
sequence of events that although accidental seems to have been planned
or arranged. There are two areas of seeming coincidence in Dr. de
Guzmans MAR. One is the coincidence of the birthday and the fatal
stabbing incident of the patient on his birthday. It appears that the two
events were destined to happen on the same day. The second coincidence
45
is the interconnection of the sadness for the relatives of the patient who
died and that of the surgeon (Dr. de Guzman) because he was not able to
save the life of the patient despite his best efforts.
of action! Make her realize the gravity of her condition and explain the
urgency of your plan of action. Take time to talk to her relatives. Their
cooperation is vital to the success of any plan and management.
Physicians are human beings who always have in their mind the inherent
duty to save life. Once frustrated in their attempts to save life, they feel
sad and at times, depressed. If this sadness is not controlled, they either
quit medicine totally or they change or go to a subspecialty in which the
chances of encountering dead patients in their hands are less. Going on
duty at the emergency room by itself is stressful. Not being able to save
the life of a patient is even more stressful, more so, if the patient dies on
his birthday. After consoling the relatives of his patient, Dr. de Guzman
consoled himself with the beautiful prayer of St. Francis Assisi - grant
that I may not so much seek to be consoled as to console. This keeps
him going as a surgeon. There are other forms of stress debriefing for
physicians. The most powerful is to talk openly to medical colleagues.
The other way is by ventilating sentiments through a MAR like this.
Link to Reporters Original MAR:
http://medicalanecdotalreportsvol1.wordpress.com/2013/10/07/
jmdeguzmans-mar-04-08-coincidence
46
75
NARRATION:
NARRATION:
LC, a 64-year-old female was diagnosed to have a diabetic foot, right. From
the moment I saw her, I knew that she would be a difficult patient, difficult
in the sense that she could not accept her present state.
When I saw the wound, I knew that she had to be admitted. She was
frightened by the idea of another admission. I asked her why she was
afraid. She told me Doctor, ayaw ko nang maputulan ng hita! (Doctor, I
dont want my thigh to be amputated!) I looked at her and saw the fright in
her eyes. I held her hands and told her Lola, magpa-admit po kayo at
gagawin ko lahat para di maputol ang hita nyo! (Grandma, have yourself
admitted to the hospital and I will do everything not to have your thigh
amputated!)
I was walking back and forth in the Operating Room (OR). There were
two ongoing cases and those were the last for that operation day. I was
making sure that everything needed for the operations were provided. I
also took time to take a look at the patients in the Post-Anesthesia Care
Unit (PACU). There were three patients in the room that afternoon. All of
them were stable, but I was particularly monitoring a 47-year-old patient
who just underwent total thyroidectomy [surgical removal of the thyroid
gland]. There was no presence of an expanding hematoma in the 1st hour
after the operation. The Jackson-Pratt (JP) drain [medical device that is
commonly used as a post-operative drain for collecting bodily fluids from
surgical sites] output was 60 cc, which was bloody. A few minutes after,
my senior, who was the surgeon for that case scrubbed in and stayed at the
PACU. He was also continuously monitoring the patient. I could see that
his eyes almost shut to his tiredness, but he made sure that he was still
keeping his eye on the patient. I told him to take a rest and that I will be in
-charge of the patient, but he stayed. On the 2nd hour after the operation,
we noted that there was an expanding hematoma and the JP drain output
already amounted to 230 cc and was bloody. My senior immediately asked
me to inform the anesthesiologist that we are going to explore on the
patient. The patient was rushed back to the Operating Room. Upon
exploration, there was a bleeding artery which was causing the hematoma
and increased output from the drain. The bleeder was ligated and the
operation went on smoothly. Before we left, my senior properly endorsed
the patient to the team-on-duty. The next day, he carefully monitored the
patient until the day that the patient was discharged. The patient was
discharged with improved condition.
INSIGHT:
INSIGHT:
This is just one of the many instances that I learned a lesson from my
senior, even with simple events that transpired over the day. In this case, I
was able to pick three (3) values that a surgeon should have. Being with
my senior for almost twelve (12) months now, Ive always admired his
passion about his work. No matter how tired he was, he would always see
to it that the patients welfare was the first priority. He wouldnt mind of
Upon assessment, the plan was to do a Below the Knee Amputation (BKA).
I explained the procedure and the urgency of the operation to her and her
relatives. The procedure went well and the patient kept on asking me when
she would be discharged. Prior to discharge, I reminded her to take her
medications. I emphasized to her to remember that she did not have a right
leg anymore. I told her this as a precautionary measure to prevent having
accidents. Her relatives asked for my cellphone number and seeing no
harm to their request, I gave them my number.
After few days, I received a text message from one of her sons informing
me that she accidentally fell and hit her amputated leg on the floor and the
wound was gaping. I told him to bring the patient to the hospital so I could
evaluate her.
This patient needs special attention. Take time to explain each move or plan
74
47
himself being tired, not being able to come to important events of his family
or friends, not being able to go home after several days of being on duty, or
him being alone in doing his job. I would often see him beside his postoperative patients and if only he was not in his uniform, you would even
think of him as the patients family taking care of the patient.
Another value was his humility. I could remember the time when he was
doing thyroidectomy and after minutes of trying to control bleeding in that
operation, he finally humbled himself and asked help from his consultant. In
this case, he was humble enough to admit that the patient had a postoperative complication. As taught, Dont be afraid to report your
complications post-operatively. Its not about you being scolded in
conferences, but its for the patient to be alive and recovered. This value of
humility that my senior has is likened to a bamboo tree. The higher he goes,
the more that he bends back.
Lastly, he imparted to all of us the value of responsibility. The moment we
decided to become doctors was also the moment that our responsibility to
other people started. We are not just doctors in this hospital. We are the
instruments of healing to our fellowmen, the sons/daughters of our
consultants, the members of this department, a colleague, a teacher and a
friend to all. Hence, our responsibility does not stop on being a doctor. We
have to serve our fellowmen, obey our seniors (consultants), be a team
player in the department, be a helpful colleague and build good relationships
with every person in this hospital. My senior was and he was admired for
being such. And now that there are just a few weeks left, I am very thankful
of everything that he taught and imparted to us. To me, he would be a
surgeon, a senior, worthy of emulation.
48
73
2.
3.
4.
As I have said, everything is easier said than done, even with the four
options I mentioned above. To further refine my recommendations and
facilitate actionability, I would suggest all departments of surgery and also
all hospital administrations meet with the leaders of the Jehovahs
Witnesses located in their catchment community to come out with shared
policies and procedures on what to do in situations in which there is an
issue of blood transfusion in the medical management of patients who are
Jehovahs Witnesses. On a personal note, I like to meet and to have a list
of Filipino surgeons who are members of Jehovahs Witnesses so that I
can learn from them first hand and I can call them when needed.
72
49
The acquisition and practice of core values by the surgical residents are
being evaluated using observations, Medical Anecdotal Reports, registry of
complaints, and the formal residents evaluation procedures. In December
2007, as part of continual improvement, indicators were established which
could provide more concrete evidences of achievement of the core values
by the residents. See links below.
As seen in this MAR of Dr. Siapno, acquisition and practice of core values
by the surgical residents can be evaluated. While Dr. Siapno was
appreciating the core values of her senior resident, she was also giving a
peer evaluation.
Another insight that I got from this MAR of Dr. Siapno is that while she
was appreciating the core values of her senior resident, I am optimistic she
will be practicing them also, as she said, worthy of emulation. Thus, the
MAR serves not only as an evaluating but also as a learning tool in the
acquisition of core values by the surgical residents of the OMMC
Department of Surgery.
Recommended Further Readings and References:
http://rojosonommcsurgeryfilesandnotes.wordpress.com/category/corevalues-of-ommc-surgery
Link to Reporters Original MAR:
http://medicalanecdotalreportsvol1.wordpress.com/2013/10/16/spsiapnosmar-12-10-a-senior-worthy-of-emulation
just stopped, let him decide for himself and discharge him afterwards.
Anyway, we could not be sued for letting the patient be because we are
backed up by the so called Principle of Autonomy. But at the back of our
mind, we know how he will end if he will not get the interventions he
needed. Can we take it? Can we just ignore it? We all well know we can
do more. Remember, we should not do our patient any harm. But doing
nothing is harming itself. As medical professionals, we should think of
what is best for our pateints because we know the situation better.
Persuading them is not a crime, unless collision sets in. In tough
situations like this, there comes a point where these known principles
conflict one another. So the dilemma goes on. Which of these laws should
guide us? Which should we pick? How would we weigh them to know
which fits better?
For me, it is far beyond naming laws. These laws and principles are just
there to guide us. They are provided for us to refrain from committing
mistakes of the past. What is more important is the sincere concern for the
welfare of our patient. Ethics is in the heart, not in books. If you have it, it
will transcend and will guide you to the right path and to the right
decision. Gladly, it transpired in me...in us.
ROJOSONs INSIGHT (TPORs):
What to do when patients refuse medically-indicated blood transfusion
on the basis of their religions doctrines?
Usually, if not the only one, it is the members of the religion called
Jehovahs Witnesses who will refuse blood transfusion even if medically
indicated. This is one of the many ethical challenges faced by physicians
in the practice of their profession.
As mentioned by Dr. Malabanan in his MAR, practicing ethics in
medicine is easier said than done. Taking a paper test on medical ethics is
easier than doing problem-solving and decision-making in real scenario
that is ladened with ethical issues such as what to do when patients and
their relatives refuse medically-indicated blood transfusion on the basis of
their religions doctrines.
In the scenario cited by Dr. Malabanan, assuming that the religion of the
patient and his relatives is Jehovahs Witnesses and assuming that the
planned operation is to be done on an urgent basis, as I see it (my TPORs
50
71
70
51
How do Filipino patients weigh the factors and how should they weigh
the factors in choosing hospital for their treatment?
At the moment, I have not encountered a formal and published study on
the differential weights used by Filipino patients on the mentioned factors
in choosing a hospital for their treatment. I just have to rely on my
personal experience in my more than 30 years of medical practice in the
Philippines to give my perceptions.
Likewise, I have not encountered a formal and published study advising
Filipino patients on how to choose a hospital for their treatment. Again, I
will just give my thoughts, opinions and recommendations on the
question of how should Filipino weigh the mentioned factors in choosing
hospital for their treatment.
From experience, from my perception, the trust on the attending
physician is the strongest driving factor.
Weighing trust of attending physicians against far location of hospitals
52
69
senior citizens, PWD and children. They can also give these privileges to
their parent-patients and relative-patients. In the MAR, Dr. de Castro did
this by taking time off from hospital duty to bring her mother to the
orthopedic consultant.
68
53
54
67
66
55
INSIGHT:
My grandfather once told me, while visiting Beijing in the late 60s, an
American tourist walked into a curio shop where he was also a customer.
The American was looking for a particular jewelry box to bring home to his
wife. Not understanding English, the shop owner shook his head in
perplexity. The American then tried explaining what he wanted louder. The
Chinese proprietor loudly answered back in Mandarin. In exasperation, the
American spoke slowly and pronouncing in syllables, willed the Chinese to
understand him. No such luck.
My grandfather approached the two and asked permission to translate one
query to the other and vise versa. They made a transaction and both parted
happily with their gain. The moral of the story: No matter how eloquent**
one is, if the audience does not identify with the speaker, then he might as
well be talking in thin air.
Some doctors have become so used to the medical language. At times they
forget that not everybody studies medicine. We must remember that the
purpose of acquiring and storing medical knowledge is not for ourselves but
for the patients, 90% of whom, could not differentiate a contusion from a
concussion. We are our patients translators.
Other doctors on the other hand, dont see the reason to explain things to
their patients. The patients usual comment is: Hindi naman ipinaliwanag
sa akin ng isang doctor. Basta kelangan daw akong operahan. (My doctor
did no explanation. He just said I need to be operated upon. ) Patients
need to be fully informed of the whys, whens and hows associated with any
medical-surgical therapy. We are our patients advisers.
Patients are thankful when one takes time to explain their condition and the
plan of management in dialogues that they understand. If patients understand our intent, wed be able to gain their trust which is the first step to
restoring health. It is therefore clear that through comprehensible
communication, we build better partnership with our patient.
*VEHEMENTLY (adv.) Violently; strongly; intensely
**ELOQUENT (adj.) Fluent; articulate; well-expressed
56
Every physician has had relatives and close friends asking for medical
advice or care of one sort or another. Most respond easily with a few
65
and help them so that they will live their remaining life in comfort and in
peace.
In a MAR of Dr. Hazel Turingan, (with the title of Holistic Surgeon also
published in this book), she wrote: Later, one of her daughters came back
and told me about her (mothers) deteriorating condition (breast cancer with
distant metastasis). I told her to get her mothers affairs in order as she may
not have the luxury of time. I told her to make the best out of her mothers
remaining days
(http://medicalanecdotalreportsvol1.wordpress.com/2013/06/19/hzturingans
-mar-holistic-surgeon)
Through these MARs, I am happy to see that surgical residents of OMMC
are being trained and know how to holistically manage patients who are
facing death.
Link to Reporters Original MAR:
http://medicalanecdotalreportsvol1.wordpress.com/2013/10/05/ctleysonsmar-04-07-to-face-death
64
57
Below, I like to share my preparedness plans (it goes without saying that
there is accompanying mind-conditioning when I was formulating the
plans):
NARRATION:
It was a Tuesday afternoon and I was at the Out-Patient Department doing
minor surgery. I just finished my first operation. I got a short break while
waiting for the next patient.
1.
After a while, the nurse approached me and said that the next patient was
ready. She was a 26-year-old female who had a mass on her right
breast. From my history and physical examination, my assessment was that
the mass was a Fibroadenoma. (A benign breast mass)
Before I started the operation, I explained to her my assessment. As I was
about to start the procedure, I noticed that the patient started to shiver and
tears started flowing from her eyes. I stopped and asked her why she was
crying. She told me that it was her first time to be operated on and she was
afraid of the mass that she had. Some of her friends told her that it might be a
cancer. I waited for a few minutes for her to calm down, after which I
proceeded with the operation and it went on smoothly.
I told her to bring the mass to the laboratory to be examined. Before sending
her home, I instructed her on proper wound care and advised her to follow up
after a week. Weeks after, she came back with the official result of the
examination of the mass that I took out. It was indeed Fibroadenoma.
INSIGHT:
2.
3.
4.
We get different reactions from our patients who consult us with their health
problems. It is imperative on our part to adjust to whatever personalities they
have to be able to treat them. We must also be equipped with the knowledge
and skill to be able to explain to them what they have and give them the
proper management they deserve.
ROJOSONs INSIGHT (TPORs):
How should physicians allay the fear and anxiety of patients who are about
to undergo an operation, particularly those for the first time?
Postscript:
In this MAR of Dr. Cecilia Leyson, she wrote: We should support them
58
63
Here are my usual strategies, divided into two phases, namely, before the
operation and during the operation.
How to manage patients facing death? How to prepare for the Great
Inevitable?
It is in managing patients who are facing death that physicians are forced to
act out their competencies in being a holistic professional heathcare provider.
In such situations, physicians should be a life coach aside from being a
biopsychosocial health restorer and promoter. In being a biopsychosocial
health restorer and promoter, they must be guided by the policy of to cure
sometimes, to relieve often, and to comfort always. In being a life coach,
they must help the patients accept the inevitable death without fear and with
peace. The latter role is not easy as acceptance of death is frequently difficult
for the conscious patients and their relatives. This is compounded by usual
hesitancy of physicians to allow nature takes its course even in patients with
statistically hopeless situation. Moreover, it is extremely difficult to tell such
patients to give up and to just accept death. The other reason why most
physicians have difficulty helping patients accept the inevitable death without
fear and with peace is that they themselves do not know how to do it as they
do not have a conditioning and preparedness plan. To be effective in
coaching terminally-ill patients, physicians must be a role model in how to
face death.
Accepting an inevitable death without fear and with peace is easier said than
done. To facilitate it, there must be preparations long before the day of the
great inevitable. There must be mind-conditioning. There must be
preparedness plans, documented, implemented, reviewed and refined at
62
During the preoperative phase, the goal is to allay fear and anxiety to the
greatest degree so that the patient will not run away from the proposed and
agreed operative plan. Majority of the patients who did not go for
admission to a hospital or did not report to the operating room as agreed
upon are usually those who have not successfully overcome their fear and
anxiety. This is also true in patients who revoke their consent for
operation in the last minute.
There are basically two strategies that physicians can do to achieve the
goal of allayance of fear and anxiety to an operation. These are, namely,
to have a proper and clear communication with the patient and his
relatives and to gain their trust and confidence. These strategies are
essentially the same as when physicians secure an informed consent for an
operation.
Physicians should give a complete explanation of the procedure to be done
inclusive of how the operation will proceed, its benefits and risks and
costs. The explanation should be done in a language and manner that the
patient can understand. Diagrams, drawings, illustrations and visual aids
should be used as much as possible. In the explanation of risks, the
explanation must be done truthfully but modulated in terms of timing, rate,
and use of comforting statistics and words to allay fear and anxiety.
59
While explaining, physicians should observe and feel the reactions of the
patients. They should determine the degree of fear and anxiety and their
causes and then manage them accordingly. For example, if cost and
inconveniences are the main causes of fear and anxiety for the operation,
physicians should offer some assistance to reduce, as much as possible. If
the discomfort and pain during and after the operation are the main concerns,
physicians should offer measures to reduce the fear and anxiety, such as
telling the patients that anesthesia will be used during the operation and
anti-pain medications, after the operation. If side-effects are the main
concerns, physicians should offer measures to allay the fear and anxiety such
as telling the patients that the risks are mere possibility; chances of the sideeffects occurring are uncommon; there are measures to combat or reduce the
side effects; etc. If a pending or uncertain diagnosis is the main concern,
physicians should give probable diagnosis rather than possible diagnosis.
When physicians communicate properly and clearly with the patient and his
relatives using the aforementioned guidelines that I shared, there is a good
chance that trust and confidence will be gained. With the latter obtained,
there is a good chance of allayance of fear and anxiety of the patient before
the operation.
During the operation (where patients are awake, such as those being
under local anesthesia) During the operative phase, the goal is also to allay fear and anxiety to the
greatest degree so that the patient will not cry and will cooperate during the
procedure.
The main strategy here is to keep on communicating with the patient during
the procedure, to tell him what will be done (essential steps only), what he
has to do, what is going on (essential steps only), how he feels, whether he
feels pain or not, etc. Use words that are not alarming and frightening. Use
comforting words such as you will feel a little pain only and almost
done. At times, the physicians can interject some conversation with the
patient in order to distract him from his state of fear and anxiety.
Link to Reporters Original MAR:
http://medicalanecdotalreportsvol1.wordpress.com/2013/10/28/rjperaltasmar-10-09-first-time
60
61