Ana Maria G. Agoo-Llado
December 14, 2002
Plato once said, “The unexamined life is a life not worth living.”
I believe him. Eversince.
It was in 1997 when I started my training.
Six years have passed. Six years of colorful, challenging,exciting, sleepless, no lunch, no dinner, no breakfast –duties and ORs, admissions, discharges, endless explor laps,mastectomies, thyroidectomies, debates, researches,reports,exams, morbidities,and mortalities. Name it and I can tell a memorable story or two. Who among us couldn’t?
Back in my clerkship years, I knew in my heart I wanted to be a surgeon. During that time, in my own criteria and standard of what a quality training is, OMMC ranks low, just watching how majority of the surgery residents go about their daily duties, ORs, and patient care and how, on the other hand, the majority of the consultants and more importantly, the department chairman, help their residents in the training program. I told myself, what the heck. I need the exposure. It would all depend on how strong I uphold the virtues and concepts I have of the kind of surgeon I want to be. Community exposure during my premed and medical school years would surely help me maintain sanity and hold on to reality as I pass through the tunnel of residency training. Knowing how numerous and varied the surgical cases OMMC caters to, I aimed for my goal and got accepted as a first year resident in 1997.
It was in the year 2000 that dramatic changes happened. With the change of the hospital director, and then our department chairman, the department’s evolution began. Three years after, our basic frameworks and core values made a 360-degrees-turn. In papers it may not seem to be this way. But in reality, it does.
Patient Management Process
We now assume responsibility as soon as patients make their first consultation. Whether a particular patient is for medical or surgical intervention, we see to it that patients seen and examined get the appropriate and most accurate disposition for the particular complaint that brought them to the hospital. More so, there is no hard and fast rules with regards to patient management. No two patients being identical, patient management varies from one patient to another. It is always tailored according to every patient’s individualized needs and condition.
Patient management process is a dynamic process which is subject to change differing from patient to patient but following the same principles: diagnosing a patient, primarily by pattern recognition, secondarily by prevalence; and treating a patient by following the benefit-risk-cost-availability table.
A patient is not an inflamed appendix, nor a necrotic breast mass, intestinal obstruction. A patient, with the ailment he/she is suffering from, experiences the pain and psychology of the disease state, anxieties and fears, and is a member of a family . Whatever problem is entailed with his situation must be elicited and be taken into consideration.
Being a conscientious surgeon entails not only giving satisfaction to one’s desire to use a scalpel in opening-up a surgical patient but also in preparing the patient as well as one’s self for the operation. Rendering the best postoperative care possible accounts for one-third of the job, the first two thirds be well spent on the preoperative counseling, and intraoperative quality of care.
Preoperative preparation does not begin and end on asking the ward nurse whether the surgical materials and other OR needs have been completed just about 30 minutes prior to OR. Ideally, this starts during the patient’s first visit, which includes explanation of the contemplated procedure, approximation of the possible expenses, length of hospital stay and discussion of the possible problems foreseen by the patient. Referral to consultant-on-deck and scheduling of the patient for OR are steps taken as part of this process.
It is the surgeons responsibility to be knowledgeable if not that skilled of all the different procedures or operations any general surgeon is expected to know. With the “HOW I DID IT, HOW I WILL DO IT” project, it is a test of one’s self on how well-versed we are on the surgeries we did and has familiarized and prepared us for whatever surgical procedure we might perform in the near future.
Problem-based and self-directed learning process
Quality analysis forms the main bulk of the learning process. Problems encountered, whether preoperative, intraoperative and postoperative are dissected on the quality assessment scheme, with the important premise that things are always controllable by one’s self, that all factors treated equal, possible loopholes are brought about by factors caused by negligence on one’s responsibilities. Witlh the pathophysiology and quality analysis of the mortalities and morbidities, we come to realize and analyze ourselves with regards to our skills, decision-making and patient management, recognize our faults and learn from them.
What the surgeon knows by heart he/she teaches not only to the clerks and interns of this training hospital, to other colleagues/co-residents and nurses but also to the patients who play an integral part in the cycle of the learning process. The learning process does not stop on one’s self. It spreads geometrically, with the “multiplier effect” on all areas and dimensions involved in our professional career.
Growth and learning goes hand in hand. Research forms one spectrum of this learning continuum. Other members of the professional community ought to know and have the right to be informed of the undertakings we have done in our institution, with the goal of spreading interest and initiatives in areas we are most concerned with as surgeons. Let it be that the effect is that of a trigger to duplicate the research initiative or further improve on it, the effect is still desirable considering the growth of us, surgeons, in the field of research.
The experience I’ve had in having been able to join in research forum/ contests has been a revelation for me. I have never imagined that the exhilaration would be that intense, defending the hard work that our team had done is fruitful enough accomplishment for me, lest be chosen as a winner was indeed more than enough. Nobody could ever take away from me the skill I have acquired in terms of the appropriate technical, philosophical and statistical approach to take in a research initiative. To that, I am deeply indebted to my department chairman who has painstakingly imparted himself to us through these aspects.
I used to think that being a physician has nothing to do with “management”, the word that is associated with business, program and projects, whatever the undertaking may be. I realized I was wrong. For a surgeon to be the best physician that there is, entails being a good manager, the cycle involving patient care, efficiency of teamwork in terms of the output measured by well-defined parameters, provision of quality surgical service measured by decreased number of complications, disability, and complaints . These would all reflect thoroughly planned strategy and execution of sound management style that we acquire through our five years of training under the tutelage of our present mentors. I never thought that my undertakings as a surgeon can be viewed in the light of capital outlay, strategies and profit. From then on, I always look at each patient exposure as a big investment for me that I should be very responsible for.
Community surgical health management process
The dimension of my being a surgeon, I have learned, does not end within the four corners of the operating rooms, nor does it end in the walls of our conference room. The missions we have undertaken, to mention the thyroidectomies and cheiloplasties we’ve had, helped me visualize a more concrete role of the surgeon in a more dynamic community set-up. Handling these initiatives of the department gave me the chance to further allow my management skills to grow deeper in the realm of the community set-up, which reflects the truth and dynamism outside the shelter of this institution.
The responsibility of my being a surgeon is not limited only to one’s patient but to the family and the community to where the patient belongs. With the goal of having a healthy, thus a productive community, projects were started with the Breast Cancer Awareness lectures, “No to circumcision”, and health advisories on ingestion of santol seeds.
Respect for human lives and human being
This value has been deeply inculcated with the concomitant change in the thrust, mission and vision of the department observed with the change in leadership in the year 2000.
Consultants, for the most part, have shared so great a part of themselves and the training they have had with regards to this value, with the likes of Drs. Joson, Yu, Guevarra, Querijero, Penserga, Bartolome, Dofitas, Belmonte, Encanto, to name a few. Before, we used to be trained as “ scalpel-happy people”. This is now a thing of the past. For what we are now is a combination of all the skills and styles of each of the consultants who has, in one way or another contributed into molding us to be humane surgeons.
We have acquired that third eye of looking to a patient in all the totality and dimension of the disease state, that physio-psychological and sociological factors be taken into consideration.
A patient will always be a symbol of human life, not just an axillary mass to be excised, an acute abdomen to be opened, an inguinal hernia to be repaired or a transected abdominal aorta. His life is at stake, he has a life of his own, a socioeconomic group where he belongs and a life-support system that needs to understand his present condition.
Honesty and sincerity
The patient deserves to know the truth about his condition, its present status, diagnosis, prognosis and how much the contemplated procedure could help alleviate his present misery. Through the years, training has taught me how sensitive a patient is about his/her doctor’s sincerity.
Cases might be numerous and abundant in one point and time but in some situations, this is not the case. This is where honesty and sincerity among us colleagues would come in. Patients be thoroughly decked and rotated among us to have equal chances of patient exposure.
We have also been trained to give our most honest and sincere feedback to each other with regards to our individual performances, whatever the case may be.
Ethics and Integrity
Reporting of actual results and intraoperative findings form an integral cornerstone of our training. Although at times, one could be tempted to invent falsified operative results so as to save one’s ass especially in cases of complications, it is just but prudent and ethical to give the most reliable report there is. Everything would come back to you. Falsify and you would still be crucified. It is better to die an honest death in the scrutiny of the consultants during presentations in the conferences rather than suffer a never-ending internal necrosis that goes deep within.
Simply expressed as coming to work on time everyday. Before a patient is wheeled in to the OR, I see to it that I am there already, properly dressed in my scrub suits or I accompany the patient from the ward to the operating suites.
I see to it that the trafficking of OR cases during my team’s schedule is systematic, for there are so many factors in the operating room that could cause delay of OR time.
Reports assigned to me, I prepare well. I see to it that I conduct myself within the bounds of how a physician should be conducting him/herself, in front of colleagues, our consultants, and most especially in front of our patients.
I always stick to the protocol we employ in referring to our consultants. I do believe they very well deserve a deep sense of professionalism, that someday I would be a consultant too. Always thinking that if I were in their shoes, what would be expected of a referring resident.
Continual improvement to achieve quality and excellence
With the present learning set-up that we have, it seems impossible that we remain dormant, unaffected by the strong drive for improvement towards quality and excellence in rendering surgical care. The quality analysis and statistics-raised consciousness helped us a lot in always being at our toes, polishing our sense of insight and foresight in the process.
Without this core value perhaps I could have not survived my residency training. It is the strength that kept us going, the light that paved our way, the energy that sustained us.
With the tremendous amount of work that we are all experiencing it is impossible not to acquire this virtue.
OMMC set-up, no matter how much we hated it, as it causes so much delay and loopholes in rendering quality patient management, brought to us the skill only an institution such as this will be able to partake: social consciousness.
Since 1969, it has always been the mission of the department to provide quality medical care at the lowest possible cost, our institution catering mostly to the needs of the indigents of all the indigents in our city of Manila.
Dealing with barangay chairmen, kagawads, media, and all the “care-of” patients coming from the city hall, OMMC personnel has somehow made this residency training at OMMC unique. As the years passed by, things that would usually annoy us at first instance we managed to deal with accordingly. We have managed to accept that this is the unique social community we are in. Our patients belong to this social strata,and we have managed to polish our skills in dealing with these kind of people in the most professional way possible.
What remains in our hearts is the authentic Manileno, indigent though he may be, who would always greet us with a smile, eyes full of gratitude for another life being saved by the resources invested on supplies and manpower in this institution, no matter how chaotic things may be on other ends, the department will always uphold its vision of being a model department, no matter how rough the road may be.
All these I carry with me as I clear my own path towards professional independence. Quality surgical care, honesty and integrity, professionalism to all my patients-to-be.
Learning is accomplished through motivation, repetition and association. Motivation, which comes from within. Repetition is obtained by reading, rereading and studying information until it is mastered. Association is obtained by connecting information that has already been mastered to some new knowledge. Associate the information to the patient for life, and the increased knowledge base will improve the quality of care for the patient. Thus, in the process of reflecting on the learning that I have acquired during my training years to become a general surgeon, I was able to reformed into being what I am now.
The reflection started with the quotation: “An Unexamined life is a life not worth living.” True. This post-training cum self evaluation is examining my life for the past six years, with this, I may say, it was worth living. No regrets.
From the start, I knew I was to undergo training for general surgery. Initially, I was aware of the learning objectives, but as time passed by, it became vague. I cannot see the structure anymore. I eventually grew up in a “let’s get this done” system, and a very independent one. At that time, I was expected to be resourceful, aggressive and independent. These were nice virtues that we have acquired, but still it was not enough. Eventually, we were given the chance to mature. This time we were on top. Our batch had the power and the determination to change things and not repeat previous mistakes. We scratched the system that we did not want, retained and added on what we wanted the department to be when we were still juniors. Until it came… the era of great change. Reorganization, system, structured program. All was new. Tradition was set aside . We became what we are now. Better individuals.
If not for this reflection paper, I can never realize and appreciate what has happened to me and what I had turned out to be. This is examining my life as a resident, and being able to verbalize it makes it more meaningful and important. For in silence, others will never know that I have lived my life to the fullest during my six years in residency.
Most of this I owe to the present leadership, who have shared so much of himself to us. And to my colleagues who have made my learning process a challenging and colorful one.
Sir, thank you very much.
With this, I rest my case.