Post-Training Reflection
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.
Basic Frameworks
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.
Operation-Surgery Process
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.
Physician-teacher process
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.
Physician-researcher process
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.
Physician-manager process
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.
Core Values
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.
Professionalism
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.
Teamwork
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.
Social Consciousness
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.
DISCUSSION:
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.
SUMMARY:
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.