Department of Surgery
Ospital ng Maynila Medical Center
JOSEPH A. ESTANISLAO
December 18, 2002
I had been with the Department for more than 5 years now. I started my pre-residency in October 1996 with Dr.Joson as the training officer of the Department then. It lasted for about 2 months. I started my official residency training in January of 1997 and I am now in the end of my 6th year in the Department of Surgery of Ospital ng Maynila Medical Center.
So as I go out of my 6 years of training in general surgery in the Department, I would like to humbly state and admit that I was not able to and could not learn everything there is to learn in general surgery. I tried but we all know that this is realistically impossible as surgery is not only an unlimited but also an inexact science with so many things to learn, with still so many unknowns and uncertainties and that no two patients are the same. However, I fervently hope that I have acquired and imbibed at least the core values and basic frameworks which serve as a foundation for a rational, effective, efficient, holistic, and humane community surgeon as well as a springboard for further learning and continual lifetime improvement.
Lastly, many of the anecdotes, examples and reflections that I mentioned in this paper will have aspects whose values seem to be overlapping.
Objectives of paper:
This to me is one of the more important things I have picked-up in my entire training. This not only made me an effective clinician, but also made me a more rational surgeon. Surgical skills can be learned by “non-doctors” by just merely reading a good book or atlas; however, this will be all dependent on a good diagnostic process. And this is what the PATIENT MANAGEMENT PROCESS has assured me.
Although many of these “patterns” and “objective findings” had already been taught to us in medical schools, and had been reiterated to us for so many times during our residency training, the process had simply “concretized” it in our minds.
As for my own experience, many of these things I had known all along even when I was still a junior resident. However, I had always been wondering when the time comes that I will take my PBS exam how I can reason it out with the experts. But ever since I was introduced to the patient management process, I no longer fear that time.
Surgery today is so complex that no one can possibly absorb it all. Only by using the patient management process as a gigantic frame to contain what I learn is it possible to integrate the numerous fragments of medical theory and practice that was taught to me during my training.
The more obvious benefit that I got in this process is exposure/ progressing maturity of my surgical know-how. However, the deeper benefit that I acquired here is how to use strategies to “advertise” or “publicize” my being a surgeon by becoming a public health problem detector.
Likewise, I also realized in this particular learning process that the pre-op, intra-op and post-op management is never routine at all. No labs are routine, no maneuver is routine and no meds are standard for any case or patient. You just have to evaluate each patient individually.
Problem-based and self-directed learning process
This to me is the learning process that I acquired that more or less teaches us to simulate our future private practice. We all know that no two locales are exactly similar: the types of diseases, the character of the people, the economics of the area. So it is up to us, as surgeons-community health problem solvers, to detect the problem, set up realistic goals, and find effective and efficient ways of solving it, in a manner that is most befitting in the community. This process does not necessarily limit itself to the diagnosis and treatment of the health problem.
During my training, I have learned that as a surgeon I must be someone who is a master of the art of learning, and of course, of the art of teaching.
As a teacher, I had become someone my patients and/or students can feel relaxed and secure with. I had become relatively strict yet warm-hearted. I started to develop a mutual relationship with my students in and out of the clinics or conference rooms. I was able to help them with their problems and was able to develop a slow temper and patience. I also started treating my students as persons who can commit mistakes rather than machines that can do almost anything.
During my training, I learned that as a physician-teacher, I should be a man of dignity, a respected fellow, standing and fighting if I know I am correct, but can also give in once I know I’m wrong.
It is only in my training that I encountered action research. In contrast to the more classic types of research, it specifically addresses a problem and attempts to provide a clear and practical way of solving it. It combines all the other types of researches and is dynamic. In short, it is primarily geared in doing an “action.” For the present-day surgeon/clinician, this type of research is more appropriate.
Today’s medicine has an ever-broadening frontier. Present-day physicians/surgeons must be able to meet the inevitably changing needs of the times and of the people. Our education should march with research. There is a synergistic relationship between education and research in medicine, without which there can be no progress. I should always strive to be both a teacher and research worker at the same time.
As we all know contemporary medicine was built on a chain of discoveries that originated from the motivations and achievements of a few men in the remote recent past. Trained to be a physician-researcher, I must continue carrying on the torch high to make the practice of clinical medicine easier, safer, more effective and pleasant.
I was initially drawn to surgery by its technical aspect. But as I matured during the training, I learned that as a surgeon I have a greater role to play in the society. No matter what role I will take in the community, officer in an organization, parent in my children’s school, drinking buddies, I am still a surgeon in the people’s eyes – respected and emulated. As a natural leader, I will always strive to move with dignity, speak with honesty and think morally.
Community surgical health management process
As a surgeon in my three-fold capacity, as a professional, as a member of society, and as a human being, I will attempt to help the community in my physical, mental and social ascent. As a professional man in particular, I will act as a healer; as a knower, for I knows the secrets of nature and of the human being; as a preventer, for I can arrest disease by forestalling its vanguards before they arrive; and as an organizer, for I am expected to guide society in fighting the historico-social process called disease. To heal, to know, to prevent, to organize – these will be my future spheres of professional activity, embraced in the expression “to be a surgeon.”
Respect for human lives and human being
This value, I believe, is one of the values that is commonly innate to us all, doctors and surgeons. On the first place, we wouldn’t be here if we don’t believe, much more, respect human lives & human being. However, during the course of my training, I witnessed furthermore the value of human life and of being human, as I have seen how swift death can occur, so many sufferings. All these things, PAIN, AGONY, SORROW, BLOOD, DEATH contributed to the strengthening of my belief and respect for the sanctity of human life.
During the years of my training, I realized that empathy must be second nature to me. Uncertainty and anxiety in a patient can magnify pain and slow the healing process, while calm reassurance from me, their surgeon/physician can speed up recovery. Because of this I always strive to know the patient as he/she is, not just the patient’s illness. I had always try to take time out to explore how they feel about their illness and how it affects their personal life. When a patient is talking, I always listen and when I say something, I make sure they understand.
At sometime during my junior and senior years of residency, I started to realize that the individual on whom I operate is more than a physiological mechanism. He thinks, he fears, his body trembles if he lacks the comfort of a sympathetic face. For him nothing will replace the salutatory contact with me (his surgeon), the exchange of looks, the feeling that I’ve taken charge, with the certainty, at least apparent, of winning. These are the imponderables which we have no right to sacrifice.
Lastly, as a surgeon, I will continuously strive to have a personality that inspires hope and confidence; my attitude toward my patients must be one of sympathy and gentle consideration, and an ever-watchful solicitude of their care and safety.
Honesty and sincerity
During my stay in OM as a resident surgeon, I encountered problems and the unexpected — before, during or after an operation. Because of these, I later on tried not to be too daring or overconfident. At this stage of my life as a surgeon, in spite of the experiences that I have gained through the years of training in a government hospital, I am still less brave and much more careful than before. I resolve to still ask for help when I need it.
It is not that age nor fear of remuneration has caught up with me. Rather, my judgment and technical skills have become fine-tuned. I have also become more cautious because of the myriad complications that I have seen and experienced as a result of sins of commission and omission of young, inexperienced colleagues, and myself, too. Braggadocio has no place in surgery. Remember that calling for help is not an admission of defeat, but rather, a sign of good judgment. I know that I will be respected and admired more when I tell my patient that I have asked others to help me. That is how the chemistry of confidence — the patient’s trust in me — is born. I always try to remember, when I am in trouble, it is my patient’s life at stake.
It is unfortunate that some surgeons make a lifetime habit of shielding their patients from other doctors. I try not to belong to this breed of doctors, selfish and uncaring. I find it despicable and immoral of a surgeon to avoid help purposely and do things his or her way when a patient needs the expertise of others. Knowing fully well that other colleagues with more superior know-how and experience are available, he or she stubbornly refuses to involve them in the care of the patient, whose very life could be imperiled as a result. I know that there will be moments in my life when I will have to ponder: Am I the right surgeon for this patient? It has happened to me several times.
My guideline up to now: Discover and humbly accept my limitations.
Ethics and integrity
There was a time when we were still junior residents, when we were being treated “inhumanely” by some senior residents. We (Bibay, Ana, Noli and myself) made a pledge to one another, that if and when we become senior residents, we would not repeat to the junior residents the things that were done to us. That if one of us is tending to become like them, anyone of us would give the person concerned a pat in the back and remind him/her and say “Remember when we were still junior residents…”
It is because of this kind of treatment that we learned to appreciate that to be a doctor/surgeon, in the true sense of the word, one should not only be a wise man but, above all, a good man. To be a doctor/surgeon is, in other words, to be a whole man (or woman), who fulfills his task as a scientist with professional quality and integrity; as a human being, with a kind heart and high ideals; and as a member of society, with honesty and efficiency.
Many things and events during my training have taught me to follow the golden rule: My duty to my patients will be to act towards them as I would wish them to act towards me: with kindness, with courtesy, with honesty. I also learned when and how to withhold the truth from my patients if by not telling them all the facts of the case I can relieve or console them, for I can cure them sometimes, and I can give them relief often, but hope I can give them always. I remember many conscientious consultants saying that a laboratory report is not an irrevocable sentence. A hematological determination, a roentgenogram, an encephalogram may supply vital information on the organic working of the body, but it is even more vital never to forget that, behind all such reports and data, there is a human being in pain and anguish, to whom I must offer something more than an antibiotic, an injection, or a surgical aid; I must, with my attitude, my words, and my actions, inspire confidence and faith, and give understanding and consolation.
To my colleagues, I have my obligation. Many of the medico-legal cases that we have encountered were borne out of some doctor’s mouth. So I resolved that if I have something good to say about a fellow physician, I’ll say it anywhere; but if I have non, then I’ll keep my mouth shut.
After taking all these things and personal lessons on ethics and integrity that I encountered in my training, I realized that I must be above reproach in order to gain the trust and confidence of my patients. I will not seek to enrich myself at my patients’ expense. I will never engage in any practice that would besmirch my reputation. Every action that I take must be in the best interest of my patient. I will be available at all times to my patients, whose needs I will prioritize. Last but not the least, I will never betray their trust.
I intend to live the ideals of surgery, as it is one of the remaining professions that still speaks of its duties in this world of today, in which almost everyone else speaks only of his rights.
For me, professionalism means going one step beyond the call of my duty, even to the point of endangering my own life. There was a time, one or two years ago, I was on duty when a patient was brought to the ER with multiple gunshot wounds in the abdomen and in the chest. All I knew at that time was he was a policeman. He was hypotensive and agonal so I brought him immediately to the OR. As I was doing the operation, several men came barging into the room. All were armed and drunk. They got inside the operating theater and started asking questions, one that I remembered well was, “Dok, buhay pa ba?” To which I answered, “We are trying our best.” I don’t know who these men were. All I know was, they were armed and drunk, the security guards were even afraid to stop them. But in the back of my mind, I had a feeling that these people had something to do with this patient’s condition. Later on, I did found out that that they were exactly the men who shot the patient.
I was labeled stupid for apparently endangering my life then, since they claimed that the patient is about to die anyway. Honestly, I was scared then. But thinking back, I will still do the same thing I did then. I will still try to save the patient’s life.
Different people may have different definitions of different things in their lives. To me, what I did was not stupidity but professionalism in the eyes of danger.
Continual improvement to achieve quality and excellence
I would like to narrate a story to exemplify my personal experience with regards to this value. We were 4th year then, year 2000. Dr. Yu came to our department. To me then, he was the ideal surgeon, approachable, humble and knowledgeable in his craft. Furthermore, I’ve known and seen some other surgeons in another place and time who seems to act as if they are god. Now comes this consultant who probably knows just as much as they do, probably even more, but very humble. That time, I thought he probably knows everything there is to know about surgery. But when Dr. Joson came, I saw the student in him. He was so enthusiastic to learn all the things that Dr. Joson brought with him: the patient management process, the newer health-process evidence-based clinical practice guidelines, surgical debates and others.
So I have come to the conclusion that if a seasoned surgeon like Dr.Yu is willing to learn and study, the same should be the attitude of a lowly surgical resident like me.
No matter how high I climb up the professional ladder, I will remain a student at heart, open to new ideas and discoveries. Just as the first step to learning is to admit that I do not know, the first stumble into the abyss of ignorance is to think that I know it all.
If there is one thing that has helped us (residents) to weather all the tests, all the hardships and failures that we have encountered in the department, I believe it is teamwork. Surviving the suspension of accreditation, the frequent and turbulent changes in the leadership of the department, the “different” treatment of previous senior residents are, I think, some of the concrete examples that if we had not chosen to work as a team, we probably wouldn’t even be here to graduate.
What I ignored in medical school started to take paramount importance when I started my training in OM. Since as many (about 80-90%) of our patients here are indigent, I started to be frugal with the patient’s money.
There are some who derogatorily label surgeons as “technicians” because there are some surgeons who simply concern themselves with operating and not the patient themselves. As a junior resident, I had the notion that the surgery proper is the main point in a surgeon’s career. The pre-op, post-op and follow-up phases in a patient’s treatment were only added work that must be tolerated in training. Somewhere in between, the patient as a “whole” slowly came into focus. “Cases” became persons. Diseases became problems seen in the backdrop of the family’s life. I started to linger with the patients, instead of the usual 2 to 3 minutes “check-the-bowel-sounds and see-the-wound” rounds.
Patients became persons. Their problems become mine. Consultations become counseling. A few of them even became my close friends.
Every day, more and more, medicine becomes, above all, prevention of disease and the promotion of health. For only by knowing the healthy man can I cure him when he falls ill. Knowledge of the healthy man is obtained by studying my fellow beings, both the healthy and the diseased, not only in the mirror of classical and modern medical literature but also in current newspapers. I then learned that poverty is still the main social cause of disease.
To be a surgeon, then, means much more than to dispense pills or to patch up or repair torn flesh and shattered minds.
Ever since the day I first said those magic words, “I want to be a surgeon,” I had been wrapped in the colorful fabric of surgery, a fabric woven from the ideals, wisdom, endeavors, and achievements of my glorious predecessors.
I know I had just embarked on a fascinating voyage leading to the harbor of one of the most dynamic professions. Year after year new windows will keep opening before my eyes, revealing the multifaceted landscape of the art of surgery.
I also know that I have chosen the most fascinating and dynamic profession there is, a profession with the highest potential for greatness, since our daily work, as surgeons, is wrapped up in the subtle web of history. My labors are linked with those of my consultants, teachers and colleagues who preceded me in history and those who are now working all over the world. It is this unity with my colleagues of all periods and of all countries that has made surgery so universal and eternal.
Just like me, most medical students are attracted to surgery. The bloody drama of the operation fascinates us; the dramatic force of some great operator stirs our admiration. We note decisive achievements and wonderful successes. We hear little of failures. We know nothing of the haunting anxieties, the keen disappointments, the baffling perplexities, the dread responsibilities, and the numerous self-reproaches of one who spends his life as an operating surgeon.
The surgeon recalls the frequent misgivings with which, on the strength of his fallible opinion, he has advised and performed operations; the excitement of a critical operation and the deep breath of thankfulness when he has succeeded in averting some grave complication; his forebodings become realities; the too often useless struggle against overwhelming odds; the distressful death; the severe self-criticism and biting regrets. And is not us, surgeons, appreciating our own unfitness in spite of years of devotion, in the position to condemn those who lightly take up such burdens without preparation and too often without conscience?
I agree that this reflection cum self-evaluation paper is the penultimate and most important basis of a summative evaluation of my training. With this paper, I was able to gauge how much I have learned during my training. I just wish that whatever I failed to mention here will not be taken as something I did not learn but rather it is because of the lack of words I can use to describe it. I also hope that I can all show you convincingly through this I imbibed the basic frameworks and core values.
I cannot have described it more aptly but with the learning period spanning 6 years and with the learning objectives necessitating repeated readings and practices, the learning activities that I went through can be described as piecemeal and supposedly cumulative. Before this reflection paper that I did, I just have a general feeling that after 5 years of residency, I learned new things and many things at that. I know that if I were to be asked what I learned, I will have difficulty answering the question in a concise manner. I will probably try to enumerate all the things that I think I learned, that come spontaneously to mind, in a random manner, with the tendency to repeating the same thing over and over again, and to the point that I cannot enumerate them all and in exasperation, just say “and other things.” With this reflection paper, I was able to have a clearer idea of what I have learned by grouping or categorizing the bits and pieces that I have learned.
Via this paper, I was able to reorganize in the sense that I was able to relate the values of the department to those that I previously held before I joined the department and then to bring them into a harmonious and internally consistent philosophy.
Before these basic frameworks and core values were taught by the present department chairperson, I was just concerned with my training to be a general surgeon, just to be able to operate. I had a vague idea of what a quality general surgeon and a quality surgery department should be. With this reflection paper, I now have a clearer idea what a quality general surgeon and a quality surgery department should be.
After reflecting on what I should have learned, I was able to get a much clearer picture of what I should have learned. Thus, in the process of doing the self-evaluation, I learned the nitty-gritty or details of what I was supposed to learn.
The other benefit that I got from the self-evaluation was getting an idea where I stand which in turn motivated me to go for improvement.
I have presented a reflection cum self-evaluation paper after my training in general surgery at the Ospital ng Maynila Medical Center. The objectives are to reflect on how much I have imbibed the basic frameworks and core values expected of me as part of my learning objectives in the training program and to formulate strategies for continual improvement after graduation. The basic frameworks consist of: 1) patient management process; 2) operation-surgery process; 3) problem-based and self-directed learning process; 4) physician-teacher process; 5) physician-researcher process; 6) physician-manager process; and 7) community surgical health management process. The core values consisted of: 1) respect for human lives and human being; 2) honesty and sincerity; 3) ethics and integrity: 4) professionalism; 5) continual improvement to achieve quality and excellence; 6) teamwork; and 7) social consciousness. Although my faculty will have a final judgment on my self-evaluation, I confidently say that I have imbibed the basic frameworks and core values which I think could serve as a foundation for my being a rational, effective, efficient, holistic, and humane community surgeon as well as a springboard for my further learning and continual lifetime improvement. With my first-hand experience, I believe this reflection cum self-evaluation is another kind of learning strategy which may turn out to be the greatest but often unrecognized force to consolidate whatever learning that has been attempted (through the process of synthesis, organization, and self-evaluation) as well as the starting point to propel further learning (through motivation brought about by the self-evaluation). I strongly recommend that this procedure of asking all prospective graduates of all departments of surgery to do a reflection cum self-evaluation paper be adopted.
As a parting word, I would like to share with you this quote that I think aptly summarizes all the things that we have worked for.
The conditions necessary for the Surgeon are four: First, he should be learned; Second, he should be expert; Third, he must be ingenious, and Fourth, he should be able to adapt himself.
It is required for the First that the Surgeon should know not only the principles of Surgery, but also those of Medicine in theory and practice; for the Second, that he should have seen others operate; for the Third, that he should be ingenious, of good judgment and memory to recognize conditions; and for the Fourth, that he be adaptable and able to accommodate himself to circumstances.
Let the Surgeon be bold in all sure things, and fearful in dangerous things; let him avoid all faulty treatments and practices. He ought to be gracious to the sick, considerate to his associates, cautious in his prognostications. Let him be modest, dignified, gentle, pitiful and merciful; not covetous nor an extortionist of money; but rather let his reward be according to his work, to the means of the patient, to the quality of the issue, and to his own dignity.
Lastly, I cannot finish this reflection paper without being able to say this: My sincerest thanks to you, my teachers, the parents of my mind. And when I say teachers, I do not mean only the consultant staff, but even my colleagues from whom I learned anything and everything—their science, art, ethics, self-denial, or example—that may become a source of inspiration in my professional life. I now honor my masters with devotion and friendship, for friendship is man’s noblest sentiment, greater even than love.