Alfred D. Troncales, M.D.
November 13, 2003
Right after passing the Philippine Board of Medicine in August 1997, I immediately went into residency training. I applied in a number of hospitals in Metro Manila but my career in General Surgery began when I got accepted at Ospital ng Maynila Medical Center. It was on January 1, 1998. For six years I have been with the Department of Surgery and this coming December 2003 it is time to bid farewell to OM. An institution that has helped mold me into what I am now. The institution that has taught me the knowledge and the skills that is required of a General Surgeon. These are the basic tools that I will be using in an entirely new environment. An environment far from the settings that I have gotten used to, cases that I have learned from and family that I have grown with.
Objectives of paper:
Patient management process
Never in my entire med school and early into my residency did I appreciate case presentations, not until I learned and familiarized myself with your manual on the, “Patient Management Process.” The manual has taught me the simplest and most logical way to analyze a case in order to arrive at the most rational diagnosis, work-up and treatment. The best part of it was that its use was not confined to the conference room but can be applied to actual practice. It is extensive that the process begins at the time you first see the patient and ends at the time you last followed him up. However, knowledge and familiarization with the process does not end there. With the “Patient Management Process,” I have learned that there are a number of ways on how to approach a case and that is why continuous reading, researching and learning is necessary.
Throughout my six years stay at Ospital ng Manila, I have learned that surgery is not all operation. It entails not only the technical aspect of a procedure but also knowing its indications, goals and outcome (benefits and risks). Be it a minor or a major procedure, one must familiarize himself with what to do, what to look for and what to watch out for. One strategy was through the “How I will do it” and the “How I did it” program. This policy of “learning before doing” has helped me develop familiarization and confidence. And as a future surgeon, being trained in a government institution was an added benefit. I was complemented with a variety of cases with a number of unusual ones and consultants who are ready to help and are considered experts in their own field. With this background in hand, I believe that I can face the outside world with confidence and conviction.
Problem-based and self-directed learning process
A surgeon must not be confined to what we he has learned and what he has been familiar with. General Surgery is a never ending learning process and a surgeon will always yearn for more information. He will always search for new knowledge and new techniques and as one of your students, you sir have taught me to be critical about it. You have taught me how to search as well as analyze data before accepting it. From using the internet as a mode for literature search to assessing journals as supporting evidences, it is at Ospital ng Maynila where I learned how to assess available data. Through our debates and case conferences, I was taught to be critical in accepting new ideas without closing my mind to reliable and valid information. This can very well serve as a basic guide to my future practice of General Surgery.
It is during my residency that I realized that the process of learning is not a passive activity. Unlike in med school wherein teaching is a unidirectional process, in residency we were trained to become students and teachers as well. We were the students to our consultants and seniors, while we were the teachers to our juniors as well as the medical interns and clerks. Through our conferences, we were encouraged to become active participants by asking questions, sharing information and relating experiences. Being able to teach and impart to others what we have learned and experienced is a good foundation to knowledge.
Research has been a part and parcel of surgical residency training at Ospital ng Maynila. Each resident must be able to submit at least one research paper per year as a prerequisite for promotion. This standing policy has opened a sleeping giant in all of us. Never did we imagine that we will be able to write contest-quality and publication-potential researches. This we have proven for the last two years. Also, through our research program we have realized that researches are not just waste materials. It is very useful that it has been used to formulate our department’s clinical practice guidelines and treatment protocols.
My management skill was tested when I started to become the team leader of our GS team. Being a team leader, a lot of responsibilities were passed on to me by my seniors which included referring all patients to our service consultants, arranging OR schedules, lining up residents on cases and mobilizing junior residents to assist us in our day to day activities. This responsibility was further broadened when I became the chief resident from July to September of 2003. My duty did not only cover my team but the whole department as well. However, despite the difficulty and challenge, it made me stronger and more responsible. The experience taught me a lot. It taught me the meaning and the importance of duty, responsibility and service. The qualities that should be present in every surgeon.
Community surgical health management process
Surgical residency training at Ospital ng Maynila is not confined to the four walls of the operating room. It involves both in-hospital and community directed basic surgical educational program. This is what we call, “Social Responsibility.” Through the print media, radio and TV, we have disseminated basic information on different surgical related issues to a lot of people. A very good example of which is our information drive on: “Tule or not Tule,” Beware of Santol Seeds,” Cancer sa Suso” and “Bosyo Program.” Through this, we have realized that there are a lot of surgically related health problems which can be immediately addressed and be very well prevented.
Respect for human lives and human being
I was made to believe that being in a government institution, we in time become numb to the pressures and demands of our chosen profession. At Ospital ng Maynila, despite the exposure and experience we were still trained to be sympathetic to our patients. Our respect for the value of human life was enhanced by our training. With the variety of personalities that we encounter day in and day out, we have learned and mastered the art of patience and respect and these are factors that we still can develop and improve on and eventually use in our future practice of surgery.
Honesty and sincerity
Honesty and sincerity are values that are sometimes the hardest to achieve. Most especially when one is faced in compromising situations like a morbidity or a mortality. However, we must remember that mistakes is part of the learning process and being able to accept ones mistake is the first step to self improvement.
Ethics and integrity
With honesty and sincerity comes ethics and integrity. Trust can be established only if one has already proven himself and it takes time to prove oneself. At Ospital ng Maynila, dealing with various people from various social classes and backgrounds help us develop and improve on these core values.
During residency training, oftentimes we are so exhausted and stressed out that our moods and attitudes come in the way of our work. Sometimes, we reach a point where tempers dominate that we forget our chosen vocation and that is, to heal our patients.” Professionalism is being able to know our role as healers and act out our duties and responsibilities as doctors to our patients. It means being there for them always and at anytime of the day. We must make sure that they are okay and have no problem. We must try to improve their well being despite the difficulties and our limitations.
Continual improvement to achieve quality and excellence
I believe that humility is the first step to learning and that is being able to accept that we do not know everything. With this in mind, there will always be room for improvement and we will have that drive for a never ending quest for knowledge. During residency, I have learned that there are activities that I can use for my personal growth and improvement such as our morbidity/mortality quality analysis, medical informatics and debates on surgical issues. These are tools which I can use and apply in my future practice in pursuit of professional development to achieve high quality and excellence.
The success and failure of an operation will depend not on the surgeon alone but the team as a whole. A surgeon will not be able to function without the anesthesiologist, the first and second assists and the nurses. Everyone in the team must work as a unit and must complement each other in order to achieve a common goal which is to heal the patient. At Ospital ng Maynila, teamwork does not work within the operating room only. It also applies in our duties, during conferences and other hospital related work.
Being able to deal with people from different background and social classes has made us aware that each one of them has their own need and expectations. It made us aware of our role as surgeons in the hospital, in the community and at home. Residency has made us aware of the prevailing problems in our society and therefore acquire the necessary skills and knowledge to determine what needs to be done and thus improve our community’s health condition.
To sum it all up, surgery is not all operation. In order to become a good surgeon you must not just acquire the necessary skills in operating but you must also have the maturity and experience in your work. It is not just the maturity and experience in diagnosing diseases, doing accurate yet cost-effective work-ups, most effective treatment and doing post-op care. It is also instilling in ourselves and in our work the Basic Frameworks and Core Values of Surgery which we have learned during our surgical residency training. Our ultimate goal is to excel in our field and chosen profession and to attain this we must be well rounded surgeons. We must not just know and memorize by heart the basic frameworks and core values but rather, we must also understand it and put it into action to attain personal development and eventual self fulfillment.
In summary, what you have read is a reflection cum self-evaluation of my General Surgery residency training at Ospital ng Maynila Medical Center. I just described what has transpired during my 6 years of training by reflecting on how much I have imbibed the basic frameworks and core values expected of me as part of my learning. 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 consist 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.
Though it will be up to the consultant staff now to pass judgment on my training, I am confident enough to say that I have imbibed the required basic frameworks and core values expected of me. This 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 as well as the starting point to propel further learning. It can fully evaluate and show how much of the training’s objectives has the student learned and imbibed. I am therefore strongly recommending that this activity be adopted and accomplished by each and every graduating resident and that it becomes a prerequisite for promotion.