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Medical Anecdotal Reports

for the Development of


Holistic, Professional and
Compassionate Physicians
in the Philippines
Volume 1

Reynaldo O. Joson, MD
2013
120

Medical Anecdotal Reports Volume 1


Table of Contents
Table of MARs by Year Reported

Table of MARs by Issues and Topics Discussed

Preface

Introduction

12

Medical Anecdotal Reports (see Tables of MARs)

14

Epiloque

98

Appendices
1

2
3
4
5
6

Medical Anecdotal Reporting as a TeachingLearning Activity in a Clinical Department in the


Philippines [Abstract] (presented in the 4th AsiaPacific Conference on Problem-based Learning in
Health Sciences in September of 2004)
List of surgical residents of OMMC Surgery who
have written MARs from 2004 to 2013
External Anecdotal Feedback on the MAR in 2005

100

Feedback on the MAR Project by Surgical


Residents in 2006
Feedback on the MAR Project by Surgical
Residents in 2012
About the Author

105

101
102

111
117

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Chairman Emeritus, Department of Surgery, Ospital ng Maynila Medical


Center (2010 2013 - )
Past Chief, Division of Head and Neck, Breast, Esophagus, and Soft Tissue
Surgery, Department of Surgery, Philippine General Hospital (July 13,
1994 - 2000) (Acting Chief 1992 1994)
Program Director, Education for Health Development in the Philippines
(1989 -) http://edhedephi.tripod.com
Project Director, Medical Anecdotal Reports, Ospital ng Maynila Medical
Center Department of Surgery (2004 - )
Author- Scientific Papers > 100; Scientific Books/Primers/Course Packs
> 80; Published papers =50 (4 - international; 47 local);(9 from 2000
to October, 2006); research awards >16 (1976 October, 2006) [Last
updating: December 2012]
Author Websites [https://sites.google.com/site/rojosonwebsites] = 198 [as
of July 29, 2013]
Contact information:
rjoson2001@yahoo.com
09188040304
Details of ROJosons Biodata:
https://sites.google.com/site/rojosonwebsites/rojoson-curriculum-vitae

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Medical Anecdotal Reports Volume 1


Table of MARs by Year Reported
Year

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

Breaking Bad Traditions


and Breaking Bad Habits

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

Learning the Hard Way

Nolan O.
Aludino, MD

24

2006

Man of Honor

Roderick S.
Mujer, MD

26

2006

10

Its Never Enough

Benjamin C.
Deveza, MD

21

2007

11

Harvey A.
Balucating, MD

40

2007

12

The Advantages of Giving


Out Your Cellphone
Number
Comprehensible
Communication: The Key
to a Better Doctor-Patient
Partnership

Haidee T.C. Cruz,


MD

55

2008

13

Ethics in the Heart, Not in


Books

Jonathan R.
Malabanan, MD

70

61

Medical Anecdotal Reports Volume 1

Appendix 6

Table of MARs by Year Reported

About the Author

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

Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg


Doctor of Medicine (MD), University of the Philippines College of
Medicine (1974)
Master in Hospital Administration (MHA), UP College of Public Health
(1991)
Master in Health Profession Education (MHPEd), UP National Teachers
Training Center for Health Profession (1993)
Master of Science in General Surgery (MSc Surg), UP College of
Medicine (1998)
Faculty, UP College of Medicine (1985 - ) [Professor 5 as of 2013]

36

Senior Vice-President for Corporate Affairs, Manila Doctors Hospital


(April, 2009 - 2013 - )
Consultant, Department of Surgery, Ospital ng Maynila Medical Center;
Philippine General Hospital; Manila Doctors Hospital
Past Chairperson, Department of Surgery, Ospital ng Maynila Medical
Center (2001 July 11, 2009)

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understanding.

Medical Anecdotal Reports Volume 1

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.

Table of MARs by Issues and Topics Discussed


Issues and Topics Discussed

Page

The Making of a Holistic Physician


What is a holistic physician?

14

How can physicians help promote good traditions and


habits and break bad traditions and habits in the
Philippines?
Is there such a thing as enough in the learning of
medicine?
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?
The Making of a Compassionate Physician

17
21
24

Which indigent patients should physicians help? How to


help indigent patients? What should physicians do when
patients or their relatives ask them for money for their
medical care?
A Patient of Honor

26

What is the Indigent Patient Help Program of the


Department of Surgery of Ospital ng Maynila Medical
Center?
How to manage abandoned patients in a hospital setting?
What is compassion? What is compassionate care? What
is the highest degree of compassionate care?
Should physicians give their cellphone number to their
patients?
To console or to be consoled?

32

30

36
40
44

The Making of a Professional Physician


What are core values? What are the core values for
physicians? What is the role of the Medical Anecdotal
Reports in the evaluation of core values of physicians?
How strong should a patients trust in a physician be a
driving factor in choosing hospital for treatment?

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47
51

Medical Anecdotal Reports Volume 1

Appendix 5

Table of MARs by Issues and Topics Discussed

Feedback on the MAR by Surgical Residents in 2012


Eugenette B. Saluta, M.D. (Incoming Year Level 1 in 2012)

Issues and Topics Discussed

Page

The Making of a Professional Physician


How should physicians promote a comprehensible
communication with their patients (and their relatives)?
How should physicians allay the fear and anxiety of
patients who are about to undergo an operation,
particularly those for the first time?
How to manage patients facing death? How to prepare
for the Great Inevitable?
How should physicians manage their parent-patients?

55

What to do when patients refuse medically-indicated


blood transfusion on the basis of their religions
doctrines?
How to deal with grumpy patients?

70

What should physicians do when they encounter


patients and relatives who have different expectations on
what they should be doing?
What is informed consent in medical management? How
should an informed consent be secured so that it fulfills
the legal requirements?
What to do when a physician has a different clinical
diagnosis in relation to another physician who was
previously consulted by a patient?
What to do when clinical and laboratory diagnoses do
not jibe with each other?
How to ensure no gauze sponge is unnecessarily left in
the operative area?
What is the value of needle evaluation of breast mass
over outright open excision-biopsy?
How should physicians fill up Social Security System
Sickness Notification forms properly and truthfully?

76

58
61
65

74

78

82
85
89
93
94

Back when I was still rotating as a clerk in the Surgery Department of


Ospital ng Maynila, I had already encountered Medical Anecdotal Reports
from the surgery residents. At first I thought they were a nice way of giving
others a glimpse on the day to day lives of surgery residents and thought
nothing much of it. But now as a Surgery Pre-Resident, I am beginning to
understand what the Medical Anecdotal Reports stands for.
A Medical Anecdotal Report as defined by the Updated Policies and
Procedures on Medical Anecdotal Reports (Dr. Joson, 2012) is a brief
report on a medically-related event encountered by the reporter which
provided an impact on the reporter, which 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, which
involves the processes of diagnosis and treatment of a medical condition;
Professional/ Ethical, which involves the handling of the patient; or
Psychosocial, which involves empathy for the patients medical condition.
As trainees in the art of surgery, we oftentimes are burdened by patient
loads and long hours that we unfortunately become jaded to our patients
sufferings. They become mere problems that we need to solve. But the
Medical Anecdotal Report I believe somehow allows the surgery residents
to see a lesson in every encounter with a patient. This reminds them that
despite the unpleasantness of a certain situation, there is a lesson that can be
learned and applied later on. As surgeons, we should all strive for continued
quality and excellence in our every work. Thus, every encounter should be
treated as a new learning experience whether it is a novel technique in
doing a routine procedure or a way of gaining the cooperation of a difficult
patient.
Surgeons of course should have excellent decision-making skills and
technical skills but our bedside manner to our patients still matters. The
patient-physician relationship could not be overemphasized. And empathy
towards others suffering as recorded in the Medical Anecdotal Reports
only confirms that we doctors are still human, capable of compassion and

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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:

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(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

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2012, Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg).


In my 12-month stay in this Department, the MAR project has developed
me not only to write a report but to reflect on myself every time I deal
with patients, colleagues and every person I am able to encounter during
work, inside and outside the hospital. Not only did it develop my writing
skills but also, teaching myself not only to hear but to listen to my fellow
residents MAR and apply the insights that they were able to share. Most
importantly, the MAR taught me discipline. We dont write the MAR for
the sake of presenting one. From one of my MAR, we do our work fast,
correct, relevantly complete and appreciated. I have a hard time putting
my experiences into words, but I always take extra time and effort to do it
right, putting into mind the objective of this MAR- development of
holistic, professional and compassionate physicians.
Lastly, I appreciate that the MAR has evolved in its own way. In time, the
MAR has moved from sharing it to residents in the Department, then to
students rotating in the Department, to colleagues through the
Yahoogroups and now worldwide through Facebook. I only recommend
that we residents, who are sharing our MAR be diligent in posting. We
have to be reminded that this is not only for us but also it may help other
physicians who are able to read these anecdotes. Also, diligent and
efficient posting would help in the compilation of the MARs for the
project of compiling it into a book.

1. As of June 2013, my estimate is that I have about 1,400 MARs (April


2004 to June 2013) to deal with in publishing a book on the MARs.
2. I will be publishing by volumes with 15 to 20 MARs per volume.
First volume should be out by November 2013. Subsequent volumes
will be out in 2014 and thereafter (I can continue to write after January
31, 2014).
3. I will be using the Internet to complement the book. Websites will be
created to host the MARs of the residents. The websites will contain
the original MARs written by the residents.
4. In the book, there will be minimal editing of the grammar and syntax
by yours truly on the MARs written by the residents. The MARs
published in the book can be compared with the original ones posted in
the websites. The comparison will allow readers to evaluate the level
of competency or degree of enhancement of the surgical residents in
their English writing skills as a result of the MAR activity.
5. At the bottom of each MAR that was written by a resident-reporter, I
will add a personal insight with a subtitle of ROJosons Insight
(TPORs). TPORs stands for thoughts, perceptions, opinions, and
recommendations. My insight will be limited to what I perceived as
actual and/or potential issues identified in and/or deduced from the
narration and insight of the residents. I will give my insight guided by
the following envisioned objectives of the MAR: development of
holistic, professional, and compassion physicians; improvement of
system of care in the department and in the hospital. I will refrain as
much as possible from commenting on the technical writing of each
resident-reporter.
I hope that with the abovementioned design, I will be approximating the
processes involved in making and presenting a MAR by the surgical
residents. The published MAR of a resident is my trigger for an insight. I
reflect and write my personal insight on the MAR of the resident. I can
have insight to his/her insight. I share my insight to the readers of this book
for feedback and more discussion through my email address:
rjoson2001@yahoo.com. With my insight directed and focusing on the
development of holistic, professional, and compassionate physicians and
improvement of system of care in the department and hospital, I hope to be
able to give to the readers something they can use in their setting, as a
patient, a medical learner or physician-student, a medical teacher or as a
hospital administrator. I hope that my thoughts, perceptions, opinions, and
recommendations (TPORs) will be able to motivate non-medical readers to
advocate for physicians who are holistic, professional and compassionate. I
hope my TPORs will be able to motivate the readers who are medical

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learners to become holistic, professional and compassionate physicians and


surgeons. Lastly, I hope my TPORs will be able to motivate the readers
who are medical teachers and hospital administrators to adopt the MAR
activity for their medical learners. All these three hopes that I just
mentioned are my ultimate goals in painstakingly publishing this book.
Only you, the readers of this book, can give me information on the impact
of this book. I will wait for your feedback in my email
(rjoson2001@yahoo.com) or through the website in which these MARs are
published (http://medicalanecdotalreportsvol1.wordpress.com).
At this point, I like to disclose that I did not hire a copy editor to check and
edit the grammar of the residents and even myself as the author of this
book. This is in consonance to my envisioned design for the book to
approximate the processes of the MAR. As mentioned above, the second
objective of the MAR is to enhance the English writing skills of the surgical
trainees. I purposely included this as another objective for the MAR
because of my personal observation that majority of Filipino physicians,
which include me, are not good English writers, even in writing technical
medical reports. With every resident writing 10 MARs a year and 50
MARs in 5 years (the duration of the surgical training), with the regular
feedback on the English grammar and syntax by colleagues and faculty (me
included), enhancement of the English writing skills is expected. I
mentioned in my action plans above that there will be minimal editing of
the MARs published in the book because I like the readers to evaluate the
level of competency or degree of enhancement of the surgical residents in
their English writing skills as a result of the MAR activity. Please give me
a feedback through rjoson2001@yahoo.com on how the surgical residents
who wrote the MARs fare in terms of English writing skills in the context
of a physician who are expected to write technical medical reports, not
literary prose. Please do the same for me as the author of this book. We
admit we are not excellent in English writing. We are contented with being
good in writing non-literary prose as long as we use English grammar
correctly; we are easily understood; and we continually improve.
I like to end my preface with acknowledgement of the following people and
institutions:
The Residents of the Department of Surgery of OMMC
The Consultants of the Department of Surgery of OMMC
The Don Go Peng Kuan Foundation
Dr. Elvie Razon
My family (Jackie, Lance aka Rey and Therese)

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

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Appendix 4
Feedback on the MAR by 15 Surgical Residents in 2006

Thank you very much for the support.


Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg
Email: rjoson2001@yahoo.com

What do you like least in OMMC Surgery MAR and why?


Residents still need to improve on English written skills.
Became a routine.
English composition skills of many are painful to the ear. After 3years of
MAR, they havent improved since they just let others edit their
compositions as needed.
Its nice to share experience but its difficult to make because its hard to
make a literary form.
Doing it on a monthly basis. mostly I ran out of interesting stories to tell.
Sometimes, I ran out of stories to share because it is done on a monthly
basis.
Having to squeeze out a story when there is nothing interesting to write
about. Being creative is tricky when one is out of material for inspiration.
In the hospital we have so many experiences regarding patients, but
formulating a topic is somewhat difficult.
The technical writing I guess because Im not a good writer. I have some
hard times putting my feelings and ideas into words.
Recommendations:
Open discussion to the medical students for insights and reactions,
furthermore, a MAR from their experience as a medical clerk in the
hospital.
Encourage everybody to make it a habit to prepare their MAR days before
the expected presentation and avoid cramming so as to produce good
compositions.
We have some of our MAR posted at the ward. I suggest we pick up
some MAR that was presented this year and post it in our hospital lobby
(tarpaulin).
We should fast track the publication of the MARs.
I like to see our fruits of labor (MAR) be published.

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11

Introduction

Appendix 4

There are 25 Medical Anecdotal Reports (MARs) contained in this first


volume, 23 written by the surgical residents of the Department of Surgery
of Ospital ng Maynila Medical Center and 2, by yours truly. Surgical
residents, in the context of this book, are those licensed physicians who
are pursuing on-the-job training to become specialists in general surgery.
In each of the 23 MARs written by the surgical residents and minimally
edited by yours truly, I added a personal insight with a subtitle of
ROJosons Insight (TPORs). TPORs stands for thoughts, perceptions,
opinions, and recommendations. My insight were limited to what I
perceived as actual and/or potential issues identified in and/or deduced
from the narration and insight of the residents. I gave my insight guided by
the envisioned key objectives of the MAR project, that is, development of
holistic, professional, and compassionate physicians.

Feedback on the MAR by 15 Surgical Residents in 2006

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.

What do you like most in OMMC Surgery MAR and why?


It helps me see things from a different prospective. I was able to learn things
based on my experience and the experiences of my co-resident.
It gave me the opportunity to share my stories and insights about it to other
residents.
MAR gives me the opportunity to express myself and share some stories
about my life as a doctor. This helps me in becoming a well-rounded
person.
It is a piece of writing wherein one is given the opportunity to reflect on the
psychosocial aspect of our profession. The sharing of emotions that exhibits
the humane facet of the mechanical world of surgery. It also brings the
consultants and residents to a carefree moment during conferences thus
building camaraderie between us.
Its an effective way of learning insights from the different levels of surgery
training from Level I to level V residents including the consultants. Each
anecdotes presented in the MAR is viewed differently by each members of
the Department and each member has an opportunity to express their views
during the open discussion.
MAR serves as a very effective training tool for us residents, not just for us
to discuss, analyze, and interact with one another the clinical aspect of our
training. It also help us to polish our attitudes, stimulate us to change toward
good behavior, serve as a constant reminder to avoid mistakes. It is also an
effective tool to polish our grammar and sharpen our writing skills.
It helped me realized that treating patient is not only by giving medicine but
also understanding them as well and also it helped to express my own
experiences to my co residents and listen to their own stories as well.

Medical Anecdotal Reporting as a Teaching-Learning Activity in a


Clinical Department in the Philippines [Abstract] (presented in the
4th Asia-Pacific Conference on Problem-based Learning in Health
Sciences in September of 2004)
List of surgical residents of OMMC Surgery who have written
MARs from 2004 to 2013

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.

External Anecdotal Feedback on the MAR in 2005


Feedback on the MAR Project by Surgical Residents in 2006
Feedback on the MAR Project by Surgical Residents in 2012

This book has an online version


(http://medicalanecdotalreportsvol1.wordpress.com).
Go to the Contents page
(http://medicalanecdotalreportsvol1.wordpress.com/contents) and click on
the links for each page, MAR and article you are interested to see and read.
In some of the MARs, there are recommended online links for further
readings. Thus, for those reading the hard copy of this book, they may have
to go online in they want to pursue the recommended supplementary
readings.
I wish every reader Happy Reading! If you have any concerns,
questions, and feedback, which I welcome wholeheartedly, please dont
hesitate to communicate with me through my email
(rjoson2001@yahoo.com) and /or cellphone (0918-8040304).
Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg

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

MAR Title: Holistic Surgeon


Reporter: Hazel Z.Turingan, MD
Year Reported: 2004

Feedback on the MAR by 15 Surgical Residents in 2006

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

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
Through the MAR, I have improved on my relational
15
skills with my patients, their relatives, my colleagues,
and my superiors.
Through the MAR, I was given the opportunity to be
15
more expressive.
Through the MAR, I was given the opportunity to
polish my written communication skills.

15

Through the MAR, I have improved on my English


composition skills.
The MAR can serve as an evaluation tool of students
learning.
Through the MAR, the cognitive domain of
competency of the students can be evaluated.

15

Through the MAR, the affective domain of


competency of the students can be evaluated.
The MAR has contributed to my discipline in terms of
following instructions and formats.
The MAR has contributed to my discipline in terms of
submitting my report on time.

15

Overall, I am satisfied with the MAR of OMMC


Surgery.
I recommend we maintain the MAR but we should
keep on refining to make it more effective and
efficient.

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

Through the MAR, I have placed more emphasis on


the psychosocial care of patient and have improved on
this aspect.
Through the MAR, I have become more aware of the
bioethical issues involved in patient care and have felt
improvement in this aspect of my patient
management.
Through the MAR, I have improved on the care of the
physical aspect of my patients problem.

14

106

ROJOSONs INSIGHT (TPORs):


What is a holistic physician?
There are varied concepts and definitions of holistic physicians. My
personal TPOR on the concept and definition of a holistic physician as of
this writing (August, 2013) consist of the following:
A holistic physician is a doctor of medicine (MD) with the following
characteristics:
1.

2.

3.

4.

A compleat physician who is highly skilled and accomplished in all


necessary and desired aspects (physician-individual-family-healthproblem-solver; physician-community-health-problem-solver;
physician-manager; physician-teacher-learner; physician-researcher).
An MD with systems approach in the management of a patient, that is,
looking simultaneously at both the parts and the whole of the patients
body and person and all the internal and external factors that may
influence the patients well-being.
An MD administering comprehensive and total care of a patient, that
is, covering all aspects of health (physical, psychological, and social
well-being), throughout the continuum of care (promotive, restorative,
supportive and preventive phases) and with management of the
external health-determining factors (social, cultural, religious,
economic, family and community).
An MD who serves not only as a biopsychosocial health counselor but
also as a life coach.

Below is a diagram that I made to illustrate the characteristics of a holistic


physician.

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

MAR as a reflective learning tool is a very strong


learning strategy in patient care.

15

MAR as a reflective learning tool has helped me


discover things in patient care that I have not known
or realized before.
MAR as a reflective learning tool has helped
reinforced the philosophies and principles on patient
care that I have held before.
MAR as a reflective learning tool has helped me
change the philosophies and principles on patient care
that I have held before.
MAR as a reflective learning tool has provided me the
stimulus for further learning, research, and
investigations on patient care.
Though frowned upon as a basis for decision-making
in patient management, experience and insight derived
from MAR, when properly used, can serve as basis
for patient care.

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

MAR Title: Breaking Bad Traditions and Breaking Bad Habits


Reporter: Jose Mario Amado M. Pingul, MD
Year Reported: 2004
NARRATION:
I was waiting at the 2nd floor lobby of the hospital when a staff from the
accounting department approached and asked me if I could circumcise her
son. I asked her how old her son was. She answered 10 years old. There
were no history of difficulty of urination and no recurrent urinary tract
infection. Otherwise the child seemed to be in a healthy state. So I asked
her why she wanted her child to be circumcised. The reply was kasi po
baka tuksuhin ng mga kaibigan. (Because he might be teased by his
friends.)
I told her that the department has a stand against routine circumcision. I
advised her that routine circumcision has no medical, spiritual, hormonal,
or economic advantage. The only indication for circumcision is the
presence of phimosis (narrow opening of foreskin) with associated
recurrent urinary tract infections. The staff is a very good friend of mine.
She approached me for help before on another patient, but this time the
help I could give her was a sound advice and reassurance that routine
circumcision is not needed. I told her that I also have a son and I have no
plan of doing routine circumcision on him.
INSIGHT:
A bad tradition begins very much like how a bad habit begins. First, there
is the experience then the acceptance, then it becomes routine, until a time
a nation is so immersed in the tradition that it cant be distinguished that it
was no good in the first place.
IDENTIFY = the first step is to identify that there is something wrong,
based on a rational, logical, and most of the time common sense analysis
of the situation.
DISCIPLINE = decide to break it and find ways to prevent it from
happening. We have to discipline ourselves as residents, always to educate
our patients against routine circumcision, and to refuse any offer in
exchange for the favor of doing circumcision.

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

John Llyod Fonte, MD


Alma Jawali, MD
Robelle Joan Peralta, MD
Marlon Caravana, MD
Ariel Celzo, MD
Aristoteles Ilarde, MD
Onofree OConnor, MD
Glenn Gervacio, MD
Voltaire Dela Cruz, MD
Rembo M. Aguda, MD
Jenny Vi H. de Castro MD
Angelica Montesa, MD
Jessie B. Oracion, MD
Romeo C. Abad, MD
Lucas Riel Bersamin, MD
Princess Beverlie Co, MD
Marco Antonio Sanico, MD
Sheena Shayne Siapno, MD
Glenn Villanueva, MD
John Alexis Canlas, MD
Marinelle Maulion, MD
Eugenette Saluta, MD
Mark Velez, MD
Owen Lizaso, 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

MAR Title: Its Never Enough


Reporter: Benjamin C. Deveza, MD
Year Reported: 2006
NARRATION:
My residency training opened my mind to a lot of things. Foremost are
the surgical cases I see, day in and day out. I said to myself, I must have
seen enough enough cases that will help me to develop my skills. But I
was wrong. I havent seen enough.
Our hospital has to undergo temporary closure and we were deployed to
another hospital, also in the City of Manila. It was my first duty in that
hospital and it was around 9 p.m. when my intern approached me and told
me that the nurse on duty had a referral. Doktor, may gustong ipakita sa
atin yung nurse. Kakaibang kaso daw. (Doctor, a nurse wanted us to see
a patient. The case is unique.) Those were the exact words of my intern.
Naturally, I wondered what it was. And so, we went to the emergency
room and checked on the patient.
He was a 47-year-old male whose skin on the ventral aspect of the shaft of
the penis got caught in a zipper. I asked him how it got there but he was
too timid to tell about it. I did my physical examination to check if there
was any other problem. After some time, I referred this to the consultant
on duty. He admitted that it was his first time to encounter such. He also
did his physical examination. He paused for a while, thinking of how we
can remove that zipper. After a few minutes, he asked the nurse to prepare
the materials. I prepared the site and placed some anesthesia. At first, we
tried to simply pull the skin off the zipper or vice versa. However, the
skin was very much adherent to the zipper. The consultant then decided to
cut a portion of the skin. And that was exactly what we did. We removed it
successfully. Before the patient left, I tried to ask him again how it got
there. All I got was a big smile and a scratch on the head.
INSIGHT:
Life is full of surprises. As well as residency.
I may have seen many cases in my almost two years in the training, cases
which help me to become a good surgeon. Some are ordinary while others
are rare. But no matter how you look at them, it will mold you in
becoming the best you can be.

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.

volume hopefully will come out by mid-2014.


Please give me feedback particularly on the following:
1. Usefulness of the book in the advocacy for the development of
holistic, professional, and compassionate physicians in the
Philippines.
2. How the surgical residents and I fare in terms of English writing
skills in the context of a physician who are expected to write
technical medical reports, not literary prose.
Thank you very much.
Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg

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.

Link to Reporters Original MAR:


http://medicalanecdotalreportsvol1.wordpress.com/2013/10/16/bcdevezasmar-06-03-its-never-enough

I included two of my personally written MARs to make a total of 25 in this


first volume, the rest of the 23 were by my surgical residents. The reason
for inclusion of my MARs is to bring out the value of role modelling on my
part.
There are 48 surgical residents who have written MARs from 2004 to 2013
(see Appendix 2). In this first-volume publication, I just picked out 23
MARs from 23 residents. The selection was done by convenience (readily
available in my files) and I made it in such a way that there was at least one
MAR per year from 2004 to 2013 and no two MARs per resident. In
subsequent volumes, the MARs of the other surgical residents not included
in the first volume, will be published. Thus, all the MARs of the 48
residents will eventually be published.
The main objective in the publication of the MARs is to advocate the
development of holistic, professional and compassionate surgeons and
physicians. I hope all the MARs in this first volume have somehow
brought out these values. Just to cite some examples, the MAR of Dr.
Turingan touches on holistic physician. The MAR of Dr. Velazquez, on
being a professional physician. That of Dr. Bersamin, on being a
compassionate physician.
In this first volume of the MARs, I included the feedback gotten in 2005,
2006 and 2008 (See Appendices 3 to 5). I plan to include feedback on this
first volume on the second volume. Thus, I would like to request all
readers of this first volume to send me feedback through email
(rjoson2001@yahoo.com) or through the online site
(https://medicalanecdotalreportvolume1.wordpress.com). The second

98

23

MAR Title: Learning the Hard Way


Reporter: Nolan O. Aludino, MD
Year Reported: 2005
NARRATION:
I was walking along the corridor of our ward when I was approached by a
middle-aged woman. She looked at me in the face and asked if I remember
her. Looking at her, I can honestly say that I didn't know her. Having been
put in an awkward situation, I told her that I have a vague recollection of
her. I then gave her a second look and saw that this woman had just
undergone a modified radical mastectomy (a breast cancer operation in
which the entire breast and the nodes in the armpit are removed).
The woman then looked at me straight in the eye and said that I was the
first doctor to see her at the outpatient department. I allegedly told her that
she had no palpable breast mass. Then she told me, "Dahil sa iyo,
naging stage two ako." (Because of you, my breast cancer became stage
2.)
INSIGHT:
As surgery residents, we encounter a multitude of patients. We
remember some of them but most escape our memories. One thing we do
not forget are the lessons we learn from each and every patient.

Link to Reporters Original MAR:


http://medicalanecdotalreportsvol1.wordpress.com/2013/10/27/allucerosmar-10-04-medical-certificate-extension

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

maximum of 120 days per year and only 90% of average


daily salary. For more information on the policies and
procedures of SSS on sickness notification and benefits, see
https://www.sss.gov.ph/sss/index2.jsp?
secid=788&cat=4&pg=null

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.

In the MAR of Dr. Lucero, she wrote:


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.
To avoid the nuisance of having to fill up another medical certificate for a
sickness extension, I suggest there be proper and clearly understood
communication with the patient at the initial certification using my usual
practices mentioned above, particularly, No. 2 (mutual agreement;
flexibility but not out of bound; making the patient aware that the SSS
physician having the final say; and limits of SSS benefits).
Physicians realize the importance being placed by their patients on the
sickness benefits that can be derived from SSS. They care for their
patients by being flexible and not be restrictive in their determination of
the recovery period. However, the caring through flexibility should not
be out of bounds. In the MAR, to place 60 days for the recovery period of
a superficial wound is really out of bounds and unrealistic. I agree with
the stand of Dr. Lucero. Again, to avoid the incidents of patients asking
for an unrealistic extension, I suggest there must be proper and clearly
understood communication with the patient at the initial certification.

Despite this unpleasant experience with a patient, regardless of whether the


allegation was true or not, Dr. Aludino looked at the incident with a
positive resolve, to learn from it and to do better next time. With humility,
he said, My encounter with this patient shows that I still have much to
learn. He appreciated the importance of learning from patients. He said,
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.
I am sure that as a result of this incident, which I think he will never forget,
Dr. Aludino will always be extra cautious in doing physical examination of
the breast to avoid a repeat of this unpleasant incident. This is learning the
hard way and its benefit is greater impact learning in terms of longer
retention of knowledge and skills.
What is the reality in learning medicine? Personally, I say learning
medicine is not easy. It is difficult. Some reasons for these two
complementary and reinforcing statements consist of the following: 1)
Medicine is an inexact science. Nothing is absolute in medicine. There are
so many labile facts and few hard facts. 2) There are so many things to
learn to be able to manage a patient effectively and holistically. 3) No two
patients are exactly the same. 4) There is no such thing as 100% certainty
and perfection 100% of the times in the management of patients, be it in
diagnosis, treatment, prevention, health maintenance and prognostication.
With this reality of difficulty in learning medicine due to the reasons
mentioned, learning medicine the hard way cannot be avoided. It will
always be there at one time or another as physicians continue to practice
medicine. They should accept this as a fact of life in medical learning and
just look at its benefit, greater impact learning.
Link to Reporters Original MAR:
http://medicalanecdotalreportsvol1.wordpress.com/2013/10/04/noaludinosmars-05-05-learning-the-hard-way/

96

25

fill up this form properly and truthfully.

MAR Title: Man of Honor


Reporter: Roderick S. Mujer, MD
Year Reported: 2006
NARRATION:
It was a fairly normal day at the Ospital ng Maynila Medical Center
Emergency Room, when a father carrying his 2-year-old son was referred
due to abdominal distention. Diagnosis was intussusception. Unfortunately,
the boys family lived in Pasay City. Hence, they were required to buy some
materials needed for the operation. Due to lack of funds, the father humbly
approached me to borrow money. He told me that he had seen me around
our neighborhood several times, openly narrating that he was a widower
with four children and without a stable job. Seeing him for the first time, I
hesitated to lend much help thinking he was pulling a fast one on me
making up the sob story.
Dawn was approaching when I saw him walk out the emergency room.
Curious, I followed him and saw him handing a pack of Skyflakes to three
young emaciated children. Each child with a hand outstretched waiting for a
piece of cracker. Seeing them aroused my compassion on their abject
condition. Right then and there, I resolved to help them with all I am able to.
I approached the father and handed him the amount he was attempting to
borrow from me earlier. I could still recall the bright smile that showed
gratitude when he took the money from my hand. He then promised to pay
me back as soon as he is able to. I never expected such, for in my heart he
had already paid me a thousandth times over. The feeling of self-respect is
priceless.

To facilitate filling up the SSS Sickness Notification forms properly and


truthfully, physicians must be familiar with the form, particularly, the part
that they as attending physicians must fill up, which is Part II Medical
Certificate (see portion of the form below). They must also be familiar
with the policies and procedures of the SSS, particularly, those associated
with the benefits that will be given by SSS and those that will be received
by the SSS member-patients.
In Part II of the form, what is challenging to fill up is the period of
convalescence or recuperation. This period is variable. I have yet to see an
official manual or reference from SSS and other health organizations in the
Philippines that contains information on the usual convalescent or
recuperation period by disease and treatment and which can be used by
physicians in filling up this particular item. Although the convalescent or
recuperation period is dependent primarily on the nature of the sickness and
the treatment administered, in reality, it is also dependent on the physical
and mental readiness, not to say, willingness, of the patients to resume their
occupational work. All these factors contribute to the challenge in filling
up the period of convalescence or recuperation.

A few weeks later, a seemingly familiar man approached me. He handed me


a white letter envelope. Still wondering, he told me that he was the father of
a previous patient, to whom the attending surgeon lent money to, in order for
the patient to live. I opened the envelope, and inside was the exact amount of
money I lent him few weeks ago.

Below are what I usually do when I fill up the period of convalescence or


recuperation:
1. I define convalescent, recuperating, or recovery period as the period it
usually takes for the patient to be ready to go back to his usual
occupational work. I consider first, experience with my previous
patients (track records) on the recovery period based on the nature of
the illness and treatment (especially, operative ones) done. Then, I
factor in the nature of the occupational work of my patient, whether
office or physical work, whether strenuous or not, etc. Lastly, I factor
in what the patient wants, such more days to stay away from work or
craving or need to go back to work in the soonest time possible.
2. Whatever period of convalescence or recuperation we agree upon, I
place it on the form. The agreement takes into the consideration the
following (aside from those I mentioned in No. 1):
A. I will be flexible but not out of bounds.
B. The patient is made aware that whatever period I place in the
form is still subject to the approval of the SSS physician.
C. I am aware and I make the patient aware of the limits of the
sickness benefits that the members can get from SSS such as

26

95

MAR Title: Medical Certificate Extension


Reporter: Alma Jawali Lucero, MD
Yea Reported: 2010
NARRATION:
We are busy attending to many patients in the Out Patient Department
(OPD) when a 31-year-old male came accompanied by one of our nursing
staff in the OPD. The patient asked me if I could sign his medical certificate
and Social Security System (SSS) form. As I read his chart, he was seen two
months ago at the emergency room. The patient sustained a laceration on the
plantar aspect (sole) of his left foot. I looked at his left foot and only a small
scar was left. I signed his medical certificate and SSS form and gave it back
to the patient. Few minutes after, the patient came back. He asked me if I
could change the duration of illness from 7 days to 60 days. He told me he
did not report to work for two months because he still experienced
occasional pain specially when wearing shoes. I told him the injury he
sustained was only a minor one and I could not extend the duration of illness
to 60 days. He told me Doctora, tulong mo na lang sa pamilya ko.
Matatanggal kasi ako sa trabaho. (Doctor, consider this as a help to my
family. I will be removed from my job.) I advised him to talk to his
employer and apologize for not reporting to work but Im sorry I could not
grant his request.

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.

Which indigent patients should physicians help? How to help indigent


patients? What should physicians do when patients or their relatives
ask them for money for their medical care?
There are three issues that I picked up from the MAR of Dr. Roderick
Mujer. See subheadings above.
Which indigent patients should physicians help?

ROJOSONS INSIGHT (TPORs):


How should physicians fill up Social Security System Sickness Notification
forms properly and truthfully?
In medical practice, physicians often encounter the situation of being asked
to fill up Social Security System (SSS) Sickness Notification forms of their
patients who are members of SSS. For this reason, they must know how to

94

In the course of practicing medicine, physicians will invariably encounter


true and dubious indigent patients. Dubious indigent patients can be
classified into two types, namely, the fake ones who actually have money
to spend for medical care but pretend to have none and those who cannot
afford medical care because of absence of drive to earn money and who
keep on relying on alms and external help. The true indigent patients are
those who do not have any amount of money at all and those who do not

27

have enough money to spend for their medical care because of


circumstances beyond their control.
I like to believe that all physicians are compassionate people as a result of
their training and by the nature of their profession. They are always willing
to help indigent patients, all if possible, if not, selective ones. Physicians
definitely will not help dubious indigent patients. Since dubious indigent
patients abound in the community, physicians are always vigilant in
distinguishing them from the true indigent patients. Otherwise, their acts of
compassion will go to the wrong recipients.

MAR Title: Needle Evaluation of Breast Mass over Outright Open


Excision-Biopsy
Reporter: Reynaldo O. Joson, MD
Year Reported: 2004
NARRATION:
A 40-year-old female came to my clinic for second opinion on her health
problem of breast mass. On palpation, she had a 3-cm breast lump on her
left breast, well-defined, movable, without any associated ipsilateral axillary
lymph node.

How to help indigent patients?


The amount of true indigent patients in the Philippines is plentiful. It is
impossible for one physician to help all true indigent patients he / she
encounters. Thus, he has to be selective. Selective can be in terms of types
of help he/she will give, such as free consultation; free operations; referral
to other institutions where the patient can afford the cost of treatment; and
even financial assistance at times. Selective can also be in terms of which
types of true indigent patients he/she wants to help, such as the abandoned
ones and those who have no money at all.
What should physicians do when patients or their relatives ask them for
money for their medical care?
Though uncommon, there are instances in which physicians are asked
financial assistance by patients and their relatives for their medical care,
particularly on urgently needed drugs and surgical supplies. The decision
to give rests on the physicians after assessing the situation. Below are my
personal practices. 1) I make sure that the patient is truly indigent and has
no resources whatsoever to tap from relatives and guardians. I give priority
to abandoned indigent patients and those who have no money at all. 2) I
give if financial assistance is direly needed to secure drugs and surgical
supplies in order to save and prolong life of patients who are not terminallyill and who have good chances for a quality and productive life. 3) If I
decide to give financial assistance, I dont exact a payback. 4) Aside from
giving financial assistance, if within my capacity and capability, I try to
help the true indigent patients in other non-financial aspects such as free
services, psychosocial support and referrals.

My primary diagnosis was benign (60%) and my secondary diagnosis was


malignant (40%).
I recommended needle evaluation to which she agreed. Through the needle
(G-19, 1.5 inch) attached to a 20-cc syringe, I aspirated 15 cc of brown fluid.
After the aspiration, the mass completely disappeared. Thus, my postaspiration diagnosis was Macrocyst, Left Breast with 99% certainty.
After the procedure, the patient divulged to me that a surgeon in another
private hospital was recommending outright operation for which she was
asked to prepare PhP 30,000.
With what I did, I saved her from an unnecessary operation, expenses of PhP
30,000, pain, and scar.
She was so happy that she gave me pizza on top of my professional fee and
she promised she will refer patients to me.
INSIGHT:
A needle evaluation can give an instant diagnosis at the clinic. It can save
unnecessary operation, expenses, pain, and scar.
It is alright that as surgeon you receive less in terms of professional fee when
you do needle evaluation compared to when you do an outright open
excision-biopsy. You are doing the patient a great humanitarian service.
You will be rewarded in the future with more patients and in other ways.
You will be known as a surgeon who is not knife-happy.

Postscript:

28

93

3.

gauze sponges with radio-opaque markers; if not, be


vigilant on tracking the sponges);
F. Gauze sponges being used are proportionately small that
can easily get lost or be difficult to track (if possible, use
proportionately big gauze sponges; if not, be vigilant on
tracking the sponges).
During all operations, the surgeon, while operating, should
constantly be vigilant in knowing where he places sponges in the
operative area and their number. He should avoid placing sponges
in areas that are at risk at getting lost or difficult to track. In other
words, he should constantly and vigilantly keep track of all the
sponges he asks and uses.

Link to Reporters Original MAR:


http://medicalanecdotalreportsvol1.wordpress.com/2013/09/24/jgguerrasmar-05-02-unaccounted-sponge/

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

recommendations) on how to ensure that no gauze sponge is unnecessarily


left behind in an operative area of a patients body:

MAR Title: A Patient of Honor


Reporter: Reynaldo O. Joson, MD
Year Reported: 2013

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.

In all operations, the surgeon as the team leader should remind


himself and his team members that at the end of the operation, no
gauze sponge shall be unnecessarily left behind in the operative
area. This reminder can be done during the time-out and signout parts of the World Health Organization Surgical Safety
Checklist. In the sign-out part of the Checklist, there is an item
that says instrument, sponge and needle counts are correct.
This item is a good preventive reminder but it is done at the end
of the operation. In the current time-out part of the Checklist,
which is done before the surgeon makes his incision, there is no
item that reminds the team of importance of sponge count. I
recommend that a reminder be done in the time-out by way of
telling the whole surgical team the initial sponge count with
identification of at least two members of the operating team who
collaborated in the counting.
Before and during all operations, the surgeon as the team leader
should assess the risk of a gauze sponge being unnecessarily left
behind in the operative area that may result from a real missing
sponge and/or from an initial incorrect count. Examples of risk
factors include the following with corresponding recommended
risk preventive measure in parentheses:
A. Incompetency of the operating team members such as in
making a correct initial sponge count and in constantly
tracking the addition and whereabouts of the used gauze
sponges (the team members should be trained on these
competencies);
B. Change of members of the operating team, particularly,
the nurses, during a long operation (there must a
counting and tracking of the sponges during the
endorsement of nurses);
C. Presence of a huge cavity with mobile viscera, such as
the peritoneal cavity, where gauzes can easily get lost or
be difficult to track (the surgeon should be vigilant
against this risk);
D. Presence of a big pool of blood and other types of fluid
where gauzes can easily get lost or be difficult to track
(the surgeon should be vigilant against this risk);
E. Gauze sponges being used have no radio-opague
markers that can be detected by x-rays (if possible, use

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.

since 1982 when I started my private practice: 1) I quote my professional


fees together with the other expenses patients have to prepare for their
medical care; 2) I allow rooms for negotiation on my professional fees
because of an openly declared policy that I will not turn down my service
just because a patient cannot afford my professional fees; 3) I allow
incomplete payment on my professional fees; 4) I do not run after those who
could not pay my professional fees in full.
This was what happened in Clementes case. I did not run after her and her
mother to pay the balance in my professional fee. I have plenty of such
cases. Clementes case stands out, not only because it is most recent but also
because it portrays her as a patient of honor.

ROJOSONs INSIGHT (TPORs):


How to ensure no gauze sponge is unnecessarily left in the operative
area?
Gauze sponges are commonly used during operations for many purposes
to blot dry and wipe clean an operative area; to press and pack to minimize
bleeding and spillage; to protect tissues from contamination and injury; to
dress wounds; etc.
Gauze sponges are usually made of cotton and therefore, considered as
materials foreign to the human body. They cannot and should not be left
behind on a permanent basis or for a long time in the patients body after
an operation. If this happens, an infection will ensue. Gauze sponges
intentionally left behind in a patients body after an operation are usually
done to control bleeding through pressure packing. A surgeon can resort to
this maneuver of controlling bleeding if he thinks it is the best procedure to
do at the time of the operation. The gauze sponges intentionally left behind
are usually removed two to three days after.
Outside the scenario of extensive bleeding in which gauze sponges can be
intentionally and temporarily left behind for pressure packing, all surgeons
should ensure that no gauze sponge is ever left behind in any operative
area.
The following are my TPORs (thoughts, perceptions, opinions, and

90

31

MAR Title: Helping an Indigent Patient throught IPHP (Indigent


Patient Help Program)
Reporter: Onofree L. OConnor, MD
Year Reported: 2012

MAR Title: Unaccounted Sponge


Reporter: Jeffy G. Guerra, MD
Year Reported: 2005
NARRATION:

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

It was a humid Sunday morning in February when I got up from bed to


prepare for another day in the hospital. Like any other duty day, I anticipated
it to be an ordinary day - morning rounds, manning the emergency room as
well as performing emergency operations. There was no indication that it
would be different from any other day.
At around 1 pm, I was called upon by my senior to operate on a 16-year-old
male diagnosed with acute appendicitis. Routinely, I did my preoperative
assessment and physical examination. In a few minutes, I and my surgical
intern and clerk were doing the operation. Step by step, I described the
operative technique, pathophysiology of appendicitis, treatment and followup plan to my assistants. The operation went on smoothly.
Before I started to close the peritoneum (a lining of the abdomen), I asked
my clerk as well as my circulating nurse to do the sponge count. After a
while, they confirmed that sponges were complete. I proceeded with the
closure of the incision. Halfway on the peritoneum, half jokingly, I asked
the nurse, "complete sponge count ba talaga?" (really complete sponge
count?) The nurse responded with a smile, "syempre doktor, gusto mo ulitin
ko ulet eh!?" (of course, doctor, do you want me to repeat the count?) She
started counting the sponges again and to my surprise, she replied in shock,
"kulang po ng isang sponge." (lacking one sponge) What??? I searched my
operative field and to my dismay, I found nothing. I instructed the nurse to
check under the operative drapes and table and still there was no trace of the
missing sponge. After repeated counting by the nurses, one sponge was
unaccounted for! Tension was building up in me and I had to say, it was
becoming unbearable. After coming from a blank wall," I regained my
composure. I decided to check the abdomen. I slightly loosened the suture
and started palpating for the sponge. After a few minutes of exploration, I
got hold of the sponge. As I was trying to recall, after the first sponge count,
it was my habit to put a sponge under the peritoneum while closing it to
prevent injury to the bowel.
At long last, my operation ended... I told myself it will not happen again.. I
hope

89

The above recommendations on what to do when the clinical and laboratory


diagnoses do not jibe are applicable in both emergency and non-emergency
settings. However, in emergency settings, promptness and appropriateness
of decision and implementation of action plans are of utmost importance in
avoiding delays of life-saving treatment. In the MAR of Dr. Fonte,
although the Focused Abdominal Sonography for Trauma (FAST) was
interpreted as normal sonogram, he decided to operate on the patient
because of the presence of distended abdomen with tenderness on the upper
quadrants which are signals for an acute surgical abdomen. The latter
means the patient had injuries in his abdomen that needed to be treated with
an operation right away. He decided to operate not opting to repeat or do
another diagnostic examination because of the urgency of the situation. His
decision turned out to be correct in terms of diagnosis and eventually the
treatment outcome.

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.

I started an Indigent Patient Help Program in 2001 when I became


Chairman of the Department of Surgery of Ospital ng Maynila Medical
Center. The objectives have been: 1) NO delay in treatment because of
indigency reason and 2) NO patient is deprived of proper surgical treatment
because of indigency reason. The program consists basically of the
Indigent Patient Help Boxes which contain stand-by surgical supplies and
medicines to be used for indigent patients when the inventory of the
hospital is depleted. Each resident has an Indigent Patient Help Box whose
inventory has been maintained through donations from external
benefactors, consultants, and alumni. The program also consists of a stand
-by emergency fund to be used for emergency purchase of supplies that are
not available in the Boxes.

Recommended Further Readings and References:


Management of a Patient Process
https://sites.google.com/site/patientmanagementprocess/management-of-apatient-process
Paraclinical Diagnostic Procedures and Processes
http://rojosonmedicaleducation.wordpress.com/2013/03/11/theparaclinical-diagnostic-process/

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:

Link to Reporters Original MAR:


http://medicalanecdotalreportsvol1.wordpress.com/2013/06/19/jlffontesmar-12-06-conflicting-results-of-clinical-and-diagnostic-examinations/

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.

There will always be indigent patient incidents in all hospitals, be it


in the private and government settings, but definitely more common in
the latter. The indigent patient incidents are a result of the presence
of indigent patients in the community and which abound in government
hospitals. These are the patients who dont have enough money to
secure the needed medicines, supplies, and tests if these cannot be
given for free.
The costs of providing and getting healthcare are very high. For these
reasons, no hospitals, particularly government ones, can claim they

33

3.

4.

5.

would be able to provide all healthcare medicines, supplies, and tests to


all patients who go to them, more so if they intend to give everything for
free. It will be extremely difficult to sustain hospitals with such an
approach.
There is a need for the governing body in the hospital to find ways on
how to help the indigent patient incidents. There should be a
reasonable contingent budget for the indigent patient incidents.
However, despite this, expect there will always be indigent patient
incidents.
There is a need for the practicing physicians to assist the hospital
administration in mitigating the indigent patient incidents. Providing
cost-effective management is one way of mitigation. With costeffective management, premature depletion of funds for indigent
patient incidents can be mitigated.
Managing patients without the needed medicines and supplies can be
very frustrating and depressing for the physicians, especially during
emergencies. This was the main driver for creating the Indigent Patient
Help Program of the Department of Surgery. The other driver for the
Program was the need to provide quality and safe patient services even
for indigent patients.

2.

3.

34

diagnosis of the physician-clinician, accept the laboratory


diagnosis and make it the pre-treatment diagnosis. In all patients
initially evaluated by a physician-clinician, there must be the socalled set of clinical diagnoses. This set should consist of the
primary and secondary clinical diagnoses. The primary clinical
diagnosis is what the physician-clinician thinks is most probable or
most likely and the secondary clinical diagnosis, the second most
probable or most likely.
If the laboratory diagnosis is not within the set of primary and
secondary clinical diagnoses formulated by the physicianclinician, he should go back to the patient and review the data he
got from the interview and physical examination. He should
recheck the completeness and accuracy of the data previously
obtained and then make a decision as to whether to stick to his
original set of clinical diagnoses or change it. He should not
change it simply because of the presence of a laboratory diagnosis
that is different from his clinical diagnoses. He must try to
reconcile the clinical diagnosis and the laboratory diagnosis. A
deciding factor is whether the data from the interview and physical
examination can support the laboratory diagnosis. If the answer
is yes, the physician-clinician should accept the laboratory
diagnosis as the pretreatment diagnosis.
If after the clinical review, the data from the interview and
physical examination cannot support the laboratory diagnosis, the
physician-clinician has the following options to help him in his
problem-solving and decision-making:
A. Study carefully the outputs of laboratory examinations and the
interpretations of the physician-diagnosticians. Look at the
outputs and make an interpretation, if the physician-clinician
is capable. Talk with the medical technician who did the
laboratory examination and the physician-diagnostician who
did the interpretation. Make a decision - accept the laboratory
diagnosis (if convinced and another round of review of the
clinical data can now support it) or put it on hold (decide on
another option - see B and C below).
B. Repeat the laboratory examination if there is something to
improve on the procedure, particularly on the technique.
Make a decision.
C. Do another laboratory examination or paraclinical diagnostic
procedure if repeating the same procedure will not be
productive as assessed by the physician-clinician. Make a
decision.

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?

For pictures of the OMMC Department of Surgery Indigent Patient Help


Box / Program, visit:
https://www.facebook.com/media/set/?
set=a.10151121154305800.438627.726455799&type=1&l=c69342cbce
Link to Reporters Original MAR:
http://medicalanecdotalreportsvol1.wordpress.com/2013/10/27/oloconnorsmar-12-08-helping-an-indigent-patient-through-iphp-indigent-patient-helpprogram

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.

If the laboratory diagnosis is the same as the secondary clinical

86

35

MAR Title: Caring for an Abandoned Patient


Reporter: Lucas Riel B. Bersamin, MD
Year Reported: 2013

MAR Title: Conflicting Results of Clinical and Diagnostic


Examinations
Reporter: John Lloyd F. Fonte, MD

NARRATION:

Year Reported: 2012

I was the surgery resident-on-duty at the emergency department when an


88-year-old man came in accompanied by several companions. He was
unkempt, rough, and seemed neglected based on the look of the dirt on his
feet and his wounds. I inquired about the reason for consult and one of
those who accompanied him explained that their patient was suffering from
a severe soft-tissue infection in the leg. He also explained that they had
been rejected by four other hospitals from two other cities. Realizing their
struggle, I accepted the patient in our institution.
After the initial survey, I asked the companions to register their patient and
bring him to our treatment area. Primary care of the patient was rendered
and some antibiotics were initially given. After a few hours seeing some
other patients in the emergency room, I noted that the patient was lying all
alone in the bed calling me for some water to drink. I asked him: Where
did your companions go? He replied: I dont know; they had somewhere
else to be I guess. I then bought him a bottle of water and asked the nurse
on duty to get him some food from the dietary supply if there were still any
left.
Twenty-four hours had gone by since then and upon going back to this
patient, he was still all alone. I admitted him under our service and provided
all forms of care possible since he was abandoned. On his first day in the
hospital, I found him in his bed with flies feasting on the stench of his
excreta. I thought that this patient was too much to handle since he could
not seem to keep himself clean and had no means of support for
medications and care. I realized that for my patient to get better, I had to
facilitate everything needed to be done in caring for him. I bathed him,
secured his medications, and even cleansed him up after a bowel
movement. Debridement (removal of necrotic tissue) was done after the
hygienic care. This continued for a time. I must admit that I become queasy
at times and feel my stomach revolting after these actions.

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

Weve been trained to apply the patient management process to arrive at a


primary clinical diagnosis with high degree of certainty enough to initiate the
most cost-effective treatment plan for our patients. With the use of the
patients history and our physical examination findings, we have learned to
recognize patterns of disease processes that we can use to arrive at a primary
and secondary diagnosis. If two or more disease entities present with a
similar pattern, then we use prevalence. After utilizing these and we do not
yet achieve the desired degree of certainty, then we can utilize paraclinical
diagnostic procedure. Proper use of these procedures is not just helpful but
also prudent if we are to put in mind the patients best interest. However, in
the face of conflicting clinical and diagnostic procedure findings, the former
should still have more bearing because the patients body will not lie. It

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/

of disbelief. Why do I do it? I seemed to have also asked myself this


question before and after caring for this abandoned patient. I just then tried
to strengthen my resolve with the thinking that the wounds will not heal if
the body is not clean. This was the reason why I kept on doing it.
INSIGHT:
In our institution, we commonly encounter neglected and abandoned
patients seeking medical-surgical attention. We should treat them
holistically, rather than just concentrating on the problems they know.
Entailing more sensibility for our humanitarian efforts, we provide our
patients complete care by treating their body and not just their limb or a
fraction of the body with injury and illness. Facilitating total care helps
them in getting better physically, psychologically, and emotionally. Caring
for these individuals, I realized that I may be the only person with
significance to them. The monetary cost for this whole process may have
been great for me but the chances of my patients survival would be a fair
trade. I also observed a chain reaction to some degree with the amount of
attention given to this patient. I found my junior residents becoming more
proactive in the care for him as well as the medical clerks and nurses. The
referral and assistance from the social service department has been fast
tracked and a steady stream of materials for care and medications has been
there from other individuals. As doctors, we may not be as comfortable
with these nursing actions but we know we had to take the lead at times
and facilitate care primarily. We should also consider conditioning these
patients that although they may be neglected in health and care, they
should not fall victim to these thoughts and lie in wait for action. Optimal
prognosis is better achieved with their participation. In the end, treating
the illness and improving the quality of life of our patients, regardless of
stature and classification, is our objective.
ROJOSONs INSIGHT (TPORs):
How to manage abandoned patients in a hospital setting? What is
compassion? What is compassionate care? What is the highest degree
of compassionate care?
All hospitals at one time or another will encounter incidents of abandoned
patients. These incidents are more common in government hospitals than
in private ones. As an offshoot of this MAR, I asked Dr. Bersamin to get
statistics on abandoned patients in OMMC. Just for the Department of

84

37

Surgery alone, the reported cases of abandoned patients were as follows:


2010 (1); 2011 (6); 2012 (11) and January to June of 2013 (4). All of the
abandoned patients who recovered from their sickness in OMMC were
eventually transferred to housing or homing institutions like Hospicio De
San Jose, Tahanang Walang Hagdan, Missionary of the Poor, etc.
Whether government or private, all hospitals must have preparedness and
response plans for abandoned patients. Upon entry of all patients to the
hospital seeking medical treatment, aside from the personal data, there must
be records of complete and accurate data of their relatives and guardians,
particularly, on addresses and contact numbers. This is the first step to
prevent and mitigate the incidence of abandoned patients. In addition to
this, there must be preparedness plans for response in case an incident of
abandoned patient was not avoided by the first step.
The response procedures must be guided by at least three policies.
First policy: The hospital is not intended to be a long-term, more so, a
permanent, housing or homing institution for abandoned patients. After
being provided treatment, an abandoned patient should be discharged in the
soonest time possible to an institution that has been prearranged by the
hospital to accept him for housing or homing purposes.
Second policy: Compassionate care, both medical- and non-medical-wise,
must be accorded to abandoned patients at all times by the hospital
administration, social service department, medical staff, allied medical staff
and support staff during their stay in the hospital.
Third policy: Expenses incurred in caring for the moneyless abandoned
patients should be charged to the compassionate care program, social
program or corporate social responsibility program of the hospital.
Thus, the first thing to do, in case an incident of abandoned patient has
occurred, consist primarily of activating the abandoned patient response
plan. This translates to the attending medical and nursing staff informing
the hospital administration and the social service department of such an
incident. An incident command or task force can be created to promote
coordination and collaboration of administration, healthcare team, and
social workers, specifically in terms of logistics, medical care, and looking
of the housing and homing institution for the abandoned patients in the
soonest time possible after medical treatment.

38

to both. Why? Because my oath is both to my patients and my


colleagues. But there should always be a balance to things. True ,the
patient has a right to complete disclosure but there will always be a way
to explain things without incriminating the first doctor who saw the
patient. It is not a healthy practice to bad-mouth our fellow physicians
especially in the light that our diagnosis is not 100% foolproof. We
should remember that what goes around comes around. The same
courtesy we give will be the same one we will get.
ROJOSONs INSIGHT (TPORs):
What to do when a physician has a different clinical diagnosis in
relation to another physician who was previously consulted by a
patient?
Clinical diagnosis refers to the assessment 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.
Oftentimes, there are differing clinical diagnoses formulated by different
physician-clinicians for the same patient. What should the second
physician-clinician do when his/her clinical diagnosis differs from that of
the first physician-clinician who previously saw the patient?
The second physician should always be professional and ethical in
thoughts and behavior in treating the first physician in absentia. He/she
should not outrightly and bluntly tell the patient and his/her relatives that
the clinical diagnosis of the first physician was wrong. When asked, he/
she should just say that there was a difference in opinion between two
physician-clinicians, which commonly occurs in the practice of medicine.
This is reason why the practice of seeking a second opinion is being
advocated.
The second physician should always give the first physician the benefit
of the doubt. The first physician may have been constrained by the
inadequate and uncertain data given to or obtained by him.
The second physician should not criticize the first physician, whether
overtly or vaguely.

83

MAR Title: Explaining a Colleagues Differing Diagnosis


Reporter: Edelweis Z. Velasquez, MD
Year Reported: 2008
NARRATION:
I got a call from one of my consultants one duty night. He informed me
that a patient from Valenzuela, a 5-year-old male complaining of abdominal
pain of 4 days duration, will be transferred to our institution. The patient
was referred to him by a Pediatric Surgery fellow from the transferring
hospital and was endorsed as a non-surgical case. Our consultant, however,
decided to have the patient observed and evaluated further. Thus, the cause
for transfer.
Upon arrival of the patient, I did my history taking and physical
examination. It was indeed a 4-day-history of vague abdominal pain which
later localized to the right lower quadrant accompanied by several episodes
of vomiting and fever. He was brought for consult at the previous hospital
and was observed for almost 2 days. Physical examination revealed a toxic
looking, lethargic, and dehydrated patient. The abdomen was distended
with guarding and tenderness on all quadrants. After my evaluation, I
thought it could not get anymore surgical than it was. I was considering a
case of ruptured appendicitis with generalized peritonitis. I informed my
consultant of my findings. I tried to explain to the parents the diagnosis,
the patients present condition, and the contemplated procedure, with its
risks and benefits. As I expected, questions as to why he was not diagnosed
earlier by the previous physician came up. Admittedly, I was annoyed with
the physician who first saw the patient but then I thought, who am I to
judge him. I was not in the perfect position to speak for the said doctor but
nevertheless, I tried. After much explaining, they consented to the operation. The patient was subsequently wheeled-in to the operating room.
True enough, the intra-operative finding was exactly what I thought it
would be.
INSIGHT:
I am sure that at least once during our entire medical career, we will
encounter a patient who was previously seen by another doctor and was
given a diagnosis that is entirely different from ours. What do we do then?
Do we blow the whistle on a fellow physician? Or do we try to white wash
the misdiagnosis? When I thought about it, I realized that I cannot say yes

82

In this MAR, one can see the 3-pronged management of an abandoned


patient in action, collaborated by the administration, social service, and
healthcare team led by Dr. Bersamin. As the attending physician, Dr.
Bersamin has shown compassion to the highest degree in caring for the
abandoned 88-year-old patient. His actuations, from medical care to
nursing care and even financial assistance, truly and literally fit into the
dictionary definition of compassion, which is a feeling of deep sympathy
and sorrow for another who is stricken by misfortune, accompanied by a
strong desire to alleviate the suffering. (http://dictionary.reference.com/
browse/compassion)
All physicians are expected to be compassionate to patients. There are
various degrees of compassion. At the moment, I have yet to come across
a standard and universally-accepted classification or categorization of the
degrees of compassion that physicians manifest towards patients. In the
absence of a classification, I will now attempt to have a simple one using
the above definition of compassion. I will start with the premise that the
deeper the sympathy, the stronger is the desire to alleviate. The stronger
the desire to alleviate, the greater and heavier the assistance to give.
Ultimately, it is the assessment of the magnitude and weight of assistance
given that determines the degree of compassion. The highest degree of
compassion will consist of giving very extraordinary assistance, especially
one that approximates the popular phrase of blood, toils, tears, and
sweat of Winston Churchill. Dr. Bersamin is a physician-surgeon.
Doing what he said I bathed him, secured his medications, and even
cleansed him up after a bowel movement is very extraordinary in his
capacity as a physician-surgeon. He was really giving the patient utmost
personal attention and care. That to me is the highest degree of
compassionate care.
To be compassionate, however, a physician does not have to be always
giving very extraordinary care. The compassionate care can be just
extraordinary or ordinary. What is most important to remember is that any
action of a physician that results from a sympathy of a patients misfortune
and which will assist or promote recovery of his health is compassionate
care and the physician who gives the compassionate care is a
compassionate physician.
Link to Reporters Original MAR:
http://medicalanecdotalreportsvol1.wordpress.com/2013/10/06/
lbbersamins-mar-13-08-caring-for-an-abandoned-patient

39

MAR Title: The Advantages of Giving Out Your Cellphone Number


Reporter: Harvey A. Balucating, MD
Year Reported: 2007

chosen. This piece of paper that contains my explanation with signature of


the patient or his guardian affixed constitutes the informed consent. I give
a copy of the informed consent to the patient and I keep one.

NARRATION:

For illustrative examples of my informed consent, see http://


medicalanecdotalreportsvol1.wordpress.com/2013/10/27/informed-consent

I first saw this patient when he was referred to me at the Out-patient


Department. He is a 67-year-old male who had been suffering from 4-year
history of difficulty in urination. He sought several consult from different
institutions before he made his consult at Ospital ng Maynila Medical
Center. His x-ray revealed a large (8 x 6 cm) urinary bladder stone. As
Urology rotator, I was the one in charge of this patient. I referred him to
our consultant. The plan of operation was cystolithotomy (removal of
urinary bladder stone) with possible open prostatectomy (operation on the
prostate), depending on the intra-operative finding. To make sure that he
would not be lost to follow-up, I readily gave my cellphone number in case
he had some inquiry about his case. Several calls and inquiries were made
between me and the patient before the he finally decided to undergo the
proposed procedure. We only did a cystolithotomy because intraoperatively, the prostate was not palpable from the bladder lumina and was
not obstructing the bladder outlet. His post-operative stay at the hospital
was unremarkable. I discharged him with advices to maintain his urinary
catheter and to take his oral antibiotics for one more week. After 1 week, I
removed his catheter. Several hours after removal, I received a call from
his wife telling me that my patient had spiking fever and difficulty in
urination. Fortunately, I was on duty at that time so I advised her to bring
the patient to our emergency room. Upon seeing the patient, I referred him
back to our consultant. He told me to reinsert the urinary catheter; resume
oral antibiotics and start alpha-2 agonist (a drug) for his benign prostatic
hypertrophy; and send the patient home. My patient and I kept our
communication during the 2-week period. I was even the one who
reminded him about his scheduled removal of the urinary catheter. There
was no problem noted after the removal of the reinserted catheter. One
week after his last consult, I received a text message from his wife.
Apparently, the patient could not move the left side of his body. I
suspected my patient to be suffering from stroke so I advised his wife to
bring him to the hospital. The following day, I again received a text
message thanking me for advising them to seek immediate consult. His
husband had a stroke and was admitted at a private hospital.

Link to Reporters Original MAR:


http://medicalanecdotalreportsvol1.wordpress.com/2013/10/27/masunazsmar-09-07-informed-consent-for-real

INSIGHT:

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81

dissatisfaction, complaint and even medicolegal suit is reduced. Patients


cooperation in the treatment is promoted and facilitated by an informed
consent.

Among the patients whom I gave my personal number to, I was able to see
the advantages in this particular patient.

When should an informed consent be secured by a physician? It should be


done anytime and before a medical procedure will be done. Examples of
procedures that need an informed consent are operations, chemotherapy,
endoscopy, inpatient admission, and radiotherapy.

1.

Where can an informed consent be secured? It can be secured at the point of


care at the physician's clinic, emergency room, inpatient room, operating
room, diagnostic rooms, etc.

3.

What are two challenges in securing an informed consent?


The first challenge is on the accomplishment of the legal requirements of the
informed consent - how the physician can make an explanation that is
complete and clearly understood by the patient or his guardian. I will give
some tips on how to cope with this challenge after I discuss briefly the
second challenge.
The second challenge is the fear and anxiety that usually arise from the
explanation, particularly on the risks of the medical procedure. The fear and
anxiety can lead to a refusal of the patient to the recommended treatment. I
have two recommendations on this challenge. One, do not omit explanation
on the risk just because of the potential fear and anxiety that may lead to
patients refusal for a medical procedure. Never say there is absolutely no
risk with the recommended medical procedure. Second, explain the risks and
side effects of the medical procedure truthfully but in a manner that is not
too fearsome. Modulate explanation in term of timing, rate, and use of
words. Allay fear with comforting words.
How should an informed consent be secured so that it fulfills the legal
requirements? There are so many ways of securing the informed consent.

2.

By giving him my personal number, I was able to coordinate with him


pre-operatively and answer his questions about his operation and
lessen his hesitancy.
On two separate occasions, I was able to catch early his surgical and
medical problem, both requiring emergent medical attention.
I still believe that we should not readily give our personal contact
number to our patients. However, in some instance that we have to
give them our contact number, we should be cautious and selective.
Patients welfare and continuance of care should be our priority and
the main reason for doing such.

ROJOSONs INSIGHT (TPORs):


Should physicians give their cellphone number to their patients?
Most physicians in the Philippines are reluctant to give their cellphone
numbers to their patients. The primary reason is that they do not want to
be disturbed by their patients after their stint of duty in the hospital and
clinic. Initially, I too, was very reluctant to give me cellphone number to
my patients. I also did not want to be disturbed. However, over the past 6
years, since 2007, I have become more liberal in giving my cellphone
number to my patients. I felt it to be a value-added service to my patients.
(Note: I remember in 2007 after the discussion of the MAR of Dr.
Balucating, although I advised the surgical residents to be selective in
giving out their cellphone numbers and make decision based on judgement
call, I was already encouraging them to be more liberal. I told them that
aside from facilitating scheduling of operations in the Department of
Surgery of Ospital ng Maynila Medical Center [OMMC] and follow-up of
medical management, the giving of cellphone numbers will establish a
patient-client base for the residents. This patient-client base will help build
the practice of the residents after graduation from OMMC.)

My practice is to write down my explanation in a piece of paper and later


signed by the patient or his guardian. My explanation includes drawings,
diagrams, and tables comparing different options of diagnostic procedures
and treatments. I use visual aids freely to reinforce my explanation. I make
the patient or his guardian affix a signature beside an option he has

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.

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41

Just like anything in life, there are pros and cons; advantages and

disadvantages; benefits and risks in giving out cellphone numbers to


patients. The guide to follow is, if the pros, advantages, and benefits
outweigh the cons, disadvantages, and risks, give out the cellphone
numbers.
What are pros, advantages, and benefits of giving out cellphone
numbers to patients?
Here are some of them:
All patients and their relatives welcome physicians giving out
their cellphone numbers. It is considered as an easy access to the
physicians in times of need. I dont think there will be a patient
or a relative in the Philippines and in the world for that matter,
who will not welcome this.
Giving cellphone numbers to patients promotes rapport. Patients
and relatives see empathy and compassion in physicians giving
out their cellphone numbers. These physicians tend to be liked,
which can contribute to an increasing patient-client base and also
patient-client or customer engagement.
The use of cellphones between physicians and patients facilitates
communication and coordination between the two parties. The
following are key activity areas: a) scheduling of operation,
admission and consultation; b) medical management outside the
hospital and clinic setting; c) referral of other patients to the
physicians; and d) feedback of patients to the physicians.
What are cons, disadvantages, and risks of giving out cellphone
numbers to patients?
From my experience, it is only the disturbance or loss of privacy created by patients texting or calling the physicians by cellphones after their
stint of duty in the hospital and clinic. The physicians particularly want to
avoid cellphone consultations.
Thus, after weighing the pros and cons, advantages and disadvantages, and
benefit and risks, I personally recommend physicians giving out cellphone
numbers to their patients. Physicians can minimize the disturbance by
instructing and advising the patients on the indications for communicating
through cellphones. To avoid abuses, I have this policy:
Communication with ROJoson through cellphones is permissible but

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

MAR Title: Informed Consentfor Real


Reporter: Michael Angelo L. Suaz, MD
Year Reported: 2009
NARRATION:
I got home late one night. Since it was already late, I was left with a dark
secluded spot along our street to park my car. As I alighted from my car, a
woman approached me from the darkness and said Good evening po,
doc. (Good evening, Dr.) My brain was already spacing out and I was not
expecting anyone to approach me that very instant so I freaked out at first.
But then the lady continued and told me Ako po yung nanay ng
pasyenteng nilagyan niyo ng tubo sa tagiliran kagabi. Ok na po siya.
Salamat po. (I am the mother of the patient whom you placed a tube on
one side of his chest last night. He is OK now. Thank you.

should be used judiciously. ROJoson reserves the right to bill for


services rendered through cellphones.
Link to Reporters Original MAR:
http://medicalanecdotalreportsvol1.wordpress.com/2013/10/11/
habalucatings-mar-07-03-the-advantage-of-giving-out-your-personalnumber

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

MAR Title: Coincidence of Unfortunate Events


Reporter: Janix M. de Guzman, MD
Year Reported: 2004
NARRATION:
A young man in his early twenties was brought in by friends. Fifteen
minutes ago, he was with them happily drinking in a birthday party. He
just turned 25. By sudden turn of events, he was apparently stabbed by
an acquaintance for some reason or other. He sustained a 2.5-cm stab
wound on the left chest at the posterior axillary line, level of the 3rd
intercostal space. The stab site was still actively bleeding.
The patient was stuporous caused maybe by too much alcohol intake.
His vital signs pointed to a much worse scenario. He was hypotensive
(abnormally low blood pressure), tachycardic (abnormally fast heart
rate), and had shallow, gasping breathing. Immediately, a primary
survey was instituted following the ABCs (Airway, Breathing, and
Circulation) of trauma. We checked his airway, assessed the breathing
and circulation, looked for deficits, and explored other parts swiftly.
Simultaneously, we went into action for it was our inherent duty to
value life and would always try our best to save one. With all the help I
could get, my team inserted an endotracheal tube to assist the patient in
his breathing, packed the stab site, put two large bore intravenous lines,
and placed thoracostomy tube on left chest.
That was a non-stop action and it did not end there. The closed tube
thoracostomy output told more. There was a continuous active flow of
more than a liter of blood. The patients condition was deteriorating.
This alarmed us.
Decision: patient needed to be opened and whatever was bleeding
inside must be controlled. I talked to the relatives about the patients
condition and the plan. We did not have the best of chance but it was
the best that we could do. They conceded. Patient was brought to the
operating room as fast as we could.
Soon after we opened the left thorax (chest), he went into arrest. After
evacuating 2.5 to 3 liters of hemothorax (blood in the chest) and noting

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.

Let PROFESSIONALISM be the main guide in their problem-solving


and decision-making in such a situation, meaning in responding to the
annoyance being created.
Stay calm and try their very best to explain things to the patients and
relatives.
Avoid interpersonal conflicts with the patients and relatives at all
costs. Dont shout. Dont say any bad words. Always be the bigger
man.
Get help from physician colleagues or other health care professionals.
Always have a witness on the interactions with the patients and relatives
and vice-versa. This witness will be of great help in case there will be
complaints filed.

Link to Reporters Original MAR:


http://medicalanecdotalreportsvol1.wordpress.com/2013/09/25/rmagudasmar-11-01-calmness-and-flexibility

77

MAR Title: Calmness and Flexibility


Reporter: Rembo M. Aguda, MD
Year Reported: 2011
NARRATION:
It was one of my duties in the emergency room (ER) when a 22-year-old
male came in with a bloodied face. The patient was allegedly mauled. We
immediately attended to the patient and noted that he was drunk but
otherwise conscious. We then cleaned his face and checked all the injuries.
He had lacerations on the left eyebrow, left chin and an avulsed wound on
the left occipital area. The patient also had contusion-hematoma (bruise) on
the right side of his face. We packed the lacerations to stop the bleeding.
We then asked the patient to wash up in the comfort room before going to
the x-ray.
While attending to other patients in the ER, one of the patients relatives,
who just came in blurted out to us doctor, wala ba kayong gagawin sa
pasyente ko? (Doctor, arent you going to do something to my patient?
We were surprised by the relatives reaction because we had clearly
attended to her patient prior to her arrival. But instead of answering
angrily, I kept a cool head and calmly said to the patients relative,
Maam, pinaghuhugas lang po namin ung pasyente nyo para po matangal
ung ibang dugo sa katawan nya. (Maam, we asked the patient to wash up
to remove the other blood stains on his body.) Then suddenly the relative
said, Hindi nyo ba trabahong linisin siya? (Isnt the wash up part of your
job?) Then I answered, Lininis na po namin yung mga sugat nya at
pinapakiusapan lang po namin kayo na linisin nyo po yung mga dugo sa
katawan nya. (We already cleaned his wounds and we are just asking you
to remove the other blood stains on his body.) Then the relative blurted out,
Wala palang kwenta mga doctor dito e. Bakit kami pa gagawa nito. (All
the doctors here are useless. Why are we the ones doing this cleaning.
I tried to talk to the relative as calmly as I could and explained to her the
situation before she came in. The patients other companion also helped
but still the relative refused to get the patient treated anymore. She then
brought the patient out of the hospital.
INSIGHT:
Our hospital is classified as a tertiary hospital and we encounter numerous
people that have different personalities. It is important for us to be flexible

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.

Birthdays are supposed to be happy occasions craved by people all over


the world. We know that there are instances in which birthdays
unfortunately turn out to be unhappy occasion just like in the MAR
narrated by Dr. de Guzman. If unhappy events occur on a birthday,
everybody feels sad. This includes the patient if he survived the
operation; the relatives of the patient; and even the physicians of the
patient. That was the reason why Dr. de Guzman said in his MAR, the
hardest part, thereafter, was informing the relatives that patient died on
the day of his birthday. For sure, Dr. de Guzman, even if he is not
related to the patient, felt extremely sad when he was not able to save a
patient who was celebrating his birthday on that day.

For us doctors, we have to be sincere. If we promise to help, we must


exhaust our means, our resources to uphold our promise. Our pledge of
quality service is considered as a sign of hope and source of strength. So we
should keep our promise.

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

ROJOSONs INSIGHT (TPORs):


How to deal with grumpy patients?
Dr. Rommel de Leon described his patient as grumpy. She is irritable;
cranky (grouchy); and fussy (showing anxious concerns). Grumpiness is
probably the, if not one of, the mildest forms of reactions of patients to a
health problem. The severe form is depression.
It is a given that patients react differently to health problems. The reaction is
dependent on their personalities, characters, mindsets, and dispositions.
It is also a given that physicians must be able to deal with patients reactions
to health problems together with their underlying personalities, characters,
mindsets, and dispositions. This is a challenge that is greater and more
difficult than treating the physical illness itself.
Whatever strategies are used, the goal is to get the patients to cooperate and
collaborate in the medical treatment. To get the patients to cooperate and
collaborate, the physicians should gain their trust and confidence. To get
their trust and confidence, the physicians should at least explain things
properly and adequately; listen to their concerns; allay fear; provide support,
particularly emotional; show empathy and sincerity in helping; and
demonstrate competency in the medical treatment.
Dr. Rommel de Leon has shown other strategies in his MAR such as giving
his cellphone number; giving discharge instructions on precautionary
measures; and seeking the support of the relatives.
Link to Reporters Original MAR:
http://medicalanecdotalreportsvol1.wordpress.com/2013/10/02/rqdeleonsmargrumpy-granny/

46

75

MAR Title: Grumpy Granny


Reporter: Rommel Q. De Leon, MD
Year Reported: 2005

MAR Title: A Senior Worthy of Emulation


Reporter: Sheena Shayne P. Siapno, MD
Year Reported: 2012

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:

Different people have different ways of handling their conditions. As for


my patient, she was really grumpy! But this doesnt mean that she should
be treated badly. She needs to be understood. Understanding her condition
and empathizing with her will abate her irritability.

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.

Recommended Further Readings and References:


Jehovahs Witnesses Main Website (http://www.jw.org/en/)
Jehovahs Witnesses Philippines Website
(http://www.jw.org/en/jehovahs-witnesses/contact/philippines/)
Watch Tower Bible and Tract Society
PO Box 2044
1060 Manila
Philippines
+63 2-372-3745
+63 2-411-6090
Jehovahs Witnesses Stand on Blood Transfusion and Recommendations on Use of Blood Substitutes (http://www.jwfacts.com/watchtower/
blood-transfusions.php)
Link to Reporters Original MAR:
http://medicalanecdotalreportsvol1.wordpress.com/2013/09/24/
jrmalabanans-mar-08-02-ethics-in-the-heart-not-in-books/

ROJOSONs INSIGHT (TPORs):


What are core values? What are the core values for physicians? What is
the role of the Medical Anecdotal Reports in the evaluation of core values
of physicians?
I believe all human beings have values that influence their behavior and
decision-making in life. Values can be superficial, deep, transitory, and
fixed. Those which are deep and more or less fixed are considered core
values, personal core values, or core values of a person.
The acquisition or development of personal core values can be spontaneous

48

73

thoughts, perceptions, opinions, and recommendations), there are at least


four options that the orthopedic or bone surgeon has to consider:
1.

2.

3.

4.

While respecting their religions doctrines, inform to the point of


convincing but without coercing the patient and relatives that
blood transfusion will be beneficial and needed to produce an
optimal result in the surgical management of the fracture. Inform
them of the risk of no blood transfusion and logistical problems
of securing blood substitutes such as erythropoeitin. Once
agreeable to having blood transfusion, make the patient and
relatives sign an informed consent. This was what actually
happened in Dr. Malabanans patient. (Note that there are some
members of the Jehovahs Witnesses who dont fully subscribe to
the no-blood-transfusion doctrines.)
If the patient and relatives are not agreeable to blood transfusion,
ask and assist them in securing blood substitutes like
erythropoietin. Have an informed consent signed to these effects
no blood transfusion, just blood substitutes. Operate and try as
much as possible to minimize operative blood loss.
If the patient and relatives are not agreeable to blood transfusion
and if they cannot afford the blood substitutes, with informed
consent particularly on the risk, proceed with operation and try as
much as possible to minimize operative blood loss.
If the patient and relatives are not agreeable to blood transfusion,
if they cannot afford the blood substitutes, and if it is against the
conscience of the surgeon to operate without blood transfusion
and blood substitutes, with informed consent, refer patient to
another bone surgeon who is willing to operate under these
conditions and preferably, if available, refer to a surgeon who is
also a member of the Jehovahs Witnesses.

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

or programmed. Spontaneous acquisition of core values means those


acquired through role model and tradition appreciation and imbibition. On
the other hand, programmed development of core values means those
acquired through a proactive plan. The organizations and institutions with
core values clearly spelled out usually program the development of core
values among their members or staff.
Is there a list of core values required of physicians that is universally
accepted? I have not encountered such a list. Some say the core values can
be derived from the Hippocratic Oath. I have yet to see an outline listing of
core values derived from the Oath. Practically all health care institutions,
particularly, medical colleges, have publicized core values. In the
Department of Surgery of Ospital ng Maynila Medical Center (OMMC),
there are 10 core values it wants to develop among the surgical residents,
namely: 1) Quality; 2) Accountability; 3) Innovativeness ; 4) Social
Responsibility; 5) Teamwork ; 6) Professionalism; 7) Respect; 8) Integrity;
9) Compassion; 10) Excellence.
In the MAR of Dr. Siapno, she identified three core values she appreciated
from her senior resident. These are, namely, passion; humility; and
responsibility. By how the three values were described by Dr. Siapno,
passion can be linked or associated with the Department of Surgerys core
values of quality, accountability, innovativeness, professionalism,
compassion, and excellence. Humility can be linked to respect,
accountability, and integrity. Responsibility to accountability, teamwork,
and social responsibility.
In 2004, when I was Chairman of the Department of Surgery of OMMC, I
initiated the formulation of core values (see above). The core values were
formulated on the basis of the following premises:
1.
2.
3.
4.

Definition of core values enduring key beliefs which the institution


should hold in common and which should guide the staff in behaving
and in performing their work.
Purpose of core values strategic tool to achieve vision-mission-goalobjectives (V-M-G-O) of the institution (these values must jibe with the
V-M-G-O).
What the institution wants to be known for in terms of its values and
culture from the perspective of the customer and owner.
The OMMC Surgery core values should serve as a touchstone for the
way we conduct business and fulfill our mission.

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

MAR Title: Ethics in the Heart, Not in Books


Reporter: Jonathan R. Malabanan, MD
Year Reported: 2008
NARRATION:
This is a case of a 34-year-old male from Manila who was admitted due to
Complete Overriding Fracture of Femur, Left. (Fracture is broken bone;
femur is the thigh bone.) Patient was then scheduled for open reduction
with internal fixation with intramedullary nailing. [Open reduction
internal fixation is an open method (an incision on the overlying skin is
involved) of surgically repairing a broken bone. Generally, this involves
either the use of plates and screws or an intramedullary (through the bone
marrow part of the bone) rod to stabilize the bone.] Patient was pale upon
admission. Complete blood count was requested and the result showed low
haemoglobin count of 7.7 grams/liter. Thus, blood transfusion preoperatively was ordered. As we tried to explain the condition to the patient, he
and his relatives declined for the procedure simply because blood
transfusion was against the teachings of their religion. We kept explaining
to them the need for such intervention and that there was no other means to
prepare the patient for the operation but to transfuse blood. We even called
up our consultant to assist us in explaining the situation to the patient and
his relatives. Fortunately, after a long conversation and repeated
explanation, the patient and relatives gave consent for transfusion. Hence,
operation was scheduled.
INSIGHT:
I can clearly remember the same situation written in my Ethics Shifting
Exam in medical school few years back. The question was, being faced
with such circumstance, what is ethically the right thing to do? There were
follow-up questions like what law will be violated if the doctor will solely
decide for the patient. Answering the exam was not that difficult because
(aside from being a multiple-choice type of question) we were taught of the
basic principles of Medical Ethics. But being put in a real scenario, one
very much similar to that in the exam, is a different story. It was not as
easy as just answering A, B, C, or D. It was not just a matter of
Autonomy, Beneficence, Maleficence, Justice and all the other laws that
you could think of. It is all about a patientmy patient and his life.
At the time the patient rejected our proposed intervention, we could have

70

MAR Title: Better Facilities or Patients Trust


Reporter: Ariel T. Celzo, MD
Year Reported: 2011
NARRATION:
I recently met one of my former patients at the outpatient department. She
came in with her mother. After a few moments of introduction, she told
me that she wanted to consult for her mothers condition. Her mother was
a 58-year-old female with a calculus (stone) of the gallbladder. She had
been complaining of right upper quadrant pain for a few months without
any accompanying symptoms. I eagerly examined the patient and after a
while we sat down to discuss her disease. After a couple of advices, I laid
down to them the possible treatment options. With the help of my former
patient, we convinced her to undergo operation. She then decided to have
her operation at our institution (Ospital ng Maynila Medical Center).
Even though she agreed to have the operation, I could see that there was
some degree of anxiousness in her. I simply asked her why they still
wanted to be operated in our hospital. I told them, with their means, they
could easily have an operation in a private hospital where they could
avail of better facilities. They surprised me with their answer. She simply
said, Id rather be with a doctor whom we trust! It just made my day.
INSIGHT:
It is true that with better facilities one can render better service, but it does
not sum it up. It then boils down to patients trust. Better facilities could
attract more patients but they do not guarantee that they would lay their
life on a doctors hand. Treatment can never be started unless a patient
entrusts his life to a physician and completely agrees with the plan. In my
experience, I have learned that this trust needs to be valued and
appreciated. This would leave a mark on our patients which would help us
deal with them more appropriately.
ROJOSONs INSIGHT (TPORs):
How strong should a patients trust in a physician be a driving factor in
choosing hospital for treatment?
There are usually five factors that influence a patients choice of hospital
for treatment. These are, namely: 1) attending physician; 2) facilities of

51

the hospital; 3) ambience of the hospital; 4) affordability; and 5)


accessibility. Translating the factors into more specific and attractive
parameters, these are, namely: 1) trust on the attending physician; 2)
modern hospital with state of the art medical equipment; 3) clean and
friendly ambience; 4) affordable treatment prices; and 5) not too far a
location.
If all the 5 attractive parameters are present, a patient will have no
problem in choosing his hospital for treatment. However, if not all of the
5 attractive parameters are present, then the patient has to weigh and
come out with a decision, a personal one.

special persons, physicians should give them courtesy-lane privileges


consisting of extra and super special accommodation, attention, patience and
perseverance. They should institute measures to avoid the notion that they
put more importance to non-relative-patients than to their parent-patients.
Link to Reporters Original MAR:
http://medicalanecdotalreportsvol1.wordpress.com/2013/10/13/jhdecastrosmar-13-04being-a-patients-relative

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

I have encountered Filipino patients coming over to the Philippines from


their places of work abroad such as Saudi Arabia, Kuwait, and even the
United States of America to be treated by their trusted Filipino
physicians. I have encountered patients from outside Metro Manila, such
as Pampanga, Ilocos, Laguna, Cavite, Batangas, Bulacan, Nueva Ecija,
Bicol, Palawan, to name a few, coming over to hospitals in Metro Manila
for treatment by their trusted physicians. I have encountered patients
travelling from one pole of Metro Manila to another pole just to be

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.

treated in the hospitals where their trusted physicians are affiliated or


practicing.

All patients, whether parent-patients, relative-patients, or non-relative


patients, should be managed uniformly with the basic set of management
of a patient processes. This set consists of establishing rapport; doing
history and physical examination; formulating clinical diagnosis; deciding
on need for paraclinical diagnostic procedures and if needed, assisting
patient on the selection; assisting patient on selection of treatment;
instituting treatment if capable, if not referring to another physician; and
giving advices and explanation throughout the phases of management.
Whenever a physician has a parent expressing a health concern, at the very
least, establishing rapport; doing history and physical examination;
formulating clinical diagnosis; and giving advices should be done. If he
can manage the patient further, he should do so. If not, he can refer.

I have encountered patients who are willing to be in hospitals with high


prices just because their trusted physicians are affiliated or practicing in
these hospitals. Initially, they might be hesitant to be in a hospital with high
prices but later, the trust on their physicians would override it. They would
muster resources to be confined in the hospital with high prices.

Thus, to repeat, my personal stand is that physicians can and should


manage their parent-patients. There should not be any difference between
managing their parent-patients and their non-parent-patients or nonrelative-patients. The approaches and principles of management should be
the same.
Postscript:
In the MAR of Dr. de Castro, she described a friction encountered in
managing her mother-patient. The types and sources of friction in
managing parent-patients that I have seen consist of the following: 1) the
parent expecting the son- or daughter-physician to know all in managing
the formers concern but in reality does not (resulting in frustration on the
part of the parent); 2) the parent does not follow the advices of son- or
daughter-physician (may be interpreted by the latter as lack of trust); and
3) the parent expecting the son- or daughter-physician to be immediately
and always around when in distress (if not fulfilled, this results in the
usual reproach that the son- / daughter-physician puts more importance to
non-relative patients than to parent-patient.) To prevent and mitigate these
potential frictions, all physicians should communicate properly with their
parents to make them understand the usual processes in the management
of a patient including a parent-patient; the limitations of physicians; and
the trust needed for an effective treatment. Since their parents are very

68

Weighing trust of attending physicians against high prices of a hospital

Weighing trust of attending physicians against poor ambience of a hospital

I have encountered patients who are willing to be in hospitals with poor


ambience just because their trusted physicians are affiliated or practicing in
these hospitals. This is especially true in patients whose resources are
limited. The MAR of Dr. Celzo who is affiliated with Ospital ng Maynila
Medical Center is an illustrative example. Another example is the Philippine
General Hospital, which has a lot of patients, both private and charity ones,
despite its ambience. The overriding factor is the reputation of PGH having
good physicians.
Weighing trust of attending physicians against facilities of a hospital
I have encountered patients who are willing to be in hospitals which do not
carry a reputation of having the most complete and most modern medical
equipment. The strongest driving factor is where their trusted physicians
are affiliated or practicing and the latter have assured them of the adequacy
of medical equipment to produce the shared targeted results of treatment.
ROJosons Advices on How to Weigh Factors in Choosing a Hospital for
Treatment
To determine the relative weights, first ask this most important question: in
the end what counts in the success of a medical treatment? Since the answer
is the physician whom the patient has chosen to treat him, give highest
points, say 5 (using a scale of 1 to 5), to attending physician, particularly on
trust.
Give 4 points to affordability because medical treatment is usually or tends
to be expensive.

53

Give 3 points to facilities because majority of hospitals in the Philippines,


once given a license to operate as a tertiary hospital by the Department of
Health (DOH), are expected to be equipped with basic modern
equipment.
Give 2 points for ambience for the same reason given above on facilities.
All DOH licensed hospitals are expected to be clean and friendly.
Give 1 point for accessibility in the light of current advances in
transportation and communication in the Philippines.
Postscript:
All physicians should promote trust and confidence from their patients.
This is not only helpful in the medical management of their patients but
also in increasing their patient-client base.
Trust can be gained by and through the following:
1. Establishing rapport with the patients and their relatives.
2. Having and maintaining a track record and reputation of effective,
holistic, professional and compassionate treatment.
3. Promoting an understandable communication with the patients and
their relatives.
4. Providing easy access to patients, particularly through cellphones.
5. Assisting in the control of the expenses of the patients.
6. Helping the hospital affiliated with provide quality and friendly
patient care.
7. Helping the hospital affiliated with provide a clean ambience.
8. Helping the hospital affiliated with provide cost-effective modern
medical equipment.
Link to Reporters Original MAR:
http://medicalanecdotalreportsvol1.wordpress.com/2013/10/11/atcelzosmar-11-08-better-facilities-or-patients-trust

54

Oftentimes, we hear there is a difference. Pending verification, I was told in


the United States of America, physicians cannot operate or do surgery on
their parent-patients. In the Philippines, I have not seen a document with
such a regulation. However, the prevailing perception, at least among
physicians, is that they should not be treating their parent-patients for the
reason that emotion can affect their decision-making in the course of
treatment. Such a perception is illustrated in the MAR of Dr. de Castro.
My personal stand is that physicians can and should manage their parentpatients. There should not be any difference between managing their parentpatients and their non-parent-patients or non-relative-patients. The
approaches and principles of management should be the same. Let me
expound on my last two statements.
The emotional attachment of physicians for their parent-patients can be the
same as for some non-parent- or non-relative-patients. In the course of the
practice of a physician, there will inevitably be non-relative patients in
whom an emotional closeness will develop. The approaches and principles
of management should be the same. If the physicians feel that emotion will
interfere with their decision-making during treatment, then they should refer
to a colleague. If not, especially, if they are in a good, if not better, position
to help because of their expertise, then they should be one to treat. The same
approaches and principles apply to relative-patients who are not parentpatients, such as children, spouses, uncles, aunts, and cousins.
All patients, whether parent-patients, relative-patients, or non-relative
patients, should be treated by the physicians holistically, professionally, and
compassionately to the same degree, meaning, equitably. Physicians cannot
say they will treat their relative-patients more holistically, professionally,
and compassionately than their non-relative-patients because they are
special people. This is considered preferential treatment and is
unethical.
In the practice of medicine, physicians are allowed to give courtesy-lane
privileges to certain groups of patients. Giving courtesy-lane privileges is
not the same as preferential treatment. Giving special accommodation to
senior citizens, persons with disability (PWD) and children is a culturally
acceptable practice in transactions in government or non-governmental
institutions, parking lots, airports, etc. Such concept of courtesy-lane
privileges can be extended to medical practice. Thus, physicians can, in fact,
they should, give courtesy-lane privileges to non-relative-patients who are

67

suggestions or a prescription of medication when the ailment is easily


identified and minor. Some are willing to attempt complex treatment of
serious or long-term illnesses among people personally close to them. As
residents-in-training, we are always in the first line of seeing and managing
throngs of patients. It brings conflict when it is our relatives or our own
parents who are sick and in need of medical attention. Often, they expect
that we manage or treat them personally, which usually brings scuffle. This
experience put me in so much emotional turmoil because it was my mother
who is in need of medical attention. At that time, I was a daughter and not
her doctor. I was not ashamed of calling for my consultant for help even
though I have an idea of what to do. I did not dare manage her myself since
I feel I cannot make an objective medical/surgical decision for her as I
would for patients who are not my relatives. This is a big part of the reason
why I believe that doctors should not operate on friends and love ones,
deliver their babies or, in my view, sometimes even prescribe them
medications. In this anecdote, I was able to experience first-hand how it
was to set an appointment with my mothers attending physician, bringing
her to the doctors clinic and having a feeling of being helpless every time
she would cry out in pain. I remember being wary and having to call my
consultant from time to time to inquire about the status of my mom. This
experience strengthens my resolve to increase patience to my patients
relatives who, like me, ask from time to time how their patients are. I felt
really bad that when she made such allegation that I failed to take care of
her at that time that she was in so much pain. It was hard to remain
professional that time but I was thankful that I was able to stand my ground
that I was on-duty and I have obligations to attend to in the hospital, to my
team mates and to my patients.

MAR Title: Comprehensible Communication: The Key to a Better


Doctor-Patient Partnership
Reporter: Haidee T.C. Cruz, MD
Year Reported: 2007
NARRATION:
What is the use of all the knowledge we store in our brains if we cannot
transmit it into words across to the most important person who needs to
understand our patient. Medical jargons that we use daily, taken for
granted that we understand each other, is as foreign to our patient as a
polar bear in the Sahara. UNDERSTANDABLE COMMUNICATION,
not just communication, is an essential element for trust/confidence to
develop between a physician and his charge.
A month ago, we had a 52-year-old plumber who sought consultation due
to intestinal obstruction secondary to post-operative adhesion. He
underwent exploratory laparotomy (operation on the abdomen) due to
intestinal perforation via gunshot 3 years ago. He had distended abdomen,
was vomiting, and without flatus or bowel movement. As the medical
clerk started to insert the nasogastric tube (NGT), he vehemently* wardoff the action. The clerk gave up after several failed attempts. An intern
followed suite with explanations of how important the NGT was as a
part of his treatment. What does it do anyway? asked the patient. Dinedecompress nya yung tiyan nyo tay para di lolobo (To decompress the
stomach so it will not be bloated.) was the answer. A resident interjected
that it was necessary while waiting for the operation to push through.
What operation? He asked wildly. He was not about to undergo one.

ROJOSONs INSIGHT (TPORs):


How should physicians manage their parent-patients?
There are many issues and challenges arising from managing parents as
patients.
The scenario is a parent of a board-certified physician becoming a patient,
which is defined as having any health concern. The physician has to
manage the health concern of his/her parent. How should the physician
manage his/her parent-patient? A more specific question is, is there a
difference between managing a parent-patient and non-parent-patient or
non-relative-patient?

66

I tried my luck by explaining the circumstances SLOWLY to him. But I


had to stop myself because the patient looked like he understood Martian
better. Nobody could seem to talk sense into this patient. But of course!
Because to the patient, nothing made sense. He was not mentally
challenged. He just did not understand. I had to make him see how
things work, the way that he will comprehend to get his
cooperation. Tay, ang bituka po kasi natin ay parang tubo ng
lababo (Dad, our intestines are like pipes of a sink.) After that, we
had no problem communicating. He permitted me to insert the NGT. He
underwent adhesiolysis. And is now well underway to full
recovery.

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

MAR Title: Being a Patients Relative


Reporter: Jenny Vi. H. de Castro, MD
Year Reported: 2013
NARRATION:
I received an alarming phone call from my mother saying that she was in so
much pain. She was the type who does not like to seek consult to a
physician. It is such a parody, so to speak, since I am one. She has been
complaining of pain on her both knees for quite some time now. She has
self-medicated with pain-relievers and food supplements. One week ago
before the call, I convinced her to have both of her knees x-rayed. It
showed narrowed angle of both of her knee joints. I referred the plates to
our orthopedic consultant who suggested injection with hyaluronic acid or
Hyaluronan (a thick liquid that helps lubricate the joints). Having fear to
needles and knives, my mother vehemently disagreed on the proposed
treatment. She insisted that I prescribe her an effective and a strongacting pain reliever instead. However, the pain worsened which made her
incapacitated. She was unable to walk anymore. She was crying in pain
when she called me. She blamed me for still being in so much pain and that
the medications that I gave her were ineffective. She demanded that I go
home and examine her knees. I was on-duty that time, so I explained that I
couldnt do so. Instead, I advised her to take a higher dose of pain-reliever
and apply warm compress on her knees. I told her I will seek consult from
my orthopedic consultant as soon as I can. She was furious with me that I
cannot be with her at that time when she was suffering in so much pain. She
reproached me that I am able to attend to my patients while I cannot even
take care of my own parent. Hurt as I was, I tried to refute her assertions
and tried to convince her to agree to my consultants plan and assured her
that I will personally take care of her. Fortunately, she was able to see
through my reasons and decided to have her knees injected with
Hyaluronan. I immediately called my consultant to order the drug and
scheduled my mother for an appointment in his clinic. The next day, after
being granted permission from my senior residents, I brought my mother to
our consultants clinic. Thereafter, she was scheduled for three (3) sessions
of injections to each of her knees, once a week for three weeks.
INSIGHT:

ROJOSONs INSIGHT (TPORs):


How should physicians promote a comprehensible communication with
their patients (and their relatives)?

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

The foremost requirement is for all physicians to explain to their patients


and their relatives the diagnosis and their bases; the whys, hows and whens
of diagnostic tests and treatment, and other needed information associated
with health restoration and maintenance.
The subsequent requirement is for the physicians to explain things in a
comprehensible manner. There are various strategies to do this.

The basic requirement of communication audible, clear, and


understandable.
Use of language and words easily understood by the lay.
Use body language.
Use illustrations.
Use drawing.
Use audiovisual aids.
Use appropriate language or words appropriate to patients culture,
lingo etc. occupations.
Use languages or words close
Translate and explain medical terms (when used).
Others

Link to Reporters Original MAR:


http://medicalanecdotalreportsvol1.wordpress.com/2013/10/09/htccruzsmar-07-01-comprehensible-communication-the-key-to-a-better-doctorpatient-partnership

64

57

planned intervals, say yearly.

MAR Title: First Time


Reporter: Robelle J. Peralta, MD
Year Reported:2009

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?

I have a life plan which I formulated formally as early as when I


was 45 years old (in 1994). My targeted lifespan is 70 years old. I
chose 70 as this is the average lifespan of Filipinos at that time and
up to this writing (2013). I have conditioned myself that death is
inevitable. I dont know when it will come. I just set a target and
try to do whatever I need to do before I leave the earth. If I go
beyond 70, that is bonus for me. If earlier than 70, I will accept it
with the thinking that I have lived my life to the fullest based on
the targeted milestones spelled out in my life plan. At least once a
year, usually in December and during my birth month, I review my
plans and refine them as necessary. (http://
rojoson.wordpress.com/2012/09/20/roj-strategic-life-plan-for2011-2019)
I have written instructions to the members of my family on what to
do when I become disabled and /or die. An example of instruction
is that I want to be cremated right after I die. The document was
written as early as 1998 and reviewed every year.
I have an advance directive or living will which I formulated in
2006 and with latest update in March 2013. This directive
documents my desires regarding medical treatment at the end of
life. I have made this known to my family. (http://
rojosonfacebooknotes.wordpress.com/2013/03/03/rojosons-tporon-advance-directive-2013)
I have a document entitled If I were to die .., what will I do
before I die? I formulated this in 2012 and I have been reminding
myself on this monthly. If I were to die tomorrow, next week,
next month, in 6 months, in one year, or in two years, what will I
do before I die? My basic answers are financial endorsement;
bonding with family; clutter management; and enjoyment of my
remaining time on earth. (http://
rojoson.wordpress.com/2012/09/20/if-i-were-to-die-what-will-i-do
-before-i-die)

Postscript:
In this MAR of Dr. Cecilia Leyson, she wrote: We should support them

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It is through this patient that I am reminded of a persons death. Faced with


the uncertainty of the future, we tend to forget ourselves and bask on the
emotions that threaten to drown us. Once we lose our masks and drop the
pretenses of being somebody we are not, we become vulnerable to fear and
uncertainty of what the future holds for us.
It is through this patient that I realize once more that despite appearance,
inside each and every one of us is a human being scared to face death.
This case reminded me of the hardships of patients having a terminal disease the physical, mental, emotional and spiritual impact to them. As a physician,
we should be compassionate in dealing with these patients. We should
support them and help them so that they will live their remaining life in
comfort and in peace.

In the medical world, an operation is a medical procedure done either for


diagnostic or therapeutic purpose. The usual concerns of patients when
faced with an operation to be done on them are the following, namely,
inconvenience resulting from a break in their routines; discomfort and pain
during and after the operation; side effects of the operation; pending
diagnosis; and cost. All the aforementioned concerns can lead to fear and
anxiety, more so in patients who will be subjected to an operation for the
first time. This is the challenge for the physician who will perform the
operation - how to manage the fear and anxiety so that the patient will not
run away from an operation that is needed and so that the operation will
run smoothly and comfortably for both the patient and the physicianoperator.

ROJOSONs INSIGHT (TPORs):

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?

Before the operation -

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

MAR Title: Facing Death


Reporter: Maria Cecilia T. Leyson, MD
Year Reported: 2004
NARRATION:
This is a case of a 49-year-old female who was diagnosed to have stage IIIB
breast cancer. She is not your typical female. Feminine hardly describes my
patient. She surely fits a different category altogether. She is what in layman
terms called tomboy or t-bird, some of the bizarre terms used for lesbians.
Weighing around 90 kilos, sporting a hair cut short enough for ROTC
(Reserve Officers Training Corps) training. She resembles a man, in built,
in looks and attire.
The first time I met her, she seemed to be a happy-go-lucky person, with a
sunny personality and of considerable strength of character. Perhaps it was
because of her appearance. There was a masculine air about her, expressed
by the way she looked and the manner with which she carried herself. She
struck me as someone very strong, someone who will face difficulties in life
head on and not back out.
The first time we told her about her condition, she looked a little bit off but
easily regain her composure. She was keen on asking questions pertaining to
her operation, indicating her interest on what was about to happen to her.
She was zealous in completing the materials needed for the operation. She
even joked around a few minutes prior to the operation while she was lying
on the operating table waiting to be anesthetized. Perhaps this was her way
of dealing with the fear of having to undergo surgery.
It was after her operation that a change in her demeanor became noticeable.
Up until that time, I was convinced that she was a very strong person, far
stronger than what was expected of her gender, but she disclaimed my
previous opinion of her. In such a short span of time when news of how
terminal her prognosis was, she took on a character vastly different from
what she unwittingly projected all along. Her fear of her uncertain fate was
like a tangible entity floating along the vicinity of her bed. Her questions
were asked not purely because of interest on whats going on in her body,
but more of its impact on her life from that point on. She confided that her
initial reaction from the news was that she cried foul and unfair.
INSIGHT:

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