Getting my Feet Wet

Reflecting upon my internship elective experience

April 2013
By Ginger Ramirez
I love water. I love jumping into it, floating, feeling the bubbles exit my nostrils and simply
allowing it to envelope me in its embrace. I love being soaked in life-giving water - being part of it
and being one with it. And this concept is something I apply to matters I am most passionate
about. Those close to me know that I am usually eager to jump into and swim through programs I
want to learn about or meaningful projects I can be part of. And so, when I was given the
opportunity to be kaladkarin with the EINC team, I simply couldnt wait to get my feet wet, swim
through, and be exposed to the work they do.
At some point during my medical training, my heart was led towards allotting a special place for
womens health. I knew I wanted to do something that involved women from an adolescent girl
struggling with the challenges of her age group, to a young adult beginning to explore her
personal values in the context of relationships, to a pregnant woman labouring through nine
months of change, a mother relishing the bittersweet entry of new life into her own, and a
woman searching for meaning while finding the balance between in caring for her family and for
herself. There was something tugging in my heart as a future physician to explore and enter a
commitment, a vocation that will help empower women to be the strong, resilient persons they
were created to be.
Fortunately, with divine intervention and the help of mentors and friends (to whom I am truly
grateful), an opportunity came to tag along with the EINC team led by Dr Mianne Silvestre. During
my first e-mail correspondence with Dr Mianne, I felt my heart jump and knew I was being led to
something beautiful and worthwhile something for women, for children, for life, for change. To
say that I was excited was a great understatement.
I had the privilege to join the team in the Essential Intrapartum and Newborn Care (EINC) Quality
Assurance Workshop for private midwives in Iloilo and Cebu last April 10 - 12, 2013 as well as
Training for Faculty Trainers for the Integration of the EINC into the Nursing Curriculum last April
18-19, 2013. These experiences gave me a glimpse of the world of public health and left with me
burning hope that I may take part in it in my own little way someday. Below are some lessons I
wish to share from this experience.
Learning 1: The Relevance of Clinical Medicine
In the world of medicine, evidence is king. We are, after all, scientists who gather knowledge and
information, who respect what can be measured and who aim to predict outcomes. One of EINCs
strengths is the evidence that its recommendations rest upon valid and objective data
evaluated by experts.
The research began with the asking of questions relevant questions encountered by clinicians. It
is their sensitivity to the questions and their courage to ask them that facilitated the process of
truly understanding the situation and finding ways to address the problems they were faced with
every day. EINC was developed because of clinicians dissatisfaction with the status quo and took
up the challenge to facilitate change.
The recommendations of EINC are based on experiential yet objective, scientific data that
provides guidance on appropriate interventions that save lives. As physicians, we are given the
privilege to take part in the critical period between life and death. And so when information

clearly points to life, it is our ethical responsibility to carry this out for our patients not only to
do no harm but to actually do good.

And, it comes full circle because as the clinicians witnessed the problems, they too share in the
celebration of victory and of life. Dr. Tetchie Cadiz, one of the Obstetrician-Gynecologists of Team
EINC, shared how she has seen critical preterm babies survive their tumultuous entry into the
world through practicing the recommendations of EINC and how satisfied the mothers are with
the new brand of evidence-based care. No one dared question the numbers and the research
because the doctor before us had proof that it really worked. The benefits are not only written but
they are also seen, felt and experienced
This learning is particularly important for me because if I dont end up being a clinician, then I
have to make sure that I nurture the relationships I have with my trustworthy future-clinician
friends. Some problems may only be seen by them and how exciting it would be to collaborate
and engage with them to develop solutions together in the future.
Learning 2: The only education thats perfect is the one that keeps going
Having a post-graduate MD-MBA degree, the assumption is that there is much that I know about.
However, one thing I learned through the workshops I attended is that half of what was taught to
us in the process of labor and delivery is actually not recommended, as articulated in the clinical
practice guidelines. I did know something but what I knew was wrong. During the past two years
of clerkship and internship, some of the interventions we were carrying out were either not
beneficial or even harmful. This was painful to realize since I knew I was getting good quality
education. Little did I know that my actions were contributing to an increased risk for illness or
even death of mothers and babies.
After the pain, guilt and whispered apologies to the patients I served, I knew that the challenge
was to keep going and keep learning. There was no room for blaming, only for growth and
improvement. I had to keep learning.
This learning came from various sources inspiring role models, witnessing good practices,
meaningful stories and lectures rich with information. Among these however, my most relevant
learning was from another learner. During the training in Iloilo, I was part of a small group of
midwives who had to conduct a return-demonstration of the EINC steps. After the session, two
midwives were asking questions to our facilitator about practices that didnt fall under the EINC
protocol. Through their questioning, they realized that some of the interventions they carried out
were not recommended, if not outright discouraged. This surprised them and obviously bothered,
one midwife looked at the other with uneasiness and asked, Paano kaya natin sasabihin kay
doc? Right before my eyes, I saw the women transform into empowered leaders. They saw an
opportunity to learn, internalized the wisdom behind the technical knowledge, immediately
applied it to their setting and even took up the challenge to be agents of change. They were not
hindered by heirarchy or role limitation. Nor did they feel frustrated that their practices were
wrong or that their midwifery education was lacking. Instead, they were open to learn, to change
and to teach. If a single-day training can develop this kind of confidence and determination to
engage in conversation and promote change, then there is much hope for the country.
They taught me that as long as we assume a disposition for learning and growth then change is
possible.

Learning 3: The value of a drop in the bucket

One drop in the bucket is simply that one small, relatively insignificant drop. With any
innovation, we know that resistance will always be met. And, in the mission of change,
sometimes it feels like one task, one group, one success is simply too small to create lasting
improvement. Im sure when the EINC team began its mission, it started with a small group of
kindred spirits who wanted to do something worthwhile. And, respecting the laws of inertia, they
encountered resistance to the status quo, with many people and groups unwilling to do things
differently. However, Im sure they experienced successes along the way also, one by one placing
a drop in the bucket one person, one hospital and one administrator through one meeting, one
project, one policy.
Although a drop in the bucket might be small in relation to the entire task (i.e. changing the
Philippine system or meeting the Millennium Development Goals), it has a considerable impact. A
drop creates ripples that go far and wide, and the EINC teams efforts have already influenced the
way women and newborns are being cared for. A little drops impact is exponential and we have
seen the advocacy grow greatly in a span of three years.
I also had an opportunity to witness the impact of one drop last week, with the potential of
creating a wave of change. The program was designed to train key nursing faculty members of
various institutions to teach them the EINC protocol. In addition, they were tasked to modify the
nursing curriculum according to the new recommendations and spearhead the training of
hundreds of other trainers until 100% coverage of all nursing schools are met. Wow. Those
participants will influence the future nurses in the country and the kind of care our Filipino
mothers and babies will receive. That was change in the national level happening right before me
- beautiful, hopeful change.
Apart from the lessons shared above, this experience has been a renewal of my commitment to
my passions. Going through the daily rigors of the duty - from duty-preduty cycle slowly stripped
off the enthusiasm I have for programs that truly engage people. I grew tired and helpless but
fortunately, not hopeless.
Thank you for this chance to be reminded of the problem of women and childrens health and to
be challenged to contribute something to address it. Thank you for igniting my passion for health
through systemic change and empowerment. This opportunity to join the team was truly a
refreshing experience not only because I was with kind, generous and passionate people, but also
because it reminded me of the things I hold dear and value. I also learned a lot from stories told about challenges, knowing the values youre fighting for and choosing your battles. Everything
begins with a good grasp of who you are, what you desire and where you seek to go. Thank you
for reminding me of that.
Thank you to Team EINC for the chance to watch you, learn from you, to be part of your activities,
to get my feet wet and to be immersed in the life-giving work that you do. I learned how to
appreciate the value of a team, of recognizing the contribution of each one and of the importance
of sharing smiles and laughter with one another. This life-giving experience is one that I will truly
treasure and will propel me to work harder during this final stretch of my internship. Thank you!