Meet The Professor

Meet the Professor
Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg
September 7, 2023
6 – 9 pm
59th Mastery in Surgery Annual Convention
Department of Surgery
College of Medicine - Philippine General Hospital
University of the Philippines Manila
Century Park Hotel
Manila
Meet the Professor
• A retired Surgery Professor from the UP College of Medicine and

Philippine General Hospital since 2014 but still holds an
appointment of Clinical Professor beyond the compulsory
retirement age of 65 up to the present time (9 years). He is now 74
years old still teaching and operating at a controlled pace.
• A former Chief of the Division of Head and Neck, Thyroid, Breast,

Soft Tissue, Gastroesophageal Surgery and Surgical Oncology
• A former Chairperson of the Department of Surgery of Ospital ng

Maynila Medical Center
Meet the Professor
This program is designed to be a free-wheeling discussion on

any topic or issues in general surgery or related to general
surgery.
It can be a free-wheeling question and answer format. You

can just ask or throw any questions to me and I will try my
best to answer as best as I can.
Meet the Professor
But, if you will allow me,
I can set initially the direction for the issues to be discussed

or suggest the issues to be discussed, so that we can
maximize the time allotted and make the best out this Meet
the Professor program.
Later on or thereafter, you can ask me any questions under

the sun.
Meet the Professor
Let me tell you first the topics or issues that I have prepared
to kick off the discussions and then you tell me if these
topics would be acceptable to you.
You can change them.
You can subtract and you can add more if you want.
Meet the Professor
Essentially, I have chosen 3 topics or issues which I think are

the first three most important, if not crucial, TIPS (spelled T,
I, P) that I intend to give younger general surgeons like you
in my twilight years of being a general surgeon.
I have been in practice as a general surgeon for more than 40

years.
I am semi-retired but I have made a personal project to give

TIPs to general surgeons. I have a website on this. Just
Google: ROJoson Tips for General Surgeons.
Meet the Professor
ROJoson’s proposed topics to kick-off discussions and interactions:
• What qualities do I personally consider in an excellent

surgeon?
• Why are there so many “variations” in medical and
surgical management? Here I will talk on ritualistic,
maximalist and minimalist physicians and patients and
patient-centered care management.
• What I think is or propose to be the mother, foundation,
or starting point of all clinical practice guidelines. Here I
will present my framework of the patient management
process which I have been using and teaching since the
90s.
Excellent Surgeon – ROJoson’s
Concepts and Perceptions
A lot of times, undergraduate medical students rotating in

surgery and postgraduate surgical residents and fellows as
well as patients and laypeople would ask me:
When do you consider a surgeon to be good (oftentimes,

they use the word “excellent”)?
It is not easy to answer this question.
One, there is no universally accepted treatise on this issue.
Second, if one searches the Internet, one will get different

concepts and perceptions by different surgeons, prominent
surgeons at that.
Three, if I give an answer, I anticipate differences if not

disagreement from my surgeon-colleagues.
So, here is the disclaimer when I answer this question.
My answers will represent my concepts

and perceptions.
Putting it simply, my personal opinions.
For me, a good or excellent surgeon is one who possesses the
following qualities:
A mindset that uses my “Management of a Patient Process”

which I consider to be the mother or foundation of all clinical
practice guidelines (which I shall present later).
[ROJoson Lecture] ROJoson Patient Management Process - An

Overview
https://www.youtube.com/watch?v=_uGAR8Wppks
For me, a good or excellent surgeon is one who possesses
the following qualities:
Is Holistic, Professional and Compassionate and practices

Patient-centered Care Management
Knows when to operate and when not to operate

With the following qualities when they operate in the

operating room (of course, with good outcome and
adequate anesthesia):
• Finesse
• Speed without too many unnecessary moves
• Decisiveness
• Cost-effectiveness
For me, a good or excellent surgeon is one who possesses the
following qualities:
With the following qualities when doing procedures when the

patients are awake (again, of course, with good outcome and
adequate pain control):
• Gentleness (magaan ang kamay)*
• Speed (mabilis)*
• Decisiveness
• Cost-effectiveness*
*Expressed by patients and relatives

I like to emphasize two other things in connection with my
concepts and perceptions of a good or excellent surgeon:
No surgeon is perfect all the time.

There is no such thing as an excellent surgeon has no
mortality or morbidities in his/her hand.
He/she has, but the number is kept to the most
minimum possible.
I like to emphasize two other things in connection with my
concepts and perceptions of a good or excellent surgeon:
All surgeons have limitations in what they can do in

the practice of surgery.
There is no such thing as an excellent surgeon being
able to do everything that needs to be done.
They can only do so much. In such instances of
limitation, they provide the best alternatives for the
patients.
End of Presentation
I encourage and welcome 2 questions and comments for the

moment.
Why are there so many variations in
medical and surgical management,
not to use the word “confusion”?
HOW TO MAKE SENSE OF THESE!
Why are there so many variations in medical and surgical
management, not to use the word “confusion”?
The root factor is the uniqueness of

individuals.
Each person or individual is unique as a
result of the interplay of genetic makeup
and environment.
This individual uniqueness leads to the following situations:
• Manifestations of symptoms and medical diseases may not

be the same for everyone.
• The path to maintaining or regaining health is not the same
for everyone.
HOW TO MAK SENSE OF THESE!
This individual uniqueness leads to the following situations:
• Medical problem-solving and decision making has to be
individualized or personalized by both the physicians and
the patients. At the end of the day, it boils down to “no
one-size-fits-all” recommendations on medical
management. Physicians have to practice PATIENT-
CENTERED CARE MANAGEMENT or INDIVIDUAL PATIENT-
FOCUSED CARE MANAGEMENT.
Patient-centered care management
Patient-centered care management is conventionally defined
as the practice of caring for patients (and their relatives) in
ways that are meaningful and valuable to the individual
patient.
It conventionally includes listening to, informing and

involving patients in their medical care, which includes
medical diagnostics and medical treatment.
Patient-centered Care – care based on individual patient’s

needs and preferences.
HOW TO MAK SENSE OF THESE!
A comment on the downside of CLINICAL PRACTICE GUIDELINES (CPG):
The current clinical practice guidelines attempt to standardize patient

management.
However, STANDARDIZING medical care using formulas and guidelines usually
runs counter to “patient-centered care” as previously defined (care based on
individual patient’s needs and preferences).
CPG are more of “system-centered or service-centered care” (care based on a

group of patients with the same disease diagnosis and prognosis and NOT on
an individual patient with a particular disease diagnosis and prognosis).
As we shall see later, ONLY THE MANAGEMENT OF A PATIENT PRINCIPLES AND

PROCESSES CAN BE STANDARDIZED.
Why are there so many variations in
medical and surgical management,
not to use the word “confusion”?
Back to this QUESTION! Why why why ……
A major contributing factor is the different and

differing mindsets of physicians as well as those of
patients.
Ritualistic, Maximalist and Minimalist
Physicians and Patients
Management of patients involves a reiterative interplay of

the mindsets of the physicians and the patients.
The mindset of both the physicians and patients can be
categorized as follows:
• Ritualistic
• Maximalist
• Minimalist
Just as there are ritualistic, maximalist and minimalist physicians,
there are also ritualistic, maximalist and minimalist patients.
PHYSICIANS
• RITUALIST physicians are those who make medical
management decisions based on HABITS and not mainly on
CRITICAL ANALYSIS (they are impulsive).
• MAXIMALIST physicians are those who institute medical
management that includes a lot of things that are NOT
essential and needed by a patient in health restoration and
maintenance.
• MINIMALIST physicians are those who institute medical
management that includes only which are essential and
needed by a patient in health restoration and maintenance.
PATIENTS
• RITUALISTIC patients are those who do self-care based on
HABITS and not mainly on CRITICAL ANALYSIS (are impulsive).
This definition may be extended to those patients who simply
follow physicians advice without doing a critical analysis.
• MAXIMALIST patients are those who want practically
everything done on their bodies, particularly diagnostic
examinations and medicines, even when they are not
essential.
• MINIMALIST patients are those who like only essential
medical management to be done on their bodies. This
definition may be extended to those patients who want
minimalist physicians to be taking care of them.
Examples to illustrate the definitions:
• RITUALISTIC PHYSICIANS. They are impulsive, doing
routines without careful thinking first, without analyzing
the specific situations, indications and contraindications.
For example: hearing a patient has FEVER – the ritualistic
physicians will give ANTIPYRETICS right away without
considerations of the levels of the temperature and patient’s
condition.
Another example: patients going to the emergency room –
the ritualistic physicians will routinely do Complete Blood
Count and Urinalysis even the patients do not have
symptoms referable to blood and urinary system.
• MAXIMALIST PHYSICIANS.
For example: hearing a patient has FEVER – the maximalist
physicians will order complete blood count, urinalysis and
other tests even when the patient has a typical presenting
symptoms or pattern of influenza. The lab tests are not
essential and not really needed by the patient.
• MINIMALIST PHYSICIANS.
For example: hearing a patient has FEVER – the minimalist
physicians prescribe ANTIPYRETICS only when needed –
when the temperature is 39 C or higher or 38.5 C with
patient feeling severe discomfort. He does not prescribe
ANTIPYRETICS to patients with temperature of 38C or lower.
He just advises observation on the flow of the temperature
while he treats the cause of the FEVER.
• RITUALISTIC PATIENTS.
For example, patients taking paracetamol if they have
measured armpit temperature of 37.5 C which may not be
needed.
Another example, patients taking antibiotics (such as
amoxicillin) if they have colds.
• MAXIMALIST PATIENTS.
For example, they want to have mammography and
ultrasound of the breast even if there are really not needed
because of low risk for cancer.
Another example, they want or permit their surgeons to
have / to do a “cardiac clearance” before an operation even
if it is not needed because of low surgical risk.
• MINIMALIST PATIENTS.
• For example, they only take paracetamol when their
measured armpit temperature is 39 C and they feel hot.
• Another example, they watch and wait for symptoms that
may disappear spontaneously rather than take medicines
and have diagnostic tests done right away.
Management of patients involves a reiterative interplay of
the mindsets of the physicians and the patients.
The mindset of both the physicians and patients can be
categorized as follows:
• Ritualistic
• Maximalist
• Minimalist
Just as there are ritualistic, maximalist and minimalist physicians,
there are also ritualistic, maximalist and minimalist patients.
HOW TO MAKE SENSE OF MINDSETS AND THEIR INTERPLAY
• There must be dialogue and collaboration between the

physicians and patients / relatives to come out with a
shared agreement on the management.
• The best combination will be minimalist physicians and

minimalist patients collaborating with each other in health
management.
• The worst combination will be ritualistic physicians and
ritualistic patients collaborating with each other in health
management.
• If the minimalist physicians encounters ritualistic and

maximalist patients, they should try first to educate the
patients before acceding to their mindsets (not just giving
in right away to patients’ choice or decision). More efforts
should be expended in educating the ritualistic patients.
Variations (Confusion) in Medical and Surgical
Management
Ritualistic, Maximalist and Minimalist Physicians
and Patients
End of Presentation
I encourage and welcome 2 questions and comments for the

moment.
Patient Management
Process
Framework
Patient Management Process
I will now present my framework of the patient
management process which
• I have been using and teaching since the 90s
• Is applicable to all types of patients, medical or surgical
• Is patient-centered
• I think or propose to be the mother, foundation or starting
point of all clinical practice guidelines (which I will explain
later after you watch the video)
Patient Management
Process
Framework
Applicable to all types of patients.
Applicable to SURGICAL PATIENTS.
Applicable to surgical problem-solving and decision-making.
• Clinical diagnostic process (pattern recognition/prevalence)
• Paraclinical diagnostic indication process (degree of certainty in
clinical diagnosis and comparison of treatment plans for primary and
secondary diagnosis)
• Paraclinical diagnostic selection processes (benefit, risk, cost,
availability)
• Treatment selection processes (benefit, risk, cost, availability)
• Intraoperative decision-making processes (benefit, risk, cost,
availability)
Treatment selection processes (benefit, risk, cost,
availability)
Example: Should a cholecystectomy be recommended for all
patients with an incidental asymptomatic gallbladder polyps
seen on ultrasound?
What are the comparative benefit-risk-cost-availability data

and information that will guide the patients and the
physicians in the selection of options (to do cholecystectomy
or not for incidental asymptomatic gallbladder polyps on
ultrasound)?
What are the comparative benefit-risk-cost-availability data and
information that will guide the patients and the physicians in the
selection of options (to do cholecystectomy or not for incidental
asymptomatic gallbladder polyps on ultrasound)?
Comparative benefit-risk-cost-availability data and

information on the 2 options
Procedures Benefit Risk Cost Availability
Option1
Cholecystectomy
Option2
No cholecystectomy
Option1
Cholecystectomy
Option2
No cholecystectomy
COMPARATIVE BENEFIT
OPTION1 (CHOLE) OPTION2 (NO CHOLE)
To be able to know for sure the true diagnosis of No operation is done as it is not
the gallbladder polyps. needed or not strongly
indicated.
To be able to catch gallbladder cancer early enough
if cancer is truly present (because of the 1% to 2%
chance of gallbladder cancer)
After operation, no more concern or worry for

future gallbladder diseases as the GB has been
totally removed already (assuming the GB cancer is
also curatively resected).
Option1
Cholecystectomy
Option2
No cholecystectomy
COMPARATIVE RISK
Risk of operation and anesthesia mortality and complications. 1-2% chance of
Mortality rate - less than 1% gallbladder cancer not
Complications: discovered and treated
7% -intraoperative now
4% - postoperative
-Injury to common bile duct (most serious - less than 1%)
-Infection *No risk for
-Bleeding cholecystectomy
-Bile Leak operation and anesthesia
-Injury to nearby organs like liver and bowel mortality and
-Blood clots (deep vein thrombosis) complications
-Pneumonia
-Scar and numb feeling at incision site
-Hernia
-Others
Option1
Cholecystectomy
Option2
No cholecystectomy
COMPARATIVE COST
Cost of operation including hospital expenses Cost of serial ultrasounds
to monitor polyps – once
Rough estimate and range depending on government or private a year for 2 years at least
hospitals and attending physicians: (P5K for 2 ultrasounds)
Ballpark figures:
P50K to P200K or even more (depending on hospital and *NO cost of operation
attending physicians) with hospital expenses
May or may not be covered by health insurances like PhilHealth NOTE: the prices are
and HMOs. variable.
NOTE: the prices are variable.
Option1
Cholecystectomy
Option2
No cholecystectomy
COMPARATIVE AVAILABILITY
Procedure of cholecystectomy readily available
(open cholecystectomy and laparoscopic
Procedure for
cholecystectomy)
ultrasound readily
Open cholecystectomy more readily available though. available
Intraoperative decision-making processes (benefit, risk, cost,
availability)
Example: If a drain is indicated after thyroidectomy, which
drain to use?
Options Benefit Risk Cost Availability
Rubber drain • Passive Wound P50 Readily
drainage (98% infection available
effective) rate (1%)
• Drain failure
(1%)
Tube drain with • Active Wound P1500 Not readily
negative pressure drainage (99% Infection available
effective) rate
• Drain failure – (1%)
clogged (3%)
Intraoperative decision-making processes (benefit, risk, cost,
availability)
Example: in the closure of a total mastectomy wound, if
continuous embedded sutures will be used, how many
layers of suturing, one layer of full thickness or 2 layers of
dermal then subcuticular?
Options Benefit Risk Cost Availability
Two-layer Wound Dehiscence • Cost of 2 Available
continuous can be theoretically lower absorbable
suturing coaptated sutures
well • Longer closure /
operating time
One-layer Wound Dehiscence • Cost of one Available
continuous can be theoretically higher absorbable
suturing coaptated but no clinical suture
well difference if done • Shorter closure /
properly operating time
Patient Management Process and
Clinical Practice Guidelines
Clinical practice guidelines, as defined nowadays, are more
of system-centered care and NOT patient-centered care.
CPG is based on a group of patients with the same disease

diagnosis and prognosis and NOT on an individual patient
with a particular disease diagnosis and prognosis.
The beauty of the management of a patient process is that it
focuses on the processes first, rather than on the what’s,
how’s and when’s of the recommended clinical treatment
guidelines.
Patient Management Processes

• Clinical diagnostic processes
• Paraclinical diagnostic processes
• Indications
• Selections (BRCA)
• Interpretation
• Treatment processes (BRCA)
Talking of standardization of management -
using the concept of ISO (standardization) which banks
on processes-based approach rather than on dictating the
specific what’s, how’s and when’s to accomplish things
the patient management process framework
can be used to standardize management of a
patient through the established processes
rather than the clinical practice guidelines.
The established clinical practice guidelines can be and
should be integrated into the management of a patient
process, particularly for the data in the Benefit-Risk-Cost-
Availability Table.
BTW – most CGPs do not input yet the factors of cost and
availability – which are important in decision-making.
Benefit Risk Cost Avaibility

Option1 CPG data CPG data
Option 2 CPG data CPG data
Option 3 CPG data CPG data
For all the above reasons,
the patient management process should come first

before the clinical practice guidelines
and
I think (and I propose) that the patient management
process framework should be the mother, the
foundation, and the starting point of all clinical
practice guidelines.
End of Presentation
Let’s now have the wider-scale open forum on all 3 topics

and others!
Welcome QUESTIONS and COMMENTS!
What are the qualities of an excellent
surgeon?
From ChatDPT
• An excellent surgeon possesses a combination of medical
expertise, technical skill, interpersonal abilities, and ethical
qualities that contribute to their effectiveness and
reputation.
• Here are some qualities that are often associated with
excellent surgeons:
surgeon?
From ChatDPT
• Medical Knowledge: An excellent surgeon has a strong
foundation of medical knowledge, including understanding
anatomy, physiology, and the latest advancements in their
field. They stay updated with the latest research and
developments in surgical techniques.
• Technical Proficiency: Surgical procedures require precise
technical skills. Excellent surgeons have steady hands,
dexterity, and the ability to perform complex procedures
with accuracy and precision.
surgeon?
From ChatDPT
• Decision-Making Skills: Surgeons must often make quick
and critical decisions during procedures. Excellent surgeons
can assess situations, identify problems, and make informed
decisions under pressure.
• Communication Skills: Communication is crucial for
interacting with patients, their families, and the medical
team. Excellent surgeons explain procedures, risks, and
outcomes clearly, ensuring patients understand their
treatment options.
surgeon?
From ChatDPT
• Empathy and Compassion: Surgeons should empathize with
their patients' concerns and demonstrate compassion. A
caring demeanor helps build trust and rapport, leading to
better patient outcomes.
• Leadership and Teamwork: Surgeons often work as part of a
larger medical team. Excellent surgeons are effective leaders
who can coordinate and collaborate with other healthcare
professionals for optimal patient care.
surgeon?
From ChatDPT
• Attention to Detail: Surgical procedures demand meticulous
attention to detail to ensure the best possible outcomes and
minimize complications.
• Adaptability: Medical situations can change rapidly. An
excellent surgeon is adaptable and can adjust their approach
as needed based on unexpected developments.
surgeon?
From ChatDPT
• Ethical Integrity: Surgeons must uphold high ethical
standards in patient care, interactions with colleagues, and
decision-making. Trust is paramount in the doctor-patient
relationship.
• Continuous Learning: Medicine and surgery are constantly
evolving fields. Excellent surgeons engage in lifelong
learning to stay current with new technologies, procedures,
and research.
surgeon?
From ChatDPT
• Problem-Solving Skills: Surgeries can present unexpected
challenges. Excellent surgeons are skilled problem-solvers
who can think creatively to overcome difficulties during
procedures.
• Professionalism: Professional demeanor, respect for
colleagues, punctuality, and maintaining patient
confidentiality are key aspects of a surgeon's
professionalism.
surgeon?
From ChatDPT
• Patient Safety: Excellent surgeons prioritize patient safety at
all times, adhering to best practices, infection control, and
proper surgical techniques to minimize risks.
• Confidence without Overconfidence: Confidence is
important, but being humble and acknowledging limitations
is equally vital. Excellent surgeons know when to seek
advice or refer patients to specialists.
• Time Management: Surgeons often handle a demanding
schedule. Excellent time management skills help ensure
efficient patient care and a healthy work-life balance.
surgeon?
From ChatDPT
• Remember that while these qualities are important, every
surgeon is unique, and the blend of attributes that makes
an excellent surgeon can vary. As medicine and surgery
continue to advance, the qualities required for excellence
may evolve as well.
What is the ROJoson Patient Management
Process
From ChatDPT
• The Rojoson Patient Management Process, also known as the "Rojoson's
Three Point Patient Consulting Protocol," was developed by Dr. Reynaldo
O. Joson, a prominent Filipino surgeon and medical educator. This protocol
emphasizes a structured approach to patient consultation, aiming for
efficient and effective patient management. It consists of three main
points:
• 1. **Data Gathering and Recording**:

• - **Point 1**: Ask the patient for all the symptoms, signs, and other
relevant information.
• - **Point 2**: Record the information given by the patient systematically
and legibly.
• - **Point 3**: Include in the record all the factors that can affect the
diagnosis and management, such as the patient's age, sex, occupation,
habits, past medical and surgical history, medications, and allergies.
Process
From ChatDPT
• 2. **Information Giving and Patient Education**:
• - **Point 4**: Inform the patient about the possible diagnosis,
management, and prognosis.
• - **Point 5**: Educate the patient on the nature of the disease, the
treatment options available, and the expected outcomes.
• - **Point 6**: Discuss the risks, benefits, and alternatives of
treatment.
Process
From ChatDPT
• 3. **Negotiation and Shared Decision-Making**:
• - **Point 7**: Decide on the plan of management and explain the
rationale.
• - **Point 8**: Include the patient in the decision-making process
by discussing treatment options and considering their preferences
and values.
• - **Point 9**: Reach an agreement on the management plan with
the patient.
Process
From ChatDPT
• This protocol emphasizes a patient-centered approach,
where the physician actively involves the patient in the
decision-making process and ensures that the patient fully
understands their condition and treatment options. It aims
to promote effective communication, patient satisfaction,
and ultimately, better health outcomes.

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

• A retired Surgery Professor from the UP College of Medicine and

• A former Chief of the Division of Head and Neck, Thyroid, Breast,

• A former Chairperson of the Department of Surgery of Ospital ng

This program is designed to be a free-wheeling discussion on

It can be a free-wheeling question and answer format. You

But, if you will allow me,

I can set initially the direction for the issues to be discussed

Later on or thereafter, you can ask me any questions under

You can change them.

Essentially, I have chosen 3 topics or issues which I think are

I have been in practice as a general surgeon for more than 40

I am semi-retired but I have made a personal project to give

• What qualities do I personally consider in an excellent

A lot of times, undergraduate medical students rotating in

When do you consider a surgeon to be good (oftentimes,

One, there is no universally accepted treatise on this issue.

Second, if one searches the Internet, one will get different

Three, if I give an answer, I anticipate differences if not

My answers will represent my concepts

A mindset that uses my “Management of a Patient Process”

[ROJoson Lecture] ROJoson Patient Management Process - An

Is Holistic, Professional and Compassionate and practices

Knows when to operate and when not to operate

With the following qualities when they operate in the

With the following qualities when doing procedures when the

*Expressed by patients and relatives

No surgeon is perfect all the time.

All surgeons have limitations in what they can do in

I encourage and welcome 2 questions and comments for the

The root factor is the uniqueness of

• Manifestations of symptoms and medical diseases may not

It conventionally includes listening to, informing and

Patient-centered Care – care based on individual patient’s

The current clinical practice guidelines attempt to standardize patient

CPG are more of “system-centered or service-centered care” (care based on a

As we shall see later, ONLY THE MANAGEMENT OF A PATIENT PRINCIPLES AND

Back to this QUESTION! Why why why ……

A major contributing factor is the different and

Management of patients involves a reiterative interplay of

• There must be dialogue and collaboration between the

• The best combination will be minimalist physicians and

• If the minimalist physicians encounters ritualistic and

I encourage and welcome 2 questions and comments for the

What are the comparative benefit-risk-cost-availability data

Comparative benefit-risk-cost-availability data and

After operation, no more concern or worry for

CPG is based on a group of patients with the same disease

Patient Management Processes

Benefit Risk Cost Avaibility

the patient management process should come first

Let’s now have the wider-scale open forum on all 3 topics

• 1. **Data Gathering and Recording**:

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• 1. Data Gathering and Recording: