How the Culture of Bullying in the Hospital Hurts Patients

I remember the first time I was fighting back tears while examining a patient as a medical intern. It was early morning when I received a referral for a motor vehicle accident patient in my Ophthalmology rotation. I did the eye exam and noted my findings on the chart, since the patient was unable to ambulate and there was no available stretcher in the crowded Emergency Room, I used some printed material instead of the Snellen chart.

I notified the resident physician and endorsed my findings. This particular resident was an intern’s monitor and projected himself as “pro-student” and having oriented us during the beginning of the rotation, I thought he, of all people would be more tolerant.

“Ano ‘to?” (What’s this?) He said as he looked at my chart entry. I explained how I did my physical exam, and since I did my clerkship in another institution, the order of my eye exam was not the standard one in the current institution.

I apologized and explained that I was confused with the order of the eye exam, but I thought as long as it was complete, it would not be that of an issue. I believed that we settled the matter then, but when he learned I used a fine print instead of the Snellen chart to check the visual acuity, he launched into a full tirade.

“Saang school ka ba graduate?” (What school did you graduate from?) He asked loudly, while we were in front of the patient and his family. He crushed out my entries.

I was aware of the particular culture in certain institutions that medical school of origin was a big deal, such that interns are judged based on where they came from. It would have not been a problem if I came from one of the top schools like University of Santo Tomas or Cebu Institute of Medicine, but I came from a modest medical school Remedios Trinidad Romualdez Medical Foundation in Tacloban. I have gotten used to people replying with, “Saan yun?” (Where’s that?). And then I had to explain where my Alma Mater was. I thought it was offensive to me why I needed to explain where I came from, I mean it is not my fault I was born in Leyte and I chose to go to school there, in fact I am proud that I am Waraynon. It was certainly nobody’s business to embarrass me by looking down on my credentials while in front of the patient and his family. The family member looked away, sensing the tension.

“Mas magaling pa sa iyo ang mga third year dito!” (Third year students here are better than you!) He said.

I was trying to hold my composure, and still tried to assist him while he was examining the patient. My vision was starting to cloud. I have very shallow tears, I tried not to blink because I was afraid my tears would fall directly to the patient’s face.

Before we were done, I curiously checked the findings he scribbled on the chart particularly the visual acuity. It turned out my findings which he crushed out were exactly the ones he wrote on the chart. It was one of those instances when I experienced bullying in the medical setting as a novice. It would not be the last.

Different forms.

Abuse comes in different forms. It could be verbal, negligence, or unjust treatment or unreasonably long hours. It is as old as the medical profession itself. People have gotten so used to it that it sometimes feels like the “norm.”

Some of my friends who took their internship in different institutions in Manila experienced being “runners” and personal servants of some of their seniors. Some interns were assigned to make coffee, some clerks designated as the “takeout person” or ones assigned to bring the bag/s of their senior while the senior strutted like a fashion model.

There is a fine line between doing a few favors and being a compete personal slave. I don’t mind holding the door open or making coffee for someone now and then, but when the tasks are not training related or nothing remotely geared towards improving one’s medical skills, then we have a problem.

As a clerk, a male surgeon once refused to be assisted by me and wanted a “pretty female clerk” (his words) who could do surgery with him all day in the Operating Room. At the end of the day, we felt sorry for our petite female colleague who had to retract all day at three nephrectomies just because she was a pretty female. The jokes and vague sexual innuendos are another thing. Hospitals have advocacies on gender sensitivity and sexual harassment, but somehow the practice is still thriving.

When Tables Turn

In the private institution where I had my clerkship, we clerks did majority of the work because interns have protected time of five hours for their board review, and when we get patients in the Emergency Room, we clerks do the history and primary intervention first before we endorse to our interns.

Since I had my internship in a large public teaching hospital, I never had the chance to experience being a “senior” because no such distinction existed between roles of clerks and interns. Only during the time when I became a resident did I experience being in a position of authority.

I remember that incident in the Emergency Room of my Ophtha rotation, and I realized every resident physician who work closely with interns and clerks actually have a choice: they can continue to perpetuate that culture or they can choose to stop the culture of bullying.

Being in a training institution meant we had an obligation to teach, rather than berate juniors when they make mistakes which is expected in the learning curve.

Far-Reaching Consequences

The consequences are not limited to the aspiring doctors who, sadly take the brunt of the abuse. These would-be doctors experience depression, feelings of inferiority, and possibly lead to more serious consequences like quitting the training program and even suicides in severe cases.

Patients also become the unwitting ultimate victims. The quality of care becomes compromised as clerks, interns, and residents focus more on avoiding the wrath of their seniors, rather than providing the utmost care. I remember a certain Emergency Medicine resident who gets severely agitated and rude when there are many patients for admission, that the interns would spend time convincing the relatives of patients to just transfer to another hospital. Sadly, some of these patients had nowhere else to go because of poverty, and in the end some do not make it at all.

As a Pathology resident now, I was surprised how other specialties also bully their way in the laboratory. Some choose not to follow the policy of 24 hours’ notice for frozen sections, which require Pathology consultants to read the slides and thus need to be properly scheduled. Some just operate on their patient and decide at a moment’s notice, which requires a written explanation by policy but such is a rule that some surgeons choose to ignore. Several times, residents of other specialties would barge in the cutting room while we are dissecting to demand that we prioritize their particular case as if we were their employees or that other cases deserved any less of our full attention. Newsflash: we are all Medical Officers- same position, different department.

Even the menial task of providing complete information on the Surgical Pathology form has a lot of benefit for the patient, which unfortunately some fail to give. I once received a modified radical mastectomy specimen which had only one phrase written on the history. I processed the specimen as usual but when I examined it microscopically, there were only fibrous tissue and very scant foci of tumor cells. My consultant had me repeat the sections of the breast thinking that I just missed the lesion but the other possibility was that the patient probably had chemotherapy beforehand which could help explain the altered morphology.

I tried contacting the surgeon to no avail. I visited the General Surgery office with a written letter inquiring about the patient’s history, but they provided no response. I went to the ward to try to see the patient and the chart but she was already discharged. Finally, I personally went to the Medical Records and dug through the bulk of files to retrieve the chart and found what I was looking for, the line that said:

“History of Invasive Ductal Carcinoma, status post 6 cycles of chemotherapy (2016).” It was all I needed and was able to sign-out the case. The morphology was altered because she had already undergone treatment and had responded well- there was only microscopic tumor foci left and all the margins were clear. Just like that, our final diagnosis hit the mark.

I was disappointed that because of the lack of information given, the patient had to wait for a longer period before we could sign out the case. Had I not investigated further, the case would have dragged on. Perhaps the surgeon thought it was only their job that mattered, when it is the pathologist who will give the final anatomic diagnosis on what the lesion is and ascertain if they had adequately treated the patient.

No doubt doctors are intelligent people, but what escapes me is how we never realize how much of a disservice we are doing to patients by bullying juniors or fellow doctors, thinking that one specialty is more superior than another. The lack of respect ultimately results in delay of patient diagnosis or inadequate treatment, something all of us should avoid at all costs. It also goes against the principle of teamwork of all members of the health care team. Lastly, let me echo the words of one of our mentors: “We all stand on the shoulders of those who came before us.” Let that be a reminder of the responsibility we have to train the younger generation of doctors and uplift the medical profession.

- Lifted from Thad Hinunangan

The Once and Future Doctor

MD Plus

By: Michael Tan

PINOY KASI, INQUIRER

Last updated 02:42am (Mla time) 12/14/2007

The title I really wanted for today’s column was “The Once and Future Doctor,” but because my column is horizontally challenged, space-wise, the title always has to be short.

I’m writing about a bold innovation at Ateneo de Manila University’s new medical school, formally known as the Ateneo School of Medicine and Public Health, or ASMPH. They took in its first batch of medical students last June, and in a few years, they will be the first medical students to graduate from a Filipino medical school with two degrees: an MD (Doctor of Medicine) and an MM (Master of Management).

People expect medical schools to produce graduates who will excel as clinicians, meaning graduates practicing medicine in a clinic or hospital setting. The ASMPH hopes to do that, and more. All this goes back to years of planning, starting with the dreams of Dr. Alfredo Bengzon, the ASMPH dean, who assembled a small think-tank to work on his vision. “I want a medical school,” he would keep reiterating, “that will produce graduates who excel as clinicians, as administrators and as public health experts.”

It’s not surprising that such a vision would come from Dr. Bengzon, given his own background and experiences. His specialization is neurology, one of the most complicated medical fields. Later, working with The Medical City, he went on to get a Master’s in Business Administration. Eventually, he became Ateneo’s vice president for Professional Schools, expanding the MBA program to include two postgraduate degrees specifically targeting health professionals.

Under the Aquino presidency, Dr. Bengzon served as health secretary, which exposed him to the country’s many daunting public health problems. His government service wasn’t limited to health; when the negotiations around the US bases in the country began, he was appointed head of the Philippine panel, not an easy task. Dr. Bengzon knows what he’s talking about when he says health is economic and social and political.

Stateside

The idea of medical schools offering two degrees is not new, at least in the United States. I checked the website of the Association of American Medical Schools and was overwhelmed by the varieties of joint degree programs.

A total of 73 American medical schools offer an MD/MPH (Master in Public Health) program. The University of Pennsylvania, with its famous Wharton School of Business, was the first to offer a joint MD and MBA program in the 1970s. Today, there are 49 American medical schools that offer such dual degrees.

I think it’s significant that Ateneo offers an MM instead of an MBA. An MBA tends to be associated with corporations and for-profit institutions while an MM degree has a broader scope, training people for a wider range of settings -- from the Department of Health to the many international health organizations. Ateneo’s MM should, hopefully, produce someone who is as comfortable in a corporate setting (which is what many hospitals are) dealing with executives, as well as a community, and with some small town’s mayor. The inputs here have come from Dr. Marife Yap, the ASMPH associate dean, who originally came in from community medicine practice. In a way then, Ateneo’s MM is an MBA and an MPH rolled into one. (Really now, working for three degrees simultaneously would have been too much.)

What are the other American joint degree programs? There are 22 medical schools offering an MD/JD program, meaning, graduates will be both physicians and lawyers. We actually have some of these doctor-lawyers (“dokattorneys,” TV host Korina Sanchez calls them) but they get there through a long route: a bachelor’s degree, followed by medical and law schools taken separately, at least over 12 years.

Many of the American medical schools offer an MD with a PhD in a specialized biomedical field (for example, immunology, neuroscience, toxicology). What surprised me though was that 103 of the medical schools now offer an MD with a postgraduate degree in an interdisciplinary field not directly related to biomedicine. Harvard, for example, offers an MD with a PhD to be chosen from three fields: Health Care Policy, History of Science or Medical Anthropology. Case Western University has an Anthropology and Medicine program where medical students can work toward an MA or PhD in urban health, cross-cultural aging, international health or psychological anthropology.

Staying home

The wave of the future in medical schools isn’t just around these dual-degree programs. What we’re seeing here is a distinct trend toward producing a “Doctor Plus,” a physician who goes beyond biomedicine. In many ways though, this is not new, representing a return to what doctors once were: people who could take time to better understand their patients. So, even without a dual-degree program, many American medical schools are emphasizing a more interdisciplinary curriculum even in their regular medical training. The University of California in San Francisco, for example, devotes its 4th year to advanced studies, where students get to pick from medical humanities, the science of medicine, or global and public health.

Disclosure time: Yes, I’ve been part of Dr. Bengzon’s think-tank from the beginning. We work without compensation, usually on weekends and in late evenings, the joy and fulfillment coming from being able to dream with Dr. Bengzon and other visionaries.

No, I have not left the University of the Philippines (yet). At UP’s College of Medicine, I’ve been working with the Department of Community and Family Medicine to find ways to equip our students to deal with the realities of medicine, outside of hospitals. We send students out for a reality check, in the streets, in the “Quiapo Medical Center” (yes, Plaza Miranda with its medicinal plants and amulets) and further afield. We remind them, too, of the importance of understanding why medicines are expensive, of looking into social and political issues from gender inequity to governance (or its lack thereof).

I think we’re doing a fairly good job at UP and ASMPH; in fact, my fear at times is that we might be doing too good a job. Our graduates won’t need to go to nursing school if they want to work overseas; instead, they’ll be very competitive as an “MD plus” when applying for the World Health Organization and other international agencies, as well as American and European hospitals that emphasize cultural competence or the ability to work with people of different ethnicities.

I can only hope that our alternative medical curricula are also strong enough to produce doctors who will be inspired to stay on and serve in the Philippines, partly because of patriotism but also, in a practical way, because they will be less prone to despair. These would be physicians confident in their ability to use the sophisticated technologies of the 21st century, but also mindful of the need to put down their stethoscopes and CT scan reports and return to the patient -- listening, observing and understanding.

The ULTIMATE QUESTION: WHY?

The Ultimate question that will be asked from you in your medical interviews is simply this:

WHY DO YOU WANT TO BE A DOCTOR?

Let me share to you this great insight I have found through days and months of searching the world wide web. I found it in the videos of The College of Medicine of Nova Southeastern University, Florida, USA. Unfortunately, the videos are down.

Luckily for you (and for me, in times of great turmoil and doubt), I have transcribed it and found it in my scribbles while I was preparing for the medical interviews.

Let me share it to you in the words of Dr. Anthony Silvagni, Dean of The College of Medicine of Nova Southeastern University, Florida, USA:

NARRATOR: Why MEDICINE?

Medicine is a very special profession. I actually perceive it as MAGIC.

When you're a doctor, people would entrust you with information and personal data that they will not share with anyone, not their parents, not their spiritual leaders, not their spouses, no one; but they will trust you. And with that trust, they will allow you with hope that you will examine their bodies in the most PROFESSIONAL WAY, looking to help them have a better quality of life and possibly the quantity of life.

In medicine, you get to be the first person to touch a new human being. To deliver a child is so magic and such an opportunity to view. To see that transition, as that child is born into a breathing, living person. You will also get to see death. 

In today's world, people do not see the transition. Someone get sick, they go to the hospital, they die and you see them in the funeral homes. Your realization as a DOCTOR is that you will PARTICIPATE in that TRANSITION.

And in that transition, you will see the power and strength of some individuals have in their RELIGIOUS BELIEFS and their understanding of the fact that LIFE IS A CYCLE. With that strength and knowledge that you've gained from those people, you will help others who do not have that power, that strength or that belief and therefore help them through that transition.

All of this makes up the 

MAGIC OF MEDICINE.

Before I Go: A Stanford neurosurgeon’s parting wisdom about life and time

In residency, there’s a saying: The days are long, but the years are short. In neurosurgical training, the day usually began a little before 6 a.m., and lasted until the operating was done, which depended, in part, on how quick you were in the OR.

A resident’s surgical skill is judged by his technique and his speed. You can’t be sloppy and you can’t be slow. From your first wound closure onward, spend too much time being precise and the scrub tech will announce, “Looks like we’ve got a plastic surgeon on our hands!” Or say: “I get your strategy — by the time you finish sewing the top half of the wound, the bottom will have healed on its own. Half the work — smart!” A chief resident will advise a junior: “Learn to be fast now — you can learn to be good later.” Everyone’s eyes are always on the clock. For the patient’s sake: How long has the patient been under anesthesia? During long procedures, nerves can get damaged, muscles can break down, even causing kidney failure. For everyone else’s sake: What time are we getting out of here tonight?

There are two strategies to cutting the time short, like the tortoise and the hare. The hare moves as fast as possible, hands a blur, instruments clattering, falling to the floor; the skin slips open like a curtain, the skull flap is on the tray before the bone dust settles. But the opening might need to be expanded a centimeter here or there because it’s not optimally placed. The tortoise proceeds deliberately, with no wasted movements, measuring twice, cutting once. No step of the operation needs revisiting; everything proceeds in orderly fashion. If the hare makes too many minor missteps and has to keep adjusting, the tortoise wins. If the tortoise spends too much time planning each step, the hare wins.

The funny thing about time in the OR, whether you frenetically race or steadily proceed, is that you have no sense of it passing. If boredom is, as Heidegger argued, the awareness of time passing, this is the opposite: The intense focus makes the arms of the clock seem arbitrarily placed. Two hours can feel like a minute. Once the final stitch is placed and the wound is dressed, normal time suddenly restarts. You can almost hear an audible whoosh. Then you start wondering: How long till the patient wakes up? How long till the next case gets started? How many patients do I need to see before then? What time will I get home tonight?

It’s not until the last case finishes that you feel the length of the day, the drag in your step. Those last few administrative tasks before leaving the hospital, however far post-meridian you stood, felt like anvils. Could they wait till tomorrow? No. A sigh, and Earth continued to rotate back toward the sun.

But the years did, as promised, fly by. Six years passed in a flash, but then, heading into chief residency, I developed a classic constellation of symptoms — weight loss, fevers, night sweats, unremitting back pain, cough — indicating a diagnosis quickly confirmed: metastatic lung cancer. The gears of time ground down. While able to limp through the end of residency on treatment, I relapsed, underwent chemo and endured a prolonged hospitalization.

I emerged from the hospital weakened, with thin limbs and thinned hair. Now unable to work, I was left at home to convalesce. Getting up from a chair or lifting a glass of water took concentration and effort. If time dilates when one moves at high speeds, does it contract when one moves barely at all? It must: The day shortened considerably. A full day’s activity might be a medical appointment, or a visit from a friend. The rest of the time was rest.

With little to distinguish one day from the next, time began to feel static. In English, we use the word time in different ways, “the time is 2:45” versus “I’m going through a tough time.” Time began to feel less like the ticking clock, and more like the state of being. Languor settled in. Focused in the OR, the position of the clock’s hands might seem arbitrary, but never meaningless. Now the time of day meant nothing, the day of the week scarcely more so.

Verb conjugation became muddled. Which was correct? “I am a neurosurgeon,” “I was a neurosurgeon,” “I had been a neurosurgeon before and will be again”? Graham Greene felt life was lived in the first 20 years and the remainder was just reflection. What tense was I living in? Had I proceeded, like a burned-out Greene character, beyond the present tense and into the past perfect? The future tense seemed vacant and, on others’ lips, jarring. I recently celebrated my 15th college reunion; it seemed rude to respond to parting promises from old friends, “We’ll see you at the 25th!” with “Probably not!”

Yet there is dynamism in our house. Our daughter was born days after I was released from the hospital. Week to week, she blossoms: a first grasp, a first smile, a first laugh. Her pediatrician regularly records her growth on charts, tick marks of her progress over time. A brightening newness surrounds her. As she sits in my lap smiling, enthralled by my tuneless singing, an incandescence lights the room.

Time for me is double-edged: Every day brings me further from the low of my last cancer relapse, but every day also brings me closer to the next cancer recurrence — and eventually, death. Perhaps later than I think, but certainly sooner than I desire. There are, I imagine, two responses to that realization. The most obvious might be an impulse to frantic activity: to “live life to its fullest,” to travel, to dine, to achieve a host of neglected ambitions. Part of the cruelty of cancer, though, is not only that it limits your time, it also limits your energy, vastly reducing the amount you can squeeze into a day. It is a tired hare who now races. But even if I had the energy, I prefer a more tortoiselike approach. I plod, I ponder, some days I simply persist.

Everyone succumbs to finitude. I suspect I am not the only one who reaches this pluperfect state. Most ambitions are either achieved or abandoned; either way, they belong to the past. The future, instead of the ladder toward the goals of life, flattens out into a perpetual present. Money, status, all the vanities the preacher of Ecclesiastes described, hold so little interest: a chasing after wind, indeed.

Yet one thing cannot be robbed of her futurity: my daughter, Cady. I hope I’ll live long enough that she has some memory of me. Words have a longevity I do not. I had thought I could leave her a series of letters — but what would they really say? I don’t know what this girl will be like when she is 15; I don’t even know if she’ll take to the nickname we’ve given her. There is perhaps only one thing to say to this infant, who is all future, overlapping briefly with me, whose life, barring the improbable, is all but past.

That message is simple: When you come to one of the many moments in life when you must give an account of yourself, provide a ledger of what you have been, and done, and meant to the world, do not, I pray, discount that you filled a dying man’s days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more, but rests, satisfied. In this time, right now, that is an enormous thing.

-Article lifted by Paul Kalanithi

Road Map. Residency.

Flowchart lifted from Fellow Blogger: JBatt (You can read the original text by clicking the link)

Not bad. Pretty Much sums up the need to find a specialty. 

But I know that I am a Pediatrician by heart, <3

Mute. An ENT Clinical Clerk's required reflection.

Ever since I could remember, I wanted to write for a living. I eat and breathe literature. But then, things turned differently when I passed the most prestigious high school (so they say), the Philippine Science High School, Main Campus. My parents did not force me (in fairness to my dad and my mom, they respected my decision just in any case), the circumstances forced me. Life was not always a silver spoon for my family. We had our ups and downs. That moment when I saw my mother cry because her head was spinning where to get the means to provide for her children was my turning point. I gave up my dream and signed that f* up contract to have a science course 4 years from that day, May of 2001. Having finished it on October 2009, after graduating from UP Diliman B.S. Biology made me feel accomplished; however another opportunity was knocking on the door--medical school.

Life was not easy. No one has it smoothly. When life throws you a ball, you throw it back. Why? Because you just got to. Nothing else to say. No more excuses. No words left. You just have to.

Easy as that. I gave up writing. I also lost the eloquence of my words through the years. Writer's drought as they call it. But bit by bit, I found my words by coming to terms with myself and I was able to live out with the decisions I've made.

Perseverance in the Face of Adversity

I'm feeling kinda down these days. Maybe it's the hormonal imbalance and the lack of appropriate sleep, but anyhuu... it's making me edgy. In addition to this, I came across some of my batchmates today who are already graduating. My heart was filled with awe and joy for them, but there were some who weren't really happy to see me.

Well... no one is perfect and maybe I did some crazy nasty things back then, but it just pains me that people can be very judgmental and that they base your very being on one or two situations or incidents.

I was happy to also see that some of them have forgotten our differences and moved on. Blessed are those kinds of people and I pray for their success each day.

I'm kinda sad and upset that I now know who my real friends are and those who were just in with me for the ride. You really can't know who to trust until you fall flat on the ground. Alas, thanks to God... I am warned. :)

All I know is that even if people are silently talking about me behind my back (or am I just paranoid? lol) and judging me harshly, here I am proudly and steadily persevering to become a doctor.

There is a deep and personal reason for my previous failures which is causing delay to my M.D. graduation. I do not have to keep explaining to people on why. I don't owe anyone any explanation.

Trust me. You will see me rise again... in God's time. For now, God has humbled me to the lowly plains to replenish me when the time is ripe.

"Defeat is precisely what the enemy wants: Adverse circumstances arise, we flee in fear or defeat, and the enemy triumphs (interesting that he is called our "adversary" in 1 Peter 5:8). The last thing he wants is for God to be glorified through the trials in our lives." - Taken from: The Identity Project

TIME OUT!

GUILTY. I told myself to get rid of any distractions for the upcoming finals in 2 weeks, but here I am blogging. DISCIPLINE!

I guess I can't help it because I am so fueled with passion and inspiration which I haven't felt in the longest time.

At present, I am reading "The Outliers" by Malcolm Gladwell, and THUMBS UP. Everything I every questioned about in my life is there. 

I will blog in detail soon. But one quick food for thought that I want to share in that book: "There is no direct correlation between intellect and achievement." You need a little bit more to excel. The ingredients for success is summed up in: passion, hardwork, talent, grabbing opportunities and entitlement.

Still in the first chapters but WOW... it gave me that extra boost to work harder in my studies :)

One quick advice for incoming medical students, don't let the day pass by without reminding yourself why you have chosen the path to become a doctor. Read inspirational books and fuel yourself with passion. Intellect, high IQ and high grades wouldn't matter that much in med school (I mean hello, will your patients ask you if you had high grades in med school?). Personal skills, compassion and personality goes a long long way, not just in med school but beyond this field we all dream of.

CHOW. :) Need to do my orthopedic paper :)

Blogging by October 2013

Hi guys who are reading this blog, I will be writing again with fresh experiences and insights this semestral break (OCT 2013)! :)

STAY TUNED! :)

Someday.

Someday. I can't contain this passion inside of me. I have been reading the book by Robert Greene entitled, "Mastery," and wow... all I can say is wow. It is such a wonder on how one book can give me so much profound knowledge and understanding.

My mind is racing with thoughts and dreams of the future. I am filled with tears with the knowledge that my passion has come back to me. Ever since my brother died 3 years ago, I felt different. As if my world changed and that everything in my life had no meaning... pointless.

Bereavement at it's finest, you may say. Many would have suggested that I should have took another year off from medical school to relieve oneself from the trauma and depression but the agony of not doing anything and the thought of not distracting myself from my grief was unbearable. So, I entered medical school even if I was in deep bereavement, which I have hidden so well with a poker face for years.

School was a routine, just to get by and I lost my vision, mission and my passion for my work. I lost sight of my goal and you may say... yes, I was indeed lost. Many asked me how I persevered, in an atmosphere where the competition is tough, where you do not know who your real friends are and where you must be cautious to trust who.... I guess, what gave me the strength was that I knew in my heart that becoming a doctor is my life's task, my calling, my vocation, my greatest achievement in my life, and my life's sole purpose.

Something to Remember Me By.

"You and I have both struggled and stumbled and in truth not always given our best but even then it was our effort... Know that you EARNED the right to be here..."

DAMN RIGHT.

The Neurological Side of Sleep

Sleep is a biologic process, which is cyclic, temporary, physiologic loss of consciousness that is readily, promptly and completely reversed by appropriate stimulus. Sleep involves all the neuro-axis, it just does not involve one part of the brain. It is a reversible behavioral state of perceptual disengagement and unresponsiveness to the environment. It is not a passive process since specialized areas in the brain work to maintain sleep.

Sleep follows a predetermined pattern of well-organized sequential stages and cycles. The structured temporal sequence produces a graphic display known as ARCHITECTURE OF SLEEP, also known as SLEEP HYPNOGRAM. Sleep will always cycle with wakefulness. You do not only sleep at one level. You sleep at different levels which also cycle itself hence there are sequential stages and cycle when we go to sleep.

The best way to determine of the patient is asleep or not is with the use of the ELECTROENCEPHALOGRAM (EEG). This is done by putting on an EEG and apply wave, which measures brain activity and you look at the brain activity of the patient. EEG is the most important means to visualize different stages of sleep by studying brain waves.

According to various sleep theories, sleep is essential for body and brain tissue restoration, memory reinforcement & consolidation, restitution for autonomous functions, energy savings, synaptic and cell network integrity and adaptation.

What will happen to your brain if you do not sleep? It has been shown that impaired concentration, psychological imbalance such as increased irritability & hallucinations and subjective well-being impairment are the aftermath of sleep deprivation. With sleep deprivation for 60 to 200 hours, human beings experience increasing sleepiness, fatigue, irritability and difficulty in concentration. Neurologic signs include nystagmus, impaired saccadic eye movements, loss of accomodation, exophoria, slight tremor of the hands, ptosis of the eyelids, expressionless face and thickness of speech with mispronounciation & incorrect choice of words. During recovery from prolonged sleep deprivation, the amount of sleep obtained is never equal to the amount lost. 

Surpassing the Disappointment and Setbacks.

I've been too hung up on the fact that I filed a LEAVE OF ABSENCE (LOA) last semester during my Third Year as a Medical Student in the University of the East Ramon Magsaysay Memorial Medical Center Inc (UERMMCI) that I have been numbed to my feelings and at the same time been avoiding the subject matter per se.

But recent events had urged me to write about the feelings of what it is like to file an LOA since a freshman student from UP Manila committed suicide because of her forced LOA in response to her inability to pay her tuition fee.

As I try to find more objective evidences about this girl, Kristel Tejada from various news sources, one thing boils down... it is the disappointment of not graduating on time and regrets that stem from your goals in life for your love ones. I can relate because here I am, excited to be an intern at last next year but due to unexpected setbacks, I just have to learn how to cope on dealing with the fact that it's going to be delayed another year once more.

The Line of Uncertainty and The Point of No Return.

I've been away for a very long time and for my readers, I apologize for that. It's just that I have been having a very emotional and rough path these days, these weeks, these months and these years.

What am I saying?

I am saying that I am undergoing a transformation which entails a lot of thinking, medication and internal peace. I am at the stage of my life right now where I am at the line of uncertainty but I have already crossed the point of no return.

I don't know if anyone has experienced what I am saying so let me further elaborate it.

Enjoy the Moment with American Idol.

I feel refreshed.

With all that stress in my neck, I really needed that break last night.

Enjoyed the American Idol Live Tour with my family courtesy of my brother, who got Patron passes from his job. He works for History Channel and I am so enjoying the perks that comes with his job.

I'm so proud of my brother for his accomplishments :)

Even if I needed to study, I chose to support him and to cherish the family bonding.

Medical school is not just about studying, you know.

There can be life aside from Med school, if only you have mastered the art of time management in your pre-medical years.

I KNOW I PAID THE PRICE BEFORE ENTERING.

I had one tough pre-med course.

Many witnessed that. 

Haha.

When in Doubt, Remember these things.

You'll need these motivational quotes in medical school.

It serves as a remembrance that positive thinking goes a long, long way.

It differs from various students however.

I, on the other hand benefit so much from reading these.

It makes me want to persevere more.

THIS TOO SHALL PASS.

*sigh*

"If only I sought the easy way out."

Don't Quit Medical School

Last week, I had all the intention to quit medical school.

Personal reasons, I hope you don't mind that I keep this to myself.

But then, I realized that I'm half way there.

It's really just a long, long, long journey and I am getting impatient.

Keys to ponder on before entering medical school.

Get ready for a roller coaster ride of emotional turmoil.

You will encounter a lot of frustration, a lot of competition, a lot of disappointments, a lot of emotional attachment with the patients (and how to cope not to get affected when they die), a lot of readings, etc...

And that's just the beginning.

So if I were you, please.

DON'T ENTER MED SCHOOL.

I have no more choice since I have already invested so much in this field. That's just me.

But for you aspiring med students, think twice, think thrice--THINK.

And If you do DECIDE on BECOMING A DOCTOR, PREPARE YOURSELF.

You got to be emotionally strong.

It's not JUST GRADES HERE YOU KNOW.

IT'S BALANCING YOUR IQ AND EQ.

BOTH WILL BE TESTED.

TRUST ME.

Take it as a Challenge.

I am ready to spread my wings and fly. 

Even if I have no sleep and no rest, it won't make me stop achieving the things that I want to accomplish in my life.

I don't know how. I am afraid. Everything is telling me that it's impossible (logically) but then again, my faith in God prevails. I know in the end, He will make all things possible if I just truly believe.

Don't let me go... I humbly pray. I am doing my best, I attest life as my bear witness.

But in the advent that it does, I will bear the pain--that awful pain of rejection and dismay.

Try as I must, but I can only do so much... I firmly pray that at least one sees that I at least did my best.

But even if no one else sees it, I will be standing still to be the only one to be proud of myself.

You don't know what I am going through so you don't have the right to comment on my very life.

You don't know what I have to endure just to withstand the pressure in this career I chose....

So close your mouth. Hush, the words come out are painful.

But in the end, I do not care since for me all your words are futile.

Trust in God, Angelica. He will be the one to get you through this unbearable test of strength in the field we chose, the field of medicine.

In the end, it would be worth-it. Just bear it mind, one day you too will be M.D.

Take everything as a challenge. Lift everything to God.

and....

LET GO.

Now, let's jump off the cliff and spread our wings up high as our Father in Heaven will bring us up high.

Find Ways to Motivate Yourself

My room is filled with little notes so that when I get depressed or burn-out with medical school, I am reminded on why I even did this in the first place.

Luckily, I have prepared my mind and soul for what awaits for me in this field. 

I guess, my one year break before med school was worth-it after all.

It taught me how to manage myself and how to stay focus despite the tough academic load. Maybe this is the reason why despite I have so much things to do for tomorrow, I find time to do what I want to do such as writing, hence the existence of this blog site.

I have pictures of people who matter the most to me so that when sh*! happens, I am reminded that they would be there for me. No matter if I would be at the lowest point of my life or at the highest, I know that they would back me up without judgment, without being too critical and without a single word that would hurt.

Thank you.

You don't know how your mere existence propels me to withstand this unbearable test of strength.

We will be doctors one day, and you wouldn't want your primary care physicians to be the first one to panic when things get rough. Maybe that's why they make things harder for us in order to be that source of strength.

I guess.

....

Like what my board says...

                                                                                                                                                 

"When life gives you a hundred reasons to cry, show life that you have a thousand reasons to smile."

                                                                                                                                                 

And so.... you are mine. Thank you. :)