The 21st Century Physician

“It is no longer acceptable for a doctor to simply be a repository of knowledge; rather, and more importantly, a doctor must be able to make sense of knowledge.”

In 2004, I started my clinical practice as a newly-minted Family Medicine Specialist. I was confident, believing that I knew more than my patients. My goal then was to showcase this expertise; create impressive visual aids and prescribing materials that would show my intellectual capacity. It was how I was taught as a medical student and as a resident too. It worked —up to a point. The disconnect became obvious when I saw my patients not getting any better. It was an eye-opener.

While it is a respectable goal to instill knowledge, I realize today that I may not be the best conduit to share mere knowledge. I do not have enough time to engage with my patients in the clinical setting in order to provide extensive patient education —fortunately, the internet can make up for this deficiency. Most of the basic teachings needed for diseases can now be accessed online and can be accessed by those without a medical background. However, there is no way to replace the presence and reassuring action of a physician in patient management. There is also a need to clarify and verify whatever information is available online.

What must a physician do under circumstances such as pandemics and false information?

While I was mulling over this question, I was inspired by a bishop’s homily about The Last Supper. He emphasized three important points about the Last Supper: Humility, Availability, and Empowerment. The Lord humbled himself as a servant, and made himself available to his disciples. And during the Last Supper, he empowered his disciples to do the same. We always hear the words: “Do this in memory of me”. I think that this must also be every physician’s goal: to create a legacy that will instill a good memory of one’s efforts.

A doctor must be humble enough today to realize that he or she does not know everything. This will push the physician to continually learn and hone their craft. A doctorate degree is not the be-all and end-all of a physician – rather, it is the beginning of a long and arduous climb towards the realization of being a true healer. It is this humility that will help a doctor reach out to patients, identifying misconceptions and risky behaviors. Genuine concern is felt when a doctor is not arrogant and all-knowing. This allows the patient to freely provide relevant data.

In the age of the internet, remote communication is a blessing. This must be maximized. It might seem to be a burden to always be within reach, an email or a text message away from a patient. While this privilege may be abused, this increases patient satisfaction and compliance. There is also the advantage of having real time information about signs and symptoms, making a doctor respond rapidly in case of emergencies.

Lastly, and most important, I am most passionate about empowerment. Doctors must empower patients to take care of their health by preaching prevention rather than cure.  The word “Doctor” comes from the Latin word “Docere”, meaning, to teach. We cannot deviate from it, for it is inherent in the medical profession to be a teacher in order for people to preserve their health. Part of the responsibility of being a Medical Professor is to inculcate this fact: as a doctor, you will be a teacher, and at the same time, you must empower your patients to make good health decisions. It is not a loss if the patient never gets sick, and if they do need a physician, they will not hesitate on whom to call first.

Humility. Availability. Empowerment. These are the lessons of the Last Supper. These are also the ideal traits of the doctor of the future. And I believe it will never go out of style. Just like your favorite clothes.

Non-Violence

Let us not seek to satisfy our thirst for freedom by drinking from the cup of bitterness and hatred. — Dr. Martin Luther King, Jr.

As the United States celebrated Martin Luther King Jr. Day last January 17, we are reminded of the significance of non-violent actions to initiate change. We have seen how violence can lead to significant upheavals, but in the long run it results in resentment and retaliation.

The Bible has this significant story of violent change. After the great flood during the time of Noah that destroyed everything, a covenant was established that it will never happen again (Genesis 9:11-16). This suggests that any violent action may produce immediate change, but there could be long-term consequences.

Dr. King was a powerful speaker, someone whose influence went way beyond his living years. We all impact other people’s lives, and we can make a difference. This was the sentiment of his attitude towards painful upheavals, and he realized that gentle change is more powerful in producing results.

At a time when the black people of the United States were considered as second-class citizens, his “I Have a Dream” speech resonated with everyone who has ever been bullied and discriminated upon. In medical care, this includes those who no longer have the capacity to choose treatment, those who cannot afford, and those who no longer have a good chance of survival.

Doing what is right for others must be entwined in our being. With the growing challenges of the pandemic, there still exists inequality in some fronts. Some are not able to access vaccines. Others still refuse to be vaccinated. We know that recently, even world-class athletes have been in the limelight as they insist on their own questionable beliefs. But we who believe in science plod on, continuing to pursue excellence with the dream of providing a better life for others.

Everyone can make a difference. We are influencers. Our inner circle can alter the behavior of others. Our decisions can change lives. In deciding to change behavior through gentleness and compassion, we may produce slower outcomes, but they last longer. There is no resentment afterwards.

In the Philippines, we can now see how palliative and hospice care has gone a long way in promoting human dignity. When I was a student before the turn of the millennium, a DNR in a patient’s chart meant “Do Not Resuscitate”. It also meant “Do Nothing, Really”.  These patients, from being monitored on an hourly basis, were suddenly dropped like hot potatoes. Medications stopped. Visitations became less frequent. Students liked to have these patients, for there was no longer anything to carry out for them.

But through the introduction of compassionate care in the medical curriculum, the landscape started to change. There were no violent protests that led to this change. It was led through example. Then it gained ground. Today, medical futility is viewed in a different light. Medical specialists recognize its reality on all fronts. There is still some resistance, as some sectors still adhere to saving lives at all costs. But aggressive CPR is a violent way to go for the terminally ill. There is a better way to say goodbye. It lies in a silent touch, a gentle whisper, a compassionate wave.

Why Do We Have Changing Guidelines For Covid-19 Quarantine And Isolation?

Guidelines, like some promises, were made to be broken.

In the midst of the record number of Covid-19 cases that are reported, there is also a lot of confusion with regards quarantine and isolation. It used to be a strict two-week isolation protocol that was instituted in the early days of the pandemic for those exposed. Today, some guidelines even state that health workers who have been given vaccination boosters do not need to isolate themselves if they are asymptomatic.

So why is it so difficult to sustain health recommendations? To get a better understanding of this dilemma, let us analyze the different factors involved in the process that leads to the dissemination of health guidelines. 

We have come to expect that scientific facts and evidence run the medical industry.  This has developed in us a sense of trust in what our health experts advise. Thus, it is  surprising to realize how these recommendations can be influenced by politics, the media, and by consumer groups.

Political groups want to get the best mileage in times of health crisis. They want to prove that they are on every aspect of care, no matter how trivial. They will try to exert influence on medical decisions. At times, this is good; at other times, this over-involvement increases health care costs.

The media is ready to pounce at every news story. An outbreak is a great story. So is a new drug, and its possible adverse reactions. Whenever there is a potential for public interest, expect the media to be there. It is a great ally for information dissemination. It is also a clear enemy of disinformation. It can shape the opinions of the masses, and mass opinion is not always right.

Public behavior in the age of social media is a powerful influencer. Man has always followed the actuations of the majority. We have seen this rear its ugly head during the pandemic, where a supposedly new concoction endorsed by a celebrity gains ground even without studies. The public, desperate for cures, tries it out and loses.

Experience teaches us that we shouldn’t jump on every new piece of advice we’re given, even if it comes from experts. This may only be a trend or a passing whim. Even in the era of evidence-based medicine, this is a reality. Yes, even experts may not have all the answers, though they may be our best bet even if they are not always correct.

Take smoking, for instance. Fifty years ago, physicians considered them to be harmless and hip. Tobacco companies invested a lot of money in promoting it,  even funding sports events with the cigarette product as the main sponsor to prove their safety. Sugar, coffee, and even sun exposure all had different recommendations and concerns in the recent past. So why all the changes?

As technology and methods prosper, there is an evolution of the different research methods that are followed in order to come up with medical answers. Past experiments are revised, researches are collated, and this collation may reveal different truths. A research method called a meta-analysis collects and analyzes the results of different studies, and this collection of data may change existing recommendations if the summarized evidence proves something different. The vast changes made over the years in health recommendations represents advancements in science. As new strategies come up, past methods are revised. New findings are generated, leading to a change in general theories, expert opinions, and eventually medical guidelines.

The public health implications can sometimes be remarkable. Twenty or so years ago, the recommended cut-off for the diagnosis of Diabetes Mellitus was at 140 mg/dL. When it was lowered to 126 mg/dL as a result of various studies, and due to the increasing number of Diabetes complications, you can imagine the turmoil this caused not only to the medical community but to the general public as well.  This also happened when hypertension guidelines were changed to represent a more aggressive stance towards lowering blood pressure. Patients became less confident in their physicians, and in turn, physicians have to deal with accepting the new recommendations.

Scientists themselves  make mistakes. Premature generalizations and information biases reveal that even the smartest among us can be prone to error. Whether they admit it or not, they can also be affected by politics or the media. This is not to mention that the promise of a huge payback may also blind their judgement.

And so we go to the problem of changing recommendations for Covid-19. Expect more changes in the future as more data come out. How long can the virus survive in our bodies? What do vaccines do, and how long can they sustain immunity? What about the new drugs – how effective can they be? Will these new methods result in a decreased need for isolation and quarantine?

Note that the reason why Covid-19 was such a concern when it came out was because of its potential to cause death. Then, it was found that there were certain comorbid conditions such as immunodeficiency, chronic illness, and advanced age that makes one susceptible to complications. Now, most infections are mild. Even the infectious agent itself has evolved into different strains with different clinical presentations.

Changes in health recommendations are entirely out of our control. However, for as much as we should trust in new and more advanced technology and the consequential findings, being critical and not accepting everything as gospel truth is important. Every case has a different situation that must be discerned specifically.  That is why it is always a good idea to keep in touch and seek expert advice, not just your own judgment. Common sense may not be so common, but in the hands of the common man, it may make things worse.

Learn from the changes. They are here to stay.

Booster

 Will the current crop of anti-COVID 19 vaccines hold up and keep us all safe from infection?

With the existing trend of COVID-19 infections, everybody is asking whether there is a need for additional vaccine doses. The new COVID-19 variants have put into question the vaccine’s effectiveness against mutating strains of the virus.

Booster doses are given to sustain protection against prevailing diseases.  Just like the vaccine for hepatitis B, for instance, the antibodies they provide may wear off with time. For the flu vaccine, boosters are provided yearly. This may also be the case for SARS-CoV2.

There is currently no clear-cut study indicating the need for booster doses of COVID-19, according to the Centers for Disease Control (CDC). Although some drug companies have made previous suggestions of lowered immunity after 6 months of immunization, this has not yet been substantiated with clear-cut recommendations for added vaccination. We need more data for this, as this would entail added costs. Is it cost-effective to add another dose for everyone?  We do not have the answers yet.

The existing vaccines have proven effective in stimulating the body’s immune response against COVID-19.  According to research studies, the memory B cells are able to produce antibodies once we are exposed to the virus or to its fragments.  This happens at least 12 weeks after infection or after immunization.

Research also reveals that COVID-19 vaccines can protect against mutant COVID-19 strains, so there is no need to be too concerned about mutant variants being resistant to the vaccine.  The Johnson & Johnson vaccine, for instance, had 73% and 82% efficacy 14 days and 28 days post-immunization against the beta variant. The Pfizer vaccine was also found to be 88% effective against the delta variant. However, boosters may be needed if an outbreak is declared. 

The best way to measure whether the vaccine induces the immune system is by measuring the antibody titers of individuals.  Some vaccines seem to induce antibodies better than others, but overall, the approved vaccines have proven to be effective in increasing antibody titers.  If and when researchers get to know how to measure vaccine-induced immunity, the next indication that boosters may be needed are breakthrough infections in older adults who have already been vaccinated.

Older individuals over 80 years of age make lower levels of antibodies after vaccination, so their immunity may disappear sooner than that of younger individuals. They are also the most vulnerable to new viral variants. Boosters may thus be necessary for them, together with those with compromised immune systems such as chronic steroid users and cancer patients. The people may not be able to produce antibodies in adequate amounts.

COVID-19 vaccines have not yet been thoroughly tested in people receiving palliative or end-of-life care, so there is some hesitancy in giving these patients the vaccine. This is because Phase I Clinical trials for new vaccines start with young healthy volunteers who have no comorbid conditions. However, results from the COVID-19 vaccine programs in Scotland and England on Pfizer-BIONTECH  and AstraZeneca suggest that both vaccines are very effective at preventing serious illness in people aged 65 years and older. People in this age group who had a COVID-19 vaccine were much less likely to be hospitalized due to COVID-19.  Thus, if they can be vaccinated and they can tolerate the possible adverse effects, they could receive immunization. It would take more studies to make a more conclusive statement, but it looks like the benefits of immunization outweigh the inherent risks for those with chronic illness.

Twenty Years After 9/11

Each of us is unique. Let us think highly of one another.

It was an ordinary day for most of us on September 11, 2001. I was on duty at the Philippine General Hospital, where I had my residency training in Family and Community Medicine. At around 8 in the evening, I saw a video clip on TV showing a plane crashing into one of the towers of the World Trade Center in New York. I thought it was a movie trailer. It was not. It was reality.

Today, I am reminded of the impact this terrorist attack had not only on those who were at the scene, but for the whole human race. Some responded with fear, living with possibility of dying while inside a tall building. Others let discrimination build inside them, eyeing bearded colleagues as potential terrorists who should not be given access to any public domain. Past exposures carry a lot of weight on how we behave in the future. And the specter of death grazes our consciousness whenever we lose friends or loved ones in unexpected circumstances.

Why does disaster carry this much influence on our thoughts? It is because we are all, in one way or another, afraid of uncertainty, especially death.

When we are young, we live like we are immortal. We shrug off physical pain easily. We recover from illness faster. But when we hit old age, the reality of leaving this world sinks in. Even then, I have seen people who could never accept that they will die soon. They bargain. They beg. They petition the heavens. Losing all their ideas, thoughts, and emotions is an unbearable undertaking.

Who among those in that tower ever thought that it would be their last day on earth? Sadly, no one was able to tell. Can we predict when we will leave this planet? Unless one is suicidal, nobody can. The terrorists on the hijacked plane were probably the only ones who were ready. But then again, we could argue that they had distorted views on life and eternity.

Do we now have respect for the human race? Do we still discriminate? Are our perceptions still clouded by our differences in culture, speech, and traditions? These biases are the ones that carried hatred and brought about the ensuing carnage. In one way or the other, have we learned to treat everyone with respect and dignity?

The attitude and air or superiority, and the feeling of being bullied and subdued, elicits the kind of hatred that costs human lives. It may start within families. It can escalate between neighbors. It then brews within communities. Finally, it explodes between races.

Let us put a stop to these harmful human tendencies. It spreads easily, and when it attains its boiling point, the only way for it to cool down is to annihilate everyone in its path. Everybody may eventually be harmed once the bullied child gets into a position of power and influence. You may win the war now, but the enemy remembers and takes its time to exact revenge. It is going to be a never-ending cycle of hatred. Unless someone takes away the oxygen and says “let’s stop this inferno.”

We only live once. We will all leave this world. But when we do, let’s leave a legacy that will foster love and respect for each other’s differences. It will not just sustain us. It will keep us rational and sane. And hopefully, those that remain get to pass it on and improve along the journey.

Whatever good we can do today will extend to future generations. The only way to end the 911 attacks is to nourish and nurture the art of respect.

Perseverance

It’s Olympic Season! Although this is an unusual Quadrennial (delayed by one year) meet due to the pandemic, it does not take away from the spirit of competition. The same desire to win persists. And the inspiring stories remain the same.

Art by: M.H.

Everybody knows the golden exploits of weightlifter Hidilyn Diaz, the first Filipino gold medalist in Olympic history. But behind that triumph, only a few remember her as a young Olympian who failed in previous attempts for a medal. In 2008, she was at the bottom of the standings. In 2012, she did not complete her clean and jerk event. Her breakthrough was in 2016, and with it, came higher expectations. Those expectations became a reality in the recent Tokyo Olympics. Although the pandemic caused her to be stranded in Malaysia, this did not prevent her from pushing through and lifting a new Olympic record. 

Carlo Paalam, our Olympic silver medalist in boxing, also has a great story.  His mother left their family when he was six years old. A former scrap collector, he rose from obscurity and made us all proud by beating a former Olympic champion. He also overcame great odds by beating a Japanese fighter in his own turf. Although Tokyo is his first Olympic games, he showed that he was ready. After winning the silver medal, he recalled all those scraps he collected, and said that it symbolized all those metals he scavenged in his life. His life will now change as he is set to win millions in prize money for his performance.

What do these narratives tell us? Do they mirror our own struggles? Do we also feel victorious when someone close to us experiences a win? Do we also celebrate the success of others?

We associate ourselves with winners, and embrace their struggles. Their triumph becomes ours too. As caregivers in the health sector, no amount of remuneration can replace the joy of seeing a dying patient recover from illness. It is not the just sick who persevere, but also those in-charge of patient management. If money were the sole motivation, not a few doctors and nurses would tell you that they might have quit a long time ago.

What if there is no improvement in sight? Hospice patients face this dilemma. How does one persevere when there is no end to suffering?

The answer? Celebrate little victories. The pain-free moments. Or even just moments when pain is less. The ability to still maintain one’s quality of life despite the terminal illness. The presence of friends and loved ones.

There is also a significant contribution of teamwork in every triumph. Although weightlifting and boxing are individual sports, there are people behind Hidilyn and Carlo who made them who they are today. It was not just their trainers and coaches. Their families also provided great support. Even the whole community, the Filipino people, who cheered them on, played a role. The same is also true for taking care of the sick and dying. They must not be left alone. There must be a team of doctors, nurses, and caregivers who look after them. And their loved ones must not leave them behind.

We always have a choice whether to push through or just let life pass us by. It’s the choices we make that will ultimately determine our happiness. Perseverance pays off, both in sports, and in life.