Surviving Medical Life: The Fifth Year a.k.a. Post-Graduate Internship

I write this entry with these people in mind: my unborn child, who [might] consider being a physician someday, for my future students [mwahahahahahaha!], and for myself, that I may be reminded of who I was as a student. This is the fifth part of the series.

You’ve survived clerkship! Congratulations! You’ve graduated and earned your Diploma. You bear the title of a Doctor. And we still have a loooong way to go!

The 5th year of Medicine is the Post-Graduate Internship year, as most Philippine Medical schools give their diplomas at the end of the 4th year. This is the year you’re no longer a student per se. You will become the Post-Graduate Intern, the “apprentice doctor”.

This is the year you will rotate one last time in all the different fields of medicine – you will be an internist, a pediatrician, a surgeon, a community doctor, an obstetrician-gynecologist, a researcher. Now that I’m close to finishing my medical internship, I realized that this is the last time, the last chance I’ll get to being as close to these fields of medicine. After this will come the board exams, and after, the many paths a doctor may take.

For the purpose of this entry, I will write about my experiences as a Post-Graduate Intern of the Department of Health – Centers for Specialized Health Care (DOH-PCSHC) program, and lessons I’ve gained along the way.

An Overview of the DOH-PCSHC Program

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The DOH-PCSHC Logo

The vision of the program is:

Five specialty medical centers under one umbrella that could provide world class specialized care to Filipinos regardless of social status in the most efficient, cost effective and sustainable way.

The mission of the program is to:

Provide a highly specialized medical SERVICE to all patients using modern, cost effective equipment and instruments.

Provide the setting and opportunities for the TRAINING and teaching of all types of health professionals

Provide the setting and opportunity for progressive and sustained RESEARCH in medicine and all its allied profession with the end in view of providing the highest quality of health service.

Institute provisions, procedures and practices that will ensure SUSTAINABILITY.

Established in 2005, the DOH-PCSHC program is one of the many Internship programs you can choose. It is a 12-month program where you will rotate in the different fields of medicine in the 5 DOH-affiliated hospitals in the Quezon Circle area – namely East Avenue Medical Center (base hospital), Philippine Children’s Medical Center, Philippine Heart Center, National Kidney and Transplant Institute, and Lung Center of the Philippines. You’ll also rotate in the Marikina Health Department for your community medicine rotation as well.

Choosing your Intenship Program

Graduating from medical school and being released into the world was initially a jarring experience for me. I was used to the systems of my former school that I found myself out of my comfort zone during my early days as a PGI.

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Working in the various DOH-PCSHC affiliated hospitals

When it comes to choosing your Internship program, you must consider the following:

  1. Desire for learning – as an oversimplification, I found that there are two types of PGIs – those who wish to focus on “book learning” and those who wish to have “experience learning”. Different programs offer different opportunities. Some programs are lighter than the others due to factors such as lesser patient loads, fewer facilities, and the like, which offer time for an intern to study. Some programs are conversely heavier than others, where one comes home, falls asleep, and survives another day. I found some PGIs chose their program that they can focus on reading their medical textbooks to prepare for the board exams, while some chose their program in order to improve their clinical skills. It is good to find a balance between the two, and to choose an appropriate program accordingly.
  2. Desire for compensation – the difference with this year and the previous one is that you’re now part of the workforce. You won’t pay any tuition fees, and some programs will even compensate you, in the form of allowance or stipends. It is in my opinion that you should put this in the least of your priorities when choosing a program, however, because the experiences you might get may outweigh any material compensation.
  3. Accessibility – Some PGIs choose their program for its proximity to their homes. I have a friend who chose her program since it was in Davao City, where she has been away from for almost a decade. Certainly being near family has helped her become happier with her work.
  4. Goals for the future – It is advisable to choose a program wherein you intend to practice in the future. It will help you get to know the culture of the program you’re contemplating, as well as getting to know your future seniors in the field. Knowing the protocols of the hospital certainly helps as well, as it will make you a more efficient and effective asset to the team should you be accepted there. One of the key advantages I noted was that I also got to know the residents and fellows of the different departments, whom I will refer to for guidance in the future.

I chose the DOH-PCSHC program for the following reasons:

  1. I wanted to improve my clinical eye by exposing myself to many varied cases. (I wasn’t disappointed with what I’ve seen along the way.)
  2. I wanted to improve my clinical skills through its performance in my duties.
  3. I wanted the challenge of working under pressure in resource limited environments.
  4. I wanted to discover the work culture and the environment I hope to work in the future.
  5. I wanted to apply for an Ophthalmology residency at the East Avenue Medical Center.

Level Up!

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Open Heart Surgery at PHC

As a PGI, you will don for the first time your white coat.

The history of donning the white coat began in the 19th century, where physicians began to wear it to symbolize the transition to the scientific approach to modern medicine, and to distance it from the quackery and mysticism of its predecessors. The white coat is more than your uniform – it is the symbol of your status as a man of science and learning. It is a reward you gain for your years of sweat and tears, and also a reminder of the responsibility of how your words and actions will impact another.

Hopefully, you worked hard as a clerk, and gained plenty of experiences and knowledge along the way. During internship, from being the “grunt”, you are promoted into a “sergeant”. During clerkship, you worked under your PGIs; now that you are one, you will take under your command your clerks, whom you will hopefully teach and nurture to become better doctors in the future.

Guiding Principles

When I was a clerk, I was exposed to different types of PGIs. There were PGIs who deserve praise and respect, as they taught me things that weren’t written in the books, and then there were those who taught me what not to be.

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Rest and Recreation is part of training too!

  1. Learn to prioritize tasks. Time management is an invaluable skill for Internship. You will be given lots of responsibilities – lab work, monitoring patients, doing paperwork, doing census, interviewing patients, assisting in procedures, to name a few. A good rule of thumb to prioritize tasks is to concentrate on those that will give the most benefit at a certain time. For example, if a patient has a deteriorating level of consciousness, certainly referring it to your senior takes precedence over doing paperwork. This is similar to the triage system in the ER, where you will focus concern on the emergency cases and less on the non-urgent ones. I found how this was not much of a concern when I was a clerk, as I only followed orders. In your PGI year, you will constantly make decisions on your feet, so make the best ones and make them count.
  2. Take care of yourself – this principle still holds until this very year. Internship will entail new responsibilities and challenges that will test you. Along the way, you might neglect your health and well-being, and it will manifest itself insidiously. At best, you’ll become irritable and you’ll feel like giving up; at worst, you’ll compromise your care of your patients. Take care of yourself. You cannot give what you do not have. There are some rotations that are lighter than the others; use them to reconnect with your old friends, go out with your family, watch movies and read non-medical books.
  3. Never forget who you were – you were once also a JI/Clerk. This year will put you in command of clerks. Do not become a “kupal” or a douchey PGI – treat your clerks the way you wanted to be treated as a clerk – with respect. They may not say it, but they will look up to you. Lead them by example. Give them time to eat and rest, and teach them concepts and skills you wish you knew at their level. Your goal should be to make them better doctors than yourself. Listen to your clerks when they refer to you, and do not discard their intuitions. I always tell my clerks that I don’t care if what they refer is trivial; as long as it makes them concerned about the well-being of a patient, they should by all means refer their concern. By doing these basic things, I found that my clerks would work harder and would generally tell me that they were happier with their rotation, despite its challenges. This would translate to better communication among the medical team, as well as better patient care.
  4. Respect your seniors – you will meet different doctors with varied personalities this year. Respect them for what they will teach you, and learn from them what books cannot explain. As you do not have a medical license, always consult with your seniors first before performing an intervention. It is their license on the line if anything happens to a patient.
  5. Teamwork is key – you will not survive this year without the combined efforts of your colleagues. The lone wolf archetype truly is not fit for medicine – you cannot treat a patient with multidisciplinary problems alone; you need the help of everyone to provide effective care.
  6. Communication! I’ve learned that the bulk (almost 90%) of medical work is communication. You communicate with patients to know their disease and other factors that affect their treatment. You communicate with your colleagues and allied health personnel. You label the specimens you send to the laboratory. You tell a brief history and physical examination when you get initial readings for imaging work. You endorse your patients to your replacements. You clarify the orders of your residents/fellows/consultants. You refer your patients to your seniors. You write (and pair) your orders in the chart. You write referral forms, discharge summaries, clinical abstracts. You talk to the patient and the family regarding their diagnosis and options for treatment. Communication. I honestly didn’t realize how medicine is unfit for introverts like myself. I confess that I also tire of talking to people, and that sometimes I wish I could just hide in my room for the day. But it is a reality you will need to accept everyday, and one that you have to strive to improve upon.
  7. Look out for opportunities, and take them – there are plenty of opportunities to learn and grow in internship. My fiance told me that internship year is mostly self-directed learning, and if you complain that you don’t learn anything in a rotation, it’s your fault for not grabbing opportunities as they come. You will only become as good as you allow yourself to be. When you come upon a new case, read about it when you can, and learn its unique signs and symptoms. Ask questions from your seniors on its management, and research updates on treatment. Don’t be afraid to attempt new procedures and grab everything opportunity you have – I once did an ultrasound guided IJ catheter insertion (and probably the last time I’ll do it in my lifetime), and I’ll never forget the thrill and reward of doing it. I once held a beating human heart, delivered a baby, saved critically ill infants, called a code, intubated an unconscious man – experiences that no book, no matter how brilliant its explanation, can ever match.

Moving Forward

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DOH PCHSC Batch 2016-2017 Team C, taken during our Med Mission at Tayasan, Negros Oriental

My Post-Graduate Internship year in the DOH program was one of my most rewarding and fulfilling years in my life as a physician. I can definitely say that I’ve grown more confident in my skills from what I’ve been exposed to in the program. I’ve seen cases that books say are uncommon, and even rare. I’ve experienced making and calling decisions to save lives. I’ve seen suffering and death, and I’ve seen health and vitality, and have grown to accept one or the other. I felt the gravity of my words and deeds to those around me. I no longer am afraid of facing a critically ill individual, because I was taught what to do. I still weep for those patients I’ve lost, and I learn to move forward for those who remain.

I’ve always wanted to become a doctor. I’ve always imagined what my 5-year-old self would think if he saw me now. Despite the dark circles under my eyes, my constant coughing fits, and my aching limbs, I’d like to think that he’ll be proud of me.

What you are right now is what kind of physician you’ll be. The medical intern is father to the physician. I hope one day that the physicians of the future will be those that their young selves would pride to boast of, those with bright passionate eyes despite the dark circles, those with pure hearts despite the unhealthy coughing fits, and those with unrelenting will despite the aching limbs. I hope we become the doctors we wanted to be.

I wish for you a prosperous and fulfilling year ripe with learning and growth! I will see you along the way.

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