Investment 101: What do I need to Invest?

This is the second [of an unknown number] of posts on a series on financial investing. I write this in order to brush up on what I learned from studying investment strategies, as well as to promote the practice with those who read it. I do not claim to be an expert, and I welcome any comments/suggestions to improve this series.

My father has always told me: “You won’t get rich from working your profession alone.” In his quest for financial security, my father has told me of the many ventures he went into different ways to gain capital, i.e. that thing you need to invest. The techniques to gain this needed resource will be discussed in this article.

What you Need: Capital!

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turningpointbizcoach.com

Capital is defined as “wealth in the form of money or other assets owned by a person or organization, or contributed for a particular purpose such as starting a company or investing.”

When you begin investing, don’t feel bad if you don’t have much of this. Capital is a powerful resource, and if you invest wisely, that small amount of money will yield great dividends in the future.

Gaining Capital

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investopedia.com

There are a myriad of ways to earn money in the world. They can be classified into each of the following techniques to [legally!] gain capital. These include, but are not limited, to the following:

  1. Wages/Professional fees
  2. Interest from Loans
  3. Business ventures
  4. Real Estate
  5. Jewelry/Possessions
  6. Investments/Securities

We’ll take these one by one, how they provide capital, assessing their pros and cons, and how you can acquire and use them in the future.

Wages/Professional fees

Your job, whatever you may do, is the backbone by which you will gain capital. Therefore, if you aren’t one “born with a silver spoon”, this is your key towards a life of financial security.

It’s a pretty straightforward way to gain capital. You come into work, put in an honest day, and get an honest day’s pay. Yet it is also one with the greatest risk, as its productivity is entirely dependent on yourself. Your ability to work will depend on several factors such as your health, your passion, your goals/dreams, and your family.

The pros of this technique is that it gives you capital continuously, assuming that the work opportunities in your area are stable. This technique also has the added benefit of giving you social capital, that is, making friends, expanding your network, and gaining expertise.

The cons of this technique is that it is still liable to the influence of market forces – the wage you earn today may not be enough to buy the goods you need in the future. Some people resolve to just put in their hours in the daily grind, earning money until their twilight years. But the problem with this technique is that it will not last forever – you will at some point have to retire, for whatever reason.

When it comes to investing, this is the technique you’ll want to give most of your energy and time into. In other words, you have to invest in yourself. Become a product that society needs, and do your work honestly and passionately. The capital will reap itself in time.

Interest from Loans

Most of you reading this will probably have a bank account already. By depositing money in a bank, you gain some interest. Interest is “money paid regularly at a particular rate for the use of money lent, or for delaying the repayment of a debt.”

The pros of this technique is that it is very low risk. In the Philippines, deposits these days are insured a maximum of Php 500,000, which has helped prevent bank runs in the past. While interest rates yield small amounts of capital, it is still capital and could be invested. This is also a technique that can be held onto indefinitely, unlike a job.

The cons of this technique is that it is generally very low return. Interest rates these days are minimal, and do not defeat inflation rates. You can check the first post of the series to know more about how inflation is the “silent killer”.

Having a bank account is a prerequisite to investing (esp. in securities), so if you don’t have one, I highly recommend opening an account. However, don’t depend on this to gain capital, because you will lose in the long run.

Business Ventures

By going into business ventures, capital can swing both ways. Lucky and prudent businesses grow into stable companies and will earn money, while the converse will lose the game.

The pros of this technique is its possibility for high returns and, if done correctly, its ability to provide the owners a means to continuously earn money. But that’s an understatement.

The cons of this technique is that it is also very high risk. The capital to establish a business is also very significant. Establishing a business requires a lot of work – you’ll have to put in time and knowledge in order to make it grow. Businesses are in the center of the storm of the market forces – hence, luck is also something you’ll need for business.

Some people were born to do business. Some people, like myself, prefer to ride the waves of their success. Keep this option open, and discover if you have the stomach for it.

Real Estate

The oldest trick in the book. You buy/inherit land, you hold onto it, and you sell it or rent it. Other variations would be building townhouses for which you can obtain lease from your tenants.

The pros of this technique is that it provides great capital and is a potential resource you can use to build capital-making businesses on. Its value also appreciates with time. This is a great technique to earn money – if you’re rich, or born into a landowning family.

The cons of this technique is that it requires great capital. Depending on its location, its value may also depreciate with time. You’ll also need to think of the taxes/bills you’ll have to expend to maintain ownership. If you’re someone trying to make it into the world, this is a technique you’ll have to bide your time for. When you’ve sufficient capital from investing in other techniques, this is a frontier you must not forget to consider.

Jewelry/Possessions

Your possessions have intrinsic value that can be converted into capital. Jewelry is one of them. I don’t know much about the trade in jewelry, however, but selling these can offer you varying amounts of money.

The pros of these include its ability to appreciate with time, but that’s about it. The cons of this would be its susceptibility to market forces, as well as its susceptibility to make you a victim of theft.

Having jewelry and possessions helps you earn, but this shouldn’t be your primary means to earn capital, unless you’re in a family of jewelers.

Investments/Securities

Investing your money into the different investment vehicles also yields capital. An investment vehicle is a product used by investors with the intention of gaining positive returns. There are many investment vehicles, such as loans (e.g. time deposits), bonds, stocks, mutual funds, and exchange-traded funds. We’ll take the nitty-gritty of each one in another article.

The pros of investments include its accessibility to the common man, and its ability to defeat market forces, if used properly and wisely over a period of time. It is also a means to earn money without physically working, and one you can do indefinitely.

I always find it funny when people would remark how they picture investors as people who wear tuxedos and use monocles and sip champagne over stock market tickers, not knowing that it is the common man who plays the game.

When I began investing years ago, I thought this way as well. These are some misconceptions I’ve had, and debunked as I went through investing:

  1. I thought that investing required great capital. No; I could invest any amount I wanted to. (Note: some products require minimum investments to open an account however, so check with your bank/broker).
  2. I thought that investing made me lose control of where I put my money in. No; I choose the companies and products I wish to invest in, and I choose when to get my money when I want to.
  3. I thought that investing was a 24/7 job that would offer you no peace. No; first, there’s a test you’ll need to take to know what your “risk appetite” is, that is, your capacity to risk your money into something. Once you know how much you’re willing to risk, you’ll decide where you want to put in your chips – in stable, growing companies, or in new, dynamic ones.
  4. I thought that investing was hard to learn. Yes, you have to do some self-studying to learn about its process and its opportunities. I spent a month poring over websites and books that teach investing before I brought shares to a company. I also went to some seminars to learn about how investing works.

I don’t claim to be an expert, but I’m surprisingly gaining capital, thanks to the help of those books, websites, and people I’ve spoken to. I’m not in the big leagues, but I’m slowly gaining financial independence.

The cons of investment is its susceptibility to market forces thus making it a risky venture. There is always a possibility that the company/product that you invest in may fail, and you may lose what you invested. There is also danger in investing in ignorance. Two kinds of people lose in the stock market game – the unlucky, and those who are ignorant. Luck will never always be on your side, but if you invest wisely, you’ll at best breakeven, and at worst, learn from your misfortune. If you don’t invest wisely and do your research, however, you can lose everything you invested.

Afterword

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basf-new-business.com

There is an adage in investing that goes: “Always be prepared to lose money.”

How is it that there are still people investing despite this adage?

It is because the wise investor only invests what he can lose (he knows his risk appetite), he accepts that market forces are fickle (he knows that, given enough time, he will regain what he loses), and he knows that fortune favors the bold.

Work smart, save up, do your research, and take the plunge.

I’ll see you along the way.

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Investment 101: Why Invest?

This is the first [of an unknown number] of posts on a series on financial investing. I write this in order to brush up on what I learned from studying investment strategies, as well as to promote the practice with those who read it. I do not claim to be an expert, and I welcome any comments/suggestions to improve this series.

What is Financial Freedom?

Financial Freedom

incomemaestro.com

Financial freedom is the ability of an individual to do anything that they want in life, without the constraints tied with that issue called “lacking money”.

So where does this go? It would extend to your lifetime and to the generations to come. A responsible move you make right now will carry on to your children, and your grandchildren, and those who come after.

Financial freedom will let you live the way you want to live, and it has the side effect of ensuring that the future of those you care about will be prosperous as well. It will ensure that your child will have a home, food on the table, a good education, and a head start in life.

A disclaimer: Financial freedom is not about becoming a greedy person. It is not about seeking riches and wealth and having all those new gadgets and houses and toys. It is about freedom from the constraints imposed by money in achieving your goals in life. Those I have known who are financially free are those who do not appear rich; rather, they live simply and simply live.

Why Invest?

I have experienced my generation’s desire to “live in the moment.” “YOLO”, which stands for “You only live once” has become the battlecry of a generation who has lived in a time of peace and plenty. Yet in this time of peace and plenty, many people are ironically destitute. I have seen people spend beyond their means, only to fall into discontent in the future. It is not wrong to live in the moment; but it is wrong to fail to account for the future.

Investing is one of the many routes towards financial freedom. It is defined as:

in·vest (inˈvest)
verb
1. to expend money with the expectation of achieving a profit or material result by putting it into financial schemes, shares, or property, or by using it to develop a commercial venture.

The reasons for investing hinge into the practical and the philosophical.

The Practical Side of Investing

 

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JamesLawson.ws

To understand why investing is important, one must understand the concept of Inflation rate. Inflation, by definition, refers to “the rate at which the general level of prices for goods and services is rising and, consequently, the purchasing power of currency is falling.”

A good example would be your everyday experience at a supermarket. In the past, you could buy all your basic necessities such as bread, fruits, vegetables, meat, fish, and some luxury goods for as low as a Php 1000, all in a nice grocery cart. Now, you’ll only get a basket of some of these goods for your money these days. What the heck happened? That’s inflation. It’s a silent killer that will bite you in the future.

I remember how my grandmother would hide her money in a tin box. I remember how my father would store his money in the bank. While your money won’t get stolen, it certainly will drop in value over time.

These days (as of April 2017), a Philippine bank’s interest rate goes from 0.25% to as high as 1% per annum. As a simplification, if you have 10,000 in the bank, you’ll get Php 10,025+ to 10,100+ at the end of the year. However, the Inflation rate of the Philippines (as of April 2017) is 3.4%, meaning that the value of your money despite the interest you get from the bank will devalue by 2.4% to 3.15% over time.

While it seems small, (in the example above, having Php 10,000 devaluing over time will make your money decrease to Php 9685 to 9760, a loss of Php 240 to 315), take note that nothing is ever static in the economy, and over time, that amount of money will lose much of its value.

Enter investing. With investing, you have a chance to defeat inflation by trying to go above that 3.4% (and ever-fluctuating) inflation rate. The rate of financial growth will be defined by yourself. That’s for another article – what do I need to start investing?

The Philosophical Side of Investing

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eco.ca

Investing a choice you’ll be making everyday of your life. Investment does not only entail financial capital; it entails a conscious decision to bear sacrifices, to dream, and to look at the big picture.

I’ve been investing for almost a decade now. I’m not rich, but I can take my fiancee on a date, I can buy stuff I want to (but I hold off on – it’s hard!), and I can rest easy at night knowing that if an emergency comes, I have the means to address them.

Investing is a great challenge that I think builds character. I’ve made a lot of sacrifices (“opportunity costs”) throughout the years – not buying this gadget, not going to that event, and the like. I’ve learned how to be innovative though; I learned to go out with friends instead of playing a video game, and to read books for self-edification instead of splurging on expensive things.

Before going into any endeavor, it is important to know why you’re doing it in the first place. Investing is more than putting your money into proverbial soil to make it grow; it is to make a commitment to become financially responsible for yourself, with the goal of achieving financial freedom.

Before going into any endeavor, it is important to know why you’re doing it in the first place. Investing is more than putting your money into proverbial soil to make it grow; it is to make a commitment to become financially responsible for yourself, with the goal of achieving financial freedom. Your decisions make you. I’ll see you along the way.

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.

Anonymity

The shield of anonymity
Is where the arrows of hatred are flung
It is the bastion of cowards
And the repose of the meek.

You do not know us
And we do not know you
Both cannot be the judge
Of the other.

Yet to hide is the prudent choice
And to stay mute is the wisest course
For to do otherwise
Is to be slaughtered.

There are multitudes of bigots
And it takes but one
That one in a million
To undo everything that has been.

We hide like cowards
And take in your scorn
Yet we will continue
With this path.

Men of Peace and Violence

In the end they would always say:
Doctor, please save my life!
I don’t want to be taken away
From my son, my daughter, my beloved wife!

“I didn’t do anything,” they would add
“I-I was just there when I was s-shot.”
I would hear them plead to their God,
As our coats would stain with their blood.

“Prepare for intubation!” my resident barks!
We suck it up; we can’t lose focus.
“Insert double lines! Prepare for cutdown!” another remarks!
We go about our organized ruckus.

A crowd forms around, and I would close the curtain
His eyes stare blankly at us. He turns pale, then blue.
We wheel him in for an exlap; his survival’s uncertain.
This could have easily been me or you.

After the commotion we go back to our seat,
To reflect in the privacy of our reticence,
To face the forces of “victory” and “defeat”
Muddled ideologies of men of peace and violence.

Surviving Medical School: The Fourth Year a.k.a. Clerkship

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 fourth part of the series.

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uerm.edu.ph

Congratulations! Third year of medical school was hell, and by surviving it, you are surely on your way to becoming a physician. You are now going to begin your clinical years, earning the experience needed to function in any setting.

When we were having our orientation at the start of my clerkship year, all of my seniors succinctly described it using this statement: “Ito ang pinakamasayang year na ayaw nyo nang ulitin.” [“This will be the happiest/funnest/best year you’ll experience that you never want to go through again.”] I kept thinking about the meaning of this statement as I went along the journey that has been this year, and only in retrospect will it be clear why.

This is the year you will experience this rite of passage for all doctors.

This year, you will be deep in the trenches, fighting in the front lines of our war against suffering and disease. You will deliver babies, you will perform minor surgery, you will perform your basic medical interventions to your heart’s content, you will talk to and examine endless numbers of patients, you will educate you patients on their diseases, you will persuade your patients to take their medications, you will perform CPR, you will hold the hand of the dying, you will talk with those who all hope is beyond reach. You will experience the highs and lows of your budding medical career; you will share in the triumphs of your patient and medical team; you will share their sadness and their pain. Friendships will be formed, and friendships will be tested.

You will find yourself in the best and the worst of times, so get ready!

Mission Briefing

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Cavite, 1898: A medic attends to a wounded Filipino soldier (peopleus.blogspot.com)

Clerkship is a 1-year “on-the-job” training, where you will rotate in the various disciplines of Medicine, namely, Internal Medicine, Surgery, Obstetrics-Gynecology, Pediatrics, Psychiatry, Ophthalmology, Otorhinolaryngology-Head and Neck Surgery, Neurology, and Community Medicine.

Your rotation will revolve around the “Pre-Duty-From” schedule. Pre-duty schedule is from 7AM to 5PM. Duty schedule is 7AM to 7AM the following day. From schedule is 7AM (following duty status) to 12PM. Pre-duty is like Sunday, feeling as if it’s before the weekdays. Duty is the weekdays, where you will grind yourself to work. From-duty is like Saturday, where you’ll get to rest. The concept of a 7-day week will transform into a 3-day week, as you will discover.

Before you start clerkship, know that this will be the year that you will discover what kind of doctor you are. Wordsworth once wrote: “The child is father to the man.” The medical intern is father to the physician.

I want you to be the best doctor you can be, but only you can make yourself so. Before you start, set your goals for yourself this year. These were mine:

  1. Learn the common diseases, their epidemiology, pathophysiology, management and prognoses.
  2. Communicate effectively with the patient and the medical team.
  3. Become skilled in the basic medical interventions (Life support, IV therapy, surgical skills, etc.)
  4. Discover how to listen more effectively to my patients and colleagues.
  5. Develop common sense.
  6. Develop compassion.
  7. Network with colleagues and friends.
  8. Accept failure, defeat, surrender.
  9. Stand again after every failure.

Ten-Hut!

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1899: Regular soldiers of the Philippine Revolutionary Army stand at attention for an inspection (explorer-philippines.com)

Preparation is key to surviving the war in the clinics.

  1. Take care of yourself. Remember to eat healthy, get good rest (if you can, that is, without being a slacker or a liability to the team), keep yourself well-groomed. The stresses you will face this year will test you, so build a good physical foundation to mount your offense.
  2. Take care of yourself, please. I forgot to mention that you should also take into consideration your emotional and spiritual well-being. Burn-out is common during this time, and you’ll need your support systems to back you up.
  3. Get the right equipment. If you haven’t bought the equipment to function effectively, do so now. Invest in good equipment – your stethoscope, sphygmomanometer, thermometer, pulse oximeter, etc.; you’ll be using it for the rest of your professional life. One thing I want to emphasize is to buy good shoes. Do not skimp on good shoes! I destroyed 4 pairs of shoes this year. The worst enemy that will gnaw at you at the end of the day will be your sore feet.
  4. Read your manual, and attend the orientation. Your medical school will probably provide you with a house staff manual or a handbook. Read it. It will save you a lot of trouble in the future. Attending the orientation wouldn’t hurt as well.
  5. Read up on the common cases in the clinics. You should always strive to arrive in the clinics knowledgeable and eager. Easier said than done, but do try.

In the Trenches

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Manila, 1941: The first “Women Guerilla” corps (theatlantic.com)

It is hard to describe how the typical day of a medical intern goes. Your day will either be benign, in between, or in hell. The level of “toxicity” will depend on the rotation, as some rotations are more demanding than others as you will learn; on your team mates, as you will see them at their best, and at their worst; and on yourself, as you will also be at your best and at your worst.

Expect anything, and expect everything.

The experiences you will face here will be unique. I have found some common tenets to live by to survive. Some of these I learned from my mentors, some I learned by making mistakes. I’d like to credit Dr. Miggy Unabia for some of them as well, as I based some of these from a post he wrote for us before our clerkship year started:

  1. Think of the patient first. It is our vow to put our patient’s welfare and well-being first before anything else. I know I wrote earlier to take care of yourself, but you will have to accept that you will make a lot of sacrifices from here on onward. You will feel dizzy of hunger, you will feel irritable of thirst, you will complain of sleep deprivation, you will feel the need to pee but can’t, you will feel depressed and burnt out. The patient feels twice, thrice, or more suffering that what you’re suffering. They look to you for help. They may not show gratitude. They may even shout at you and curse you. You will feel frustrated. Yet our promise to serve humanity is our ultimate purpose.
  2. Be civil to everyone. Clerkship will put you in close proximity to people. People who you respect and will most likely refer patients to in the future. People who disgust you and feel disappointed for. People who you will work with for a year, or possibly a lifetime. We had this story of an intern who was approached by an old lady, dressed in simple clothing, who was asking about a patient. The intern, who was under stress at the time, was brusque in his reply, only to be met by the seething bite of an offended consultant.
  3. Don’t be a doormat. Then again, don’t be afraid to stand up for what is right. If there is a problem, isolate the person you have a problem with, and fix it among yourselves. Never humiliate anyone. Sadly, there are some people you can never seem to get along with. You can’t please everyone, and you will have to accept this fact. At some point, you will need to hurt some people to avoid a lot of pain in the future. At some point, you will need to call out the bullshit on your colleagues to make them better doctors.
  4. Have initiative. Clerkship is the best time to learn how to be a great doctor. Use all of your senses. Observe how physicians you admire communicate with the patients, and discard the bad behavior of those who do not. Ask questions (In a respectful way! In the right setting!), occasionally challenging your consultants. Read the patient charts, get to know their cases, read up on their disease. Update yourself on their clinical course. Take a look at the patients, politely examine them, talk to them, see them as people. I would have to admit that my best teachers were my patients. I learned how to do effective colostomy care from Ms. GO, how to act when suspecting a stroke from Mr. ME, how to analyze psychosocial conflicts from the AG twins. When I see a case, I see the patients I had the chance to meet. Meet as many patients and doctors as you can, and learn from them.
  5. Have a sense of urgency. This is a job where your actions can mean life or death, and a minute could be minute too late. I think it is best that when you are confronted with a task, assess its importance and urgency, and prioritize accordingly. The Eisenhower matrix is a good means for decision making in this setting, and I recommend you to study it as a guide.
  6. Endorse properly. Proper endorsement is an art that I admit I still need to develop. At first, you will endorse poorly, but over time, you will learn how communicate properly as a doctor to another doctor. There is nothing more irritating in the medical world than to receive an endorsement of a patient who is relayed to you as just a room number and the type of monitoring interval required. Go beyond that. Your goal is to make the patient be seen not as a case, but as a person. Also, it wouldn’t hurt to give written endorsements just to remove any further misunderstanding and make your instructions clear.
  7. Always consult with your superiors before doing any major interventions. At this point in time, you will be the grunt in the war, so you’ll have a lot of superiors breathing down your neck. Always inform them of the status of the patients, and if you have any interventions you plan to do, especially those concerning administering medications and any invasive procedures. You don’t have a license yet, so it is wise to ask, no matter how stupid the question may be; a life depends on it. Besides, your superiors have their own superiors too, and if you mess up, you’ll get them into trouble. Keep the peace and choose your battles wisely.

 Move Out!

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Waters off Palawan, 2015: Armed Forces of the Philippines board a landing craft air cushion

This year you will discover yourself. You will marvel at how you are able to stand without eating or sleeping for hours. You will marvel at your ability to go to work even when you’re sick. You will pull out creative solutions out of nowhere when everything seems hopeless. You will be frustrated for your mistakes and your failures. You will be burnt out and you will be depressed. You will feel like your life is not going anywhere, that you are stuck in the rut in the gears of life.

You will make a difference in the lives of other people.

You will become a great doctor.

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gettyimages.com

Never forget this year. This year, you are the grunt, at the bottom of the food chain. As much as it is hard to admit, the caring profession is unfortunately uncaring to those who practice it. There will be times when you will feel injustice done against you by other doctors, by the staff, by your colleagues. You will feel frustrated and disappointed in yourself, in others, and in your profession. You will feel anger and sadness at this reality. Discard their ways and use them as a guide on what not to be on your way to becoming a physician.

It is time to change the uncaring culture of Medicine, and it begins with you. This is the time not only to learn how to be a great doctor, but also to develop yourself into a decent human being. Become the doctor the world desperately needs: a doctor with a sharp and focused mind, gentle and caring hands, and a compassionate and understanding heart.

You will meet the best people and mentors this year. You will be inspired by their ability to keep calm under pressure, their unending vitality and vigor despite their lack of food or sleep, their warm and gentle guidance to you and to their patients. They will treat you as equals, and will listen to your opinions. They espouse the highest form of excellence and deserve the respect and love we give unconditionally. Use them as your guides towards progress and growth. Seek to become like them, and beyond.

I wish you all the luck and strength and wisdom for your fourth year! I will see you along the way.

Quarter of a Life

A quarter of a life
Is a breath and a gasp
A sigh and a heave
A whisper.

A quarter of a life
Is a leap and a bound
A step and a push
And yet a whisper.

A quarter of a life
Is a moment to a river
A flicker to a mountain
A whisper to a star.

Surviving Medical School: The Third Year

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 ofwho I was as a student. This is the third part of the series. 

Third year medicine is, in my opinion, the “boss level” of your academic life. I have never worked as hard as I could until this year.

This year will sum up the discipline you’ve acquired throughout your years of formal schooling. This year will be a year of challenges, a year of great expectations, a year of tribulations. When it is finished, you will find that it will have also been a year of hope, a year of discovery, a year of vindication. By the end of third year, you will feel like a physician, at least in theory. By the end of this year, you will be one step closer to your dreams.

Keeping up the Pace

ECG

pinterest.com

A medical student is a marvel of creation. We are a juxtaposition of contrasts. We feel dumb, but we can answer (some) questions our consultants throw at us. We feel sleep-deprived most days of the week, but we manage to pull through our examinations. We are caffeine-laced junkies, but we can fall asleep on command. We feel like robots in a daily grind, yet we feel compassion and empathy when we talk to our patients. We feel stupid most of the time, but for some reason, our patients and our relatives believe in our abilities. (If you’re my child, I’ll probably be bragging about you to everyone.)

It is essential to keep in mind that taking care of yourself is your first priority. Eat a well-balanced diet, exercise often, go on dates or parties, don’t neglect your personal hygiene, and sleep adequately. There will be lots of times when you will feel burnt out. You’ll try to force yourself to keep going, but you won’t likely be productive if you do. I’ve done that many times, but I would just be frustrated and miserable after.

It is important to know yourself this year. It is important to accept that you are only human, and you will probably not be able to read everything or practice all your skills. It is equally important that you believe you have what it takes to be a doctor. It is important that you discover in yourself the grim determination that will spur you to face your fears.

The greatest challenge this year is not really the tons of material, the gaggle of paperwork, or the physical exhaustion, but the lack of motivation that will sap your strength and affect everything else. Keep up the pace. You’ll get there.

From a Marathon… To a Triathlon

Ocean

zarmeenk.wordpress.com

When I first started third year, it felt like being dropped into the ocean. Initially, you’ll feel the unforgiving chill, you’ll thrash about helplessly, you’ll be brought down by the endless waves.

Up to this point, I’ve treated medical school like a marathon, where all you had to do was to keep placing one foot in front of the other. This year, you will need to be faster and stronger and wiser. You will find that you have less time to study because you have to do a lot of paperwork and projects on top off trying to live like a normal decent human being with a social life.

The greatest skill you must master this year is time management. There are many ways to become productive, but the one I’ve always found useful is to divide your day into a pie. Allot 8 hours of rest and 8 hours of lectures everyday, and probably an hour or two for personal hygiene and eating. This will leave you with 6 hours to choose between studying and not studying. How you use those 6 hours is up to you.

If you’re like me, the internet is a bad distraction. I remember looking at a clock and saying: “Hey, I’ll just surf the net for half and hour.” When I look at the clock, it’s jumped by 6 hours. Try to remove distractions from your life and focus on getting to where you want to be.

Smart is the Way to Go

Tactics

forum.ea.com/uk

Studying smart is the norm for third year. You can try to read all the material, but it’s no use if you don’t understand it. I’ve applied new tricks to keep up with the material, some of which are:

  1. Strengthen your basic knowledge by brushing up on your past lectures. I’ve found that having a good background on pathophysiologic processes will allow you to quickly understand material, as well as allowing you to reason logically when confronted with a case you’re not familiar with. An example would be how you’d suspect leukemia in a patient presenting with anemia, easy bruising, and frequent infection. You’ll even know what type of leukemia it is just by recalling your basic knowledge. If you don’t understand what you’re reading, I strongly suggest going back to the basics. If it seems too tedious, know that ultimately, you’ll work faster as you master the basic sciences.
  2. Know the common diseases, their diagnostic criteria, their treatments, and their quirks. Staple cases would be lifestyle diseases such as hypertension, diabetes, and obesity. Infections and antibiotic treatment are also frequently discussed topics. How would you know what the common diseases are? Listen to your lecturers! Or if you really need to sleep in class, at least list down what they’re talking about and just go back to them later.
  3. Simplify! I would suggest using a small index card to take note of the important characteristics of a disease, as above. It will force you to put only the essential information, and it doesn’t hurt how writing helps integrate these into your memory. Another way to simplify is to consider how diseases can be grouped according to their core pathophysiologic concept and directing treatment accordingly. The Integrated Management of Childhood Illnesses (IMCI) chart is a good example of this. Find such material, or develop them yourself.
  4. Use mnemonics, use humor, enjoy the material! Think of funny ways to remember diseases. I remember Takayasu disease being a “pulseless disease” because you can’t “Takaya-pulse”. Or how to memorize the order of CT scan radiodensity: “be sure where fart arises” (bone-soft tissue-water-fat-air). Medicine has a lot of information, so you might as well find humor in it.
  5. Put in your hours everyday. Third year is the worst time to cram. Try your best not to fall into this, as the material this year is not only voluminous, but also requires time and effort to understand. By breaking up huge diseases into simpler concepts, you’ll have a finer understanding and appreciation for the material, as well as the luxury of good sleep during the exam weeks.
  6. Be a team player. Did you forget about the paperworks you’ll have to do already? Because there are a lot of paperwork. Our team created rotations schedules to guide those who are decked to interview patients. This ensures that we all get to hone our skills, as well as getting some respite. Now, don’t be that team member who hogs all the skills, nor be that team member who is just dead weight for the group. You are going to be a doctor, and how you behave with your team will reflect the kind of doctor you’ll be in the future.

For You, Only the Best

Heart

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I believe that a medical student should strive to be the best physician they can be. There will be many times when you’ll be tempted to just breeze through the material and pass the exams. There will be times when you’ll feel lazy and just read through previous exam review questions and hope those concepts will come out of the test. These things have happened to me. But now I have to brush up on cervical cancer because I know squat about it, and OB-Gyne will be my first rotation this April. I’ve learned how each concept you slack off from will bite you back someday.

Third year is the time to think about the future. When you’ll be in the clinics, patients won’t come to ask how you did in an exam; they’ll ask if you can help them. What good is knowing that secondary amenorrhea is caused by polycystic ovarian syndrome 80% of the time when you don’t know what the diagnostic criteria are, or how to treat it? You have to learn these diseases well enough so that you can spot them in the clinic, diagnose them, and treat them accordingly.

In the end, it will all boil down on how much you care about your patient. If you care sincerely enough, you will see all the exams and papers you’ll do as essential steps to become the best physician you’re meant to be. You will grumble and fret, but take each day at a time, and before you’ll know it, you’ll be where I stand now – at the brink of clinical clerkship, anxious and excited at the same time.

I hope this year will be good to you, and I hope to see you along the way.

The Great Pagliacci

I went to a play by Pagliacci,
He was recommended by my doctor.
So I went to his play to truly see,
His proven cure with sharp wit and humor.

In came with flair The Great Pagliacci,
Rotund, vacuous, clown on a bike riding,
His appearance filled the crowd with glee,
As he regaled us with inane rambling.

“I sure would like to be Pagliacci,
Seems he never loses his wit and smile!”
Said the people beside and behind me.
I found my cure with his devilish wile.

I left with mem’ries of Pagliacci,
How funny the world through his sight may be!
He takes life with zest and security,
How happier can a person ev’r be?

One day I chanced passing by the theatre,
To my surprise there was no queue, no line,
No people demanding that they enter.
“Pagliacci is dead” was on a sign.

I mourn for him, The Great Pagliacci,
I wonder how the world without him will be.

I dedicate this to Mr. Robin Williams (1951-2014), a great man who made the world laugh, cry, and think.

On Homosexuality

I used to be a homophobe.

I studied in an all-male school for 13 years. As can be expected in a school full of confused teenagers, there would be bullying among the batch. I once bullied a classmate who was gay. Her name is Angel.

I don’t know where it all began. I guess if you put boys together, the ones who “aren’t like the rest” get treated differently. It started out subtly enough. I was weirded out by Angel. Where we would have dirty bathroom jokes, Angel wouldn’t laugh. Where we would curse and banter like sailors, Angel would just be quiet. Where we would play basketball, Angel would be at the bleachers, opting to play volleyball instead.

Then there were others like Angel, who would openly strut their stuff in the hallways, who would have rumors saying that they had a crush on a fellow classmate, who would group together and be noisy in a way that bothered me then.

Then the teasing started. It would be subtle at first, such as ignoring the person intentionally. It would then escalate to name-calling, to outright mocking of the person. I remember being such a condescending piece of shit those days. Angel was a good person. One day she just ignored me. She kept being herself despite the hurtful words and deeds we did. She even seemed happy with her friends. We who were looking down on her found ourselves being looked down by her.

Why did I do this? I realized then that I did because I felt inferior. I too, was bullied when I was a kid. I was a scrawny, wimpy, nerdy kid who got picked on by the bigger kids. That produced an anger within me that I projected to those I perceived as “weaker”. How foolish have I been! Angel is one of the strongest people I know. Angel was a better person.

I apologized to Angel for what I did. I asked for forgiveness for the taunts, the jabs, the harsh words. It was at a hallway in our school. I told her these rather awkwardly. She didn’t say anything, but from then on, I got to know her better and found out that she was like one of us, in that she eats without a tomorrow and she’s strong as hell (she once dislocated my right thumb during an accident).

My Christian Living teacher once told us how she boarded a bus full of passengers that she had to stand. Near her were two seats occupied by two men; one was the typical “macho” guy, and the other was a gay man. The gay man promptly stood up and offered her seat to my teacher.  Our CL teacher then posed the question: “Who was more of a gentleman of the two?”

The standards we live by are no longer confined to “What is manly? What is feminine?” The standards we live now should answer “What does it take to be a decent human being?”

Homosexuality is not any threat to the concepts of manliness, or femininity, or family, or society. It is merely a question of which we have miserably failed to answer.

In Russia, there is an anti-homosexuality law that represses this minority from being themselves. “You could say that being gay in Russia is like living in the closet, a very big and very comfortable closet.”, so says Alexey Mukhin, Director General of the Center for Political Information under Putin. But then again, a cage is still a cage.

In the Philippines, being gay is still seen as being taboo. Some parents are ashamed that their children are gay. Some of my gay friends are ashamed they’re gay, and don’t want to admit it to their parents. I won’t be surprised if there’s still bullying in my former school for being “different”. It’s not only a problem of boys being boys, but of the milieu these boys live in.

Where do we find the answer? I come from a religious family. I used to teach catechism for Sunday school. I once preached that homosexuality is a sin “because the Bible said so.” I didn’t teach it just for the heck of teaching it; it’s in that syllabus we use for teaching children. Yet I was not a decent human being, for I preached denying someone their right to be themselves.

I found my answer in the many gay friends I’ve made along the way. I found the answer in the shoulders I could cry on, upon ears that would listen, and the in arms that would give a tight embrace. That my fears were unfounded. That I had been very, very wrong.

That I could change. That we can, too.

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    Jian Carlo R. Narag, MD

    2005-2017