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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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.

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

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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

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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

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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.

Majesty

Mt. Pulag It was on a day like that when my father’s notion of the whole being greater than the sum of its parts moved from my head to my heart. The view from my sycamore was more than rooftops and clouds and wind and colors combined.

It was magic.

And I started marveling at how I was feeling both humble and majestic. How was that possible? How could I be so full of peace and full of wonder? How could this simple tree make me feel so complex? So alive.

Flipped by Wendelin Van Draanen, 2003 December 20, 2014. Sunrise on the summit of Mount Pulag, Northern Philippines

Surviving Medical School: The Second 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 of who I was as a student. This is the second part of the series. 

It’s a Marathon, not a Race

thehealthybackblog.com

I wrote earlier that going to medical school is like running a seemingly never-ending marathon. In the second year, you will feel out of breath, out of strength, and out of willpower. This is normal, and you’ll experience it every once in a while. But if you took my advice and took care of yourself and your studies, you’ll be very surprised at what I have to say.

The Parable of the Snowball

I will never forget the advice told to my college roommate by his uncle, a medical doctor:

Take the basics seriously.

I was told how his uncle regretted not taking the first year subjects seriously, and how he struggled with catching up on the higher subjects. I would have to say that this advice is one of the best I followed, and I wish to emphasize this with a parable.

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On a mountaintop, a boy rolled over two snowballs. One snowball rolled downhill and became larger in size. It unfortunately slowed down when it hit some rocks, and stopped completely when it hit a tree. The other snowball rolled resiliently, and despite opposition from jagged rocks, it accumulated more snow and turned into a mighty avalanche that carved the mountainside a path of destruction.

Moral #1: Avalanches are bad for your life.

Moral #2: During the second year, I’ve found out how Medicine is like rolling a snowball on top of a mountain. When you begin the path towards becoming a doctor, you start out as a tiny little snowflake. During the first year, you accumulate the language and grammar of medicine, just as a snowflake rolls over more snow and turns into a snowball. Eventually, this turns into a powerful avalanche  that becomes unstoppable.

A practical illustration would be that during a subject you will take in second year, Pathology. This subject builds upon the knowledge you have of Histology and Physiology, and some Biochemistry. If you don’t know what a kidney looks like under the microscope, and you don’t know the three phases of renal physiology, you will have a difficult time understanding why a kidney looks weird in a case of renal failure.

Practical Tips Section

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I realized that my posts up to this point aren’t really about practical stuff for medical school. Hehehe. The reason is that no two medical students learn the same way. These are some techniques I’ve come up so far to learn medicine effectively and efficiently. My disclaimer is that I’m more of a visual-kinetic learner, but I’ll put in some feedback from audio-learner friends:

  • Take care of yourself: body, mind and spirit. This is the foundation that you will build your character as a professional.
  • Know what you don’t know: I’ve once ploughed through a chapter of a book without understanding a single word of it. Never again. I’ve learned that when I don’t understand something, stop, look for the concepts that I don’t understand, review those concepts, then continue learning. It’s no use reading the different mechanisms of diuretics if you don’t know the renal pumps.
  • Write stuff down!
    • For processes (such as the RAA cascade or the fetal circulation), you can use flowcharts to illustrate how things are interconnected. This really comes in handy during Pathology, where you can see the disease processes simultaneously. Also works great for Pharmacology, for learning the modes of actions of drugs.
    • For info-overload subjects, use tables! This especially comes handy for Pathology, where’ you’ll be asked to compare the different types of cardiac failures (Left vs. Right, Systolic vs. Diastolic) and the different types of cancers (the bane of every medical student).
    • For memory-retention, use index cards. This is especially useful for information that requires one to memorize numbers *shivers* such as equations for Epidemiology, Pediatrics, and Medicine. I also use index cards to summarize some chapters from Harrison’s such as “Approach to a Patient with Rash”, writing the important points to be found when faced with a patient with a rash (Number one: watch out for meningococcemia!)
  • Say concepts aloud: my audio-learner friends tell me that in order to learn, they sometimes talk to themselves aloud to get aural feedback. They also said that they like listening or talking to people about the information they need to learn.
  • Realize that there are a ton of material that can help you learn!
    • YouTube, and other Video sharing sites: can’t understand a concept? Look for videos! I learned the intricacies of the renal countercurrent exchange mechanism *puts nerd glasses up* that way.
    • Board Review Series, “Dummies” books, etc.: I remember in Biochemistry that I understood nothing reading up on the Central Dogma on the prescribed text *puts nerd glasses up*. So I read a simplified book on Biochemistry. When I attempted to read the prescribed text again, I understood it. Disclaimer: simplified books are no substitute for the big books but are a great place to start if you have any difficulty.
    • Your colleagues: this includes your medschool friends and your teachers. A medical student is not a John Rambo cutting through the vast forests of medical knowledge. A medical student is a part of a community that works together for the advancement of medical knowledge.  It’s better to look like a fool asking a question than doing a foolish action that could cost someone’s life.
  • Practice makes perfect: Throughout second year, you’ll learn skills that will help you diagnose disease. Skills are attained through constant practice. I practice my physical examination skills by checking up on my father every other semester; to my unborn child, I’d be willing to be your dummy.
  • Expose yourself to experiences and opportunities: During the second year, you’ll start doing paperwork (at least in the medical school I’m attending), which, while it adds to the workload, exposes you to the drama of the human condition. There are some things that my patients taught me that aren’t in the books. There are also conventions and medical missions you can participate in to hone yourself further.
  • “See one, do one, teach one”: This is a tenet of Surgery, in which one progresses from being a passive observer, to an active learner, to a teacher when learning surgical skills. The ultimate form of learning is teaching. Help others understand a concept that they have a difficulty in. After all, our professional oath exhorts us: I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.”

Learn to be a Doctor, not Study to be one

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There’s a fine line between studying and learning. Studying, according to the MW dictionary is “the activity or process of learning about something by reading, memorizing facts, attending school, etc.” Learning, on the other hand is “to gain knowledge or skill by studying, practicing, being taught, or experiencing something.” On these definitions, one can discern that the former is a passive process and the latter an active one. Strive to be the latter.

Let’s face it: medicine is a competitive profession. In pursuit of good grades and high marks in order to secure good training programs, I’ve seen how the pursuit of knowledge becomes a rat-race in which only one person wins. Medicine should not be like this; it is a profession where teamwork is of utmost importance. The foe of an aspiring doctor is not the subject matter; it can be learned. The foe of an aspiring doctor are not the marks of his peers; it won’t affect him in any other way anyway. The foe of an aspiring doctor is the self.

It’s quite existential, but second year is a continuation of the struggle against yourself. You see in your everyday medical school life forks in the road that diverge into paths that you will never cross again: “Will I spend 2 hours discerning the intricacies of the protozoa, or will I spend 2 hours playing this awesome video game?” “Will I go out this weekend or will I use it to learn the difference between the different types of cardiac drugs?” I’m not saying this to tell people to become hermits, only to emerge into medical prodigies without a social life (read the first post again); I’m asking you, a future doctor, to make choices. “To be a doctor, will I study, or will I learn?”

Keep going towards your dream! I’ll see you along the way.

Concept

ConceptJonas hesitated.

“I certainly liked the memory, though. I can see why it’s your favorite. I couldn’t quite get the word for the whole feeling of it, the feeling that was so strong in the room.”

“Love,” The Giver told him.

Jonas repeated it. “Love.”

It was a word and concept new to him.

The Giver by Lois Lowry, 1993

March 31, 2009, in a messy room

What I Want in a Teacher

I’ve always wanted to be a teacher. I’d be a Social Sciences Professor who’d rave and rile my students into opinionated individuals. My dream is not but a passing melancholy; one day I will be a teacher.

I’ve had the honor of being under the tutelage of great teachers in my life. I write this entry while I am a student that I may never forget what qualities such great people had. I aspire to be such when I realize my dream. This list is in no particular order.

1. Competence in the Field

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I think the foundation of successfully teaching is knowing the subject matter itself. This is what differentiates a teacher from any other individual. Someone may be nice, good natured, and kind, but that’s just the base where one adds other qualities that make the person stand out, or in this case, a professional.

When I speak of competence, I do not only desire a teacher who knows the inner workings of the mitochondria (the “powerplants” of cells) ; I want a teacher who applies such knowledge clinically in all aspects. I once had a teacher who always made my jaw drop when she explains those tiny details you miss but are very crucial for patient care.

I once took care of a baby with Biliary Atresia. Children like them have bloated abdomens (ascites). When she asked how my patient’s breathing was, I was stunned. I didn’t consider that fact. She explained that the condition can cause difficulty in breathing because it can mechanically compress the lungs when the child is lying down. So the best move would be to put the child in a side-lying position to ease the breathing. Bam. Competence at its finest.

Competence is a dynamic quality that must be constantly developed. I want a teacher who maintains competence by practicing the profession, taking continuing education courses, keeping up to date on the literature, and those things I’ll *probably* be complaining about in the future.

2. Ability to Communicate Well

Communication

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All knowledge is for naught if a teacher is unable to communicate ideas effectively. In retrospect, the best teachers I had were those who had the ability to make me understand things I didn’t want to understand.

Communicating ideas is in a way, selling these ideas. Communicating effectively requires getting the attention of the student, stoking the flames of interest, and leaving the student craving for more.

The best ways I find effective in communicating ideas from great teachers are:

  • Providing Analogies. Instead of saying that a heart attack occurs secondary to a block in the coronary arteries by an emboli, a teacher can liken it to a bad traffic jam (or a pile-up) that disrupts the flow of supplies. From that concrete image, a student would be able to translate it into an abstract thought.
  • Telling stories. I had a Psychiatry professor notorious for this. She would tell the natural courses of the diseases of her patients, and through these vignettes, I was able to understand the diseases better than reading the prescribed texts.
  • Analyzing and Correlating. An adage I picked up through the years: “Analyze, don’t memorize; correlate, don’t reiterate.” It is one thing to provide facts, but it is another to transform these facts into tools one can use. Besides, I think that it is by analysis that one can discard useless information and better “memorize” concepts. Learning is further strengthened by correlating ideas with one another, which forms a “web” of concepts that mutually strengthen each other.

3. A Person of Noble Character

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I mentioned awhile ago that being “nice, good natured, and kind” are the base where other qualities and abilities are added. Nobility far exceeds these aforementioned traits. It is hard to define what a noble character is – so I will just describe what a noble charactered teacher made me feel.

These are teachers, when I meet them, I feel that I can trust. When I approach them, they welcome me and  take time to hear me out. When they answer, it is with equal curiosity as to the manner I inquired; they are not condescending. When out of the classroom, they smile and greet their students, a great bonus if they know our names. When I think about them, I want to be just like them. When we part ways, I feel afraid, but incredibly inspired to be better.

I guess for my future self, the closest concept would be the Golden Rule. Do that which ennobles the self and others.

4. Strives for Excellence

cartoonmotivators.com

A teacher becomes outstanding when the students feel that they are  in school to become better people. It’s one thing to treat teaching students like a factory, and another to help every student maximally achieve their potential.

I want a teacher who continuously grows and becomes better, and who doesn’t accept mediocrity from the students. I want a teacher who says bluntly: “You’re not living up to your full potential. I know you can do better, but you just don’t want to.”

And lastly, on the flip side…

5. Never Forgets What it Means to be a Student

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Often I find teachers who act all high and mighty with their students. They forget that they, too, were those same scared clerks who didn’t know the difference between that crumdumgeon Nephrotic and Nephritic Syndrome (it’s the spelling. DUH.) A teacher always remembers their roots, and accept, that they too, are students who are also learning and making mistakes.

I remember one instance when I  taught a strict professor a lesson. She was then helping a classmate of mine collect a urine sample from a bedridden old lady in the ICU. After all preparations were done, I noticed that they didn’t drape the cover curtain around the patient, so I just walked over and closed it for them. I heard her saying “Oh yeah… [we forgot that detail].” Mind you, I love that professor, but boy, was it sweet.

Those who can, teach!

5 Lessons Learned From Jogging

The more I learn about Medicine, the more I’m becoming a hypochondriac. I guess that’s a good thing though, since I’ve started jogging again. Here are 5 lessons I’ve learned from jogging.

1. Set Goals

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I don’t know who said it, but he or she said that “a goal set is half the work done.” To set the intangible goal is as important as attaining the tangible product. This is a fact that is often overlooked by people, who in their zeal, just plow right into the fray without asking themselves the what’s, the why’s and the how’s of what they’re doing.

Before I began jogging again, I spent the first day on a walk around the path I’d be running. The walk took me about an hour. I began to feel the vastness of the distance I’ll be running, and doubt began to shake my resolve to even start jogging again. So I divided the course into parts, which were “marked” in my mind, and I resolved to conquer, a run at a time.

When I did a “test run”, where I would just run and stop whenever I felt like I couldn’t run anymore, I found that I finished less than half of the course, panting heavily and sweating profusely. It was a good start.

From that baseline, I began to increase my jogging distance with each subsequent run, and now I find myself running farther than I have ever ran before.

And now for a nerd moment. Physiologically, the body releases a chemical called Dopamine, a  chemical that is released whenever we accomplish something. This “feel-good” chemical makes us happy when we’ve eaten that cake – on the flip side, it also makes us happy when we finish our “Rocky” training montage of a day. By application, setting a goal, even a small one, like running the extra 5 meters makes one feel satisfied.

In the greater scheme of things, I find that setting goals (and gradually achieving them) helps me stay more motivated. When the run seems long and arduous, you can always take satisfaction that you ran an extra mile each time.

2. Consistency is Key

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Consistency should be a lesson taught to everyone at a young age. We’re taught to be honest, to be kind, to be diligent, but in a weird way, not so much on being consistent. Consistency is that virtue that creates powerful habits that break equally (if not more) powerful vices.

Nerd moment number two. The brain is an organ that is complex, but very stubborn. It is an organ that knows its potential yet feels very snug in the status quo. To challenge the brain with change will be met by strict opposition. Who hasn’t had the experienced of making a New Year’s resolution, then breaking it the next day? And who cringed at the obvious grammatical error of the previous sentence? That is the brain screaming at you to comment on my bad writing.

In jogging, being consistent made me get up from bed (the hardest part) and run. It was an internal voice that nagged me to run. It was the voice that told me: “Hey, you ran this far yesterday, so you can run further today.”

In life, consistency allows one to create habits. As of this writing, I find myself automatically putting on my jogging shoes every other day and just running. Mind you, in the past, the thought of going out and jogging was met with: “But I just wanna sleep/watch a movie/read!”

It turns out, I have the ability drag my sorry butt out of bed and make me do things that matter.

3. Everything in Moderation

inspiringbetterlife.blogspot.com

I usually jog alone. During jogging, there are two conflicting voices that battle in my mind: the “Keep Running!” voice and the “Hey, I’m tired. Ugh, your body hurts. Hey, let’s just watch a movie.” voice.

The experience made me realize that your greatest foe is also your greatest ally: yourself. We are limited by what we limit ourselves, and conversely, we can achieve as much as we want to achieve. Now, I don’t mean it in a way that says “I am an invincible being! Feel my wrath!”

I mean it in a way that says: “we should see limits as frontiers of what we can do, and of achievement as a gradual process of breaking limits.” That said, in jogging, you don’t just plot a course and run through it all – you might overexhaust yourself.

The two voices in my head are two sides of the same coin: the “Keep Running!” voice is a whip that inspires me, yet if I listen to it alone, I might destroy my body. The “Hey, I’m tired… blablabla” voice obviously, will keep me lazy if I listen to it exclusively, but it also has the wisdom of telling me to not kill myself in the pursuit of health.

Nerd moment three. The body is well made to handle stress. Take the lungs for example. During exercise, it is able to oxygenate the blood adequately, such that even during times of severe exercise, blood is close to a 100% saturated with oxygen. Then take the heart. It has the ability to pump blood to meet the demands of the tissues, and has several fail-safe mechanisms to keep it running under various conditions. Then take the muscles. Muscles have the ability to keep contracting and contracting as long as it’s ordered to. In fact, it still has enough energy to contract despite seeming tired. The one that limits the body then, is the brain, which feels pain and fatigue – but it doesn’t contract or do any of the work the lungs or the heart or the muscles do. But it’s an important organ that tells you not to kill yourself in the pursuit of health.

As I began to jog more consistently, I began to discover that I should listen to the two. In essence, there will always be two voices in your head – the angel and the demon. You need to listen to both – not just one.

4. Ditch the Distractions

mashable.com

I’ve tried running with earphones on. Bad idea, in my opinion. For one, your safety will be compromised. You can’t hear a brakeless car heading your direction with the “Final Countdown” song blaring at your ears. It’ll also be too late when you feel your leg being gnawed on by a dog you didn’t hear chasing you. Second, it’s a surefire way to destroy that electronic equipment, especially if you sweat profusely. Third, it robs you of the experience of feeling and appreciating  your body.

The last statement may be due to my habit of running alone. It is during jogging that I get to commune with my body, feeling my heart beating faster, my lungs breathing deeper; my feet striking the ground and my muscles tightening.

Sometimes, before I jog, I latch onto one idea – it may be an experience, a problem, or a thought, and think about it during the run. Or, since this number has to have a nerd moment, I also ruminate on a concept in my studies when I run. I find that after running, I become enlightened on that idea I meditated upon.

5. The Last Stretch Syndrome

hdw.eweb4.com

In this post, I defined the “Last Push Syndrome”. The Last Stretch Syndrome is the opposite of that. It is when a person, in his desire to finish a goal, burns himself out in the process. These are periods of extreme zealousness that causes one’s downfall.

I usually feel this when I’m at the last mile of my run, when I see the electric post that marks my “finish line.” In the past, when I saw the post, I would make a mad dash towards it. Most of the time, it would lead to my downfall – I would tire out and stop at the sidewalk, and feel disappointed and confused.

I was *this* close. When I realized what I was doing, I began, at first, to look down when I saw that finish line. To achieve is a tempting thing, and it can cause one to lose focus. Over time, I managed to rein myself enough to keep the pace and finish the course.

In life, there will be many opportunities when goals seem to be in one’s grasp. However, one must not lose sight that it is the journey (or the run), and not the achievement, that makes us the better people we are today.

Nerd Moment Five: Jogging improves your cardiovascular health.

Purpose

I see a beautiful city and a brilliant people rising from this abyss. I see the lives for which I lay down my life, peaceful, useful, prosperous and happy. I see that I hold a sanctuary in their hearts, and in the hearts of their descendants, generations hence. It is a far, far better thing that I do, than I have ever done; it is a far, far better rest that I go to than I have ever known.

– Charles Dickens’ A Tale of Two Cities, 1859

November 24, 2011. Returning home from a day’s work. Brgy. Libato, San Juan, Batangas

The Noob

I looked over my “To-Do List” the other day and I noticed something was missing: Firing a gun. After updating my bucket list, I continued with living as usual. I didn’t know that day would come so soon.

I jokingly told my father to take us to the gun range today, as a belated birthday present for me. I didn’t expect him to humor me, and 30 minutes later, we were at the gun range. For those who don’t know me, I ironically have a fear of thunder and lighting. I hate to be even near balloons, and I feel queasy when that squeaky noise is produced by rubbing the surface of a balloon.

As we approached the shooting range, I could hear shots being fired. No turning back. We head to the reception and pay the fees, and of course, sign a waiver. I fired a civilian handgun, a standard 9mm. Papa asked us how many rounds we were going to fire, and my brother and I went for 20 rounds each. The receptionist gave us some goggles and a head set thing to suppress the gunshots, and we were then led to the live rounds area.

Papa loaded the 9mm and demonstrated to us how to safely handle a gun and how to use it. The gun range had it plastered on its lobby.

The four rules of gun safety are:

  1. Treat every gun as if it were loaded.
  2. Never point a gun at something you’re not prepared to destroy – Never point a gun at a living thing.
  3. Keep your finger off the trigger until you’re sure to shoot.
  4. Be aware of what lies beyond your target.

Papa’s a good shot. He fired only 4 rounds until he hit the center of the target. He hasn’t fired a gun for almost 3 years. After his demo, my brother had his turn. When he fired… He immediately hit close to center. Wow. And like a first person shooter with road rage, he spent his cartridge after a minute. Most of them hit. Did I mention that he was left handed? And that he was using a right handed gun?

So, it was my turn already. To be honest, firing a gun isn’t what it looks like! Even though I’m good at FPS games, those do not approximate the sheer rush one gets from firing a real gun. (To FPS gamers out there who are bored during the “training missions” where you learn to fire at a gun range, go to a gun range. You will not be bored.) Thankfully, there was an instructor with us there who gave me tips on firing along the way. Turns out, firing guns should be done with your body as relaxed as possible. While I was firing my very first shot, I remember pulling the trigger quickly, and with tensed arms tried to catch the recoil. The recoil felt like being given a straight pass of a ball that weighs roughly a half of a standard bowling ball. I felt the adrenaline rush in, and it felt good. I waited to see the result of my first shot.

After the smoke cleared, I looked at my target (7 feet away) and saw… that I had missed. In a zombie apocalypse, I would be dead. In an alien infestation, I would be dead. Never! So I shot away. After spending my cartridge of 9 bullets, I am proud to say that I hit 3. Yeah! Die zombie!

So, deciding that I was not going to let that possible death in an apocalypse or in an infestation become true, I slowly faced my fear of loud noises and flashy lights slowly at the gun range. Tips that the instructor (bless him) told me were the following:

  • Stance: if your trigger finger is your right, put your right foot back, and vice versa.
  • Breathing: I was told to fire the gun holding my breath. I found it easier to fire after exhalation.
  • Arm position: Since I was a rightie, my right hand was my trigger finger. My left hand acted as support on the other side. My index finger rested on the gun safety. Here’s the tricky part for me. The left arm should be more tense than the right arm. The right elbow should be slightly bent and relaxed than the left arm. The reason for the tension difference is that the right arm bears the brunt of the gun recoil, and giving it some slack allows you to aim straight on without deviating to a side.
  • Squeezing the trigger: For a noob like me, I squeezed the trigger quickly, which led to me hitting the floor of the gun range. I was told to squeeze the trigger halfway until the hammer cocked, so that I would have better gun control.
  • Aiming: I had no problem aiming, since I do play FPSs. But in a 3d world, it was new to me.

My first 20 rounds came by without notice. I told Papa: “Ubos na?” (“No more rounds left?). He said: “Oo, gusto mo pa ba?” (“Yes, do you still want to fire some rounds?”). Like eager children, my brother and I nodded our heads in delight. So Papa bought some more rounds, and we went on firing. As we fired off, I felt easier and more relaxed at shooting the gun. As I felt more at ease, I began to hit the target’s body. The closest I came to the center was about 2 cms. Most of my shots were to the left chest. I would have shot more, until Papa pointed out that we had already fired a total of 200 rounds. When I looked at the spent casings on the floor, I saw that a pile of them had built up and had to painstakingly stop myself from asking for more.

Next time, you white tape!

It was fun firing a handgun today. I really look forward to being a better shot next time. As I look at the target I brought home as a souvenir, I found that I had hit it 57 out of 95 times. Next time, I’ll do better!

On Being a Community Health Nurse

Pottery Set

I had the fortunate opportunity to be a community health nurse during the past 8 weeks in Barangay Libato, San Juan, Batangas. It has been a journey of highs and lows, but overall, it was a journey that I will cherish for the rest of my life.

When I first took up nursing, I thought that a nurse is confined to the job description: being a nurse. No, a nurse does not simply play a client’s advocate. A nurse is also a teacher, a researcher, a supervisor, a community organizer, a leader. All these roles I had the chance to play during my stay in Batangas.

Everyday as a community nurse was not the boring job description I thought it would be. Everyday was different from the last: in the morning you were caring for clients with different needs or immunizing children, and in the afternoon you were a researcher analyzing data or an organizer planning a big community activity. Different situations are thrown to you, and it tests your limits and shapes who you are for the better.

The part that I love about being a community health nurse is the independence given to me by my clinical instructor. I wrote in a past entry how we are no longer students to her, but colleagues who do what should be done out of personal responsibility. I guess that our clinical instructors are giving us the highest challenge posed to future professionals: the capacity towards being self-directed individuals who do what they do not because they are told, but because they genuinely desire to do it.

Besides all the work there, being a community health nurse is also being a human being who does human being stuff. I can say that we have integrated into the community that we have come to love. I think we had about 10 parties during our stay here. The food was great! I especially love pinaltok, a glutinous rice dish served with coconut milk and ube and ginataang monggo, also a glutinous rice dish served with fried mung beans. We went to baptisms, birthdays, and even a death anniversary gathering. We exchanged Christmas gifts with them, we played basketball in their court, we walked with them under the midday sun, and we shared the same dreams with them.

There is a particular client that I will never forget. The Conservado family was my first family in Batangas that I cared for. At one point, the head of the family had flaring episodes of gouty arthritis, and had no medications for it. I remembered how the pansit-pansitan plant (Peperomia pellucida) can be used for such cases, and recommended it to the family. However, the family did not know what the plant looked like, so I volunteered to look for one in the vicinity. I spent an hour looking for the plant, and in my stubborness not to stop, ended up being almost a mile away from the family’s home, searching under the trees in the middle of the rice fields (the plant usually grows in dark, damp places). The distance I reached was enough to cover the family’s home with my thumb. I actually felt disappointed as I did not find that plant.

I trudged back to tell the sad news to the family. Ironically, there was a neighbor who had the plant growing in a pot, who, ironically as well, thought that it was a weed. Heh, next time, I should ask first before going head on in the mud. I had fun looking for that plant, though I came back muddy and with Amorseco spikes embedded into my pants. When I returned to the family, they were very happy, and saw what I did as, to quote: “Hindi iyan gagawin ng kahit sinong doktor o nars na dadaan dito, pero ginawa mo.” (“No one would do this for us, be it a doctor or a nurse, but you did it for us.”)

When it came for us to part, the family members cried, and wished that I remember them fondly. They gave me a beautiful miniature pottery set, whom Mrs. Conservado told me to give to my mother and to “my future wife”, and bunches of bananas for the road home. To the Conservado family, if you happen to read this, know that I will never forget your kindness to me.

The best lesson taught to me by my experiences in Batangas is succinctly expressed in a quote by Confucius: “Choose a job you love, and you will never have to work a day in your life.” I think that this applies in all professions, whether it be health-related or not, that in the end, it all boils down to one’s passion. What sustained me throughout the challenges I faced in my stay was due to the passion that I held all this time: to make my clients happy by helping them achieve optimal health. All those long walks, those times burning the midnight oil, those papers: all worth it. All of it. All just to see my clients become healthy and happy once again.

I left my heart in Barangay Libato, San Juan, Batangas. The memories, the experiences, I will never ever forget.

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