When Things Go Wrong

Would life be better if all the things that I wanted is always served in a silver platter? Would I be saved from crying bitter tears, from the frustration or from heartache? 

in everything

There is a time for everything...

In this life, if I do not know the character of God, I would be swept away by the negatives of this world.

Because God is amazing; He always provides a way out.

-----x------

A household with a husband in a newly married set-up is tough.

Even the way I cut the garlic or the onions for that adobong pusit recipe can be an issue; and if I would dwell on it, it can lead to arguments and other complications.
ANSWER: Compromise.
But sometimes, the way to make a compromise is so difficult also. Voice and tone check; breathing check and the eyebrows positioned not high above the forehead.


Grocery time is no different either... why would I want to buy more than two packages of toothpaste?! or the kind of fish that we need to buy in the market... "you ask me what I want, and then when I make my choice, .... you have all sorts of excuses not to buy it.... why don't you go ahead with the purchase?!"


-----x-----


Realization: Between hubby and I, I am no longer the "kuripot" that I thought I was...

Next time, that portion for savings goes to hubby. No questions ask.

He Who Provides

I have been nagging, berating - plain and simple making"yawyaw" with every chance I can get, because of what I feel as a lousy handling and discussion of my "admitting privileges" by the powers-that-be. I overheard some members talking about my approval and yet, no official document/statement have been made. I need evidence!

                                                                                                                                                                                                                                                                                                                                                                                                        My family and mentors have always encouraged me to remain patient because truly God would give me what He had promised at the the proper time.

I am just glad that God is giving me the grace to listen. 

So, What Now?

I have been sad borderline frustrated about how the Team is handling my case. They are still "talking" about my application for admitting privileges. They asked the Department of Family Medicine to furnish them with an guidelines for admissions, for which I helped in drafting.  I can only guess about their perception of Family Medicine. Is this about patient turfing? I don't know, because I feel its too lame to be used as an excuse. After all, it is a specialty both here and abroad, even qualified to be gatekeepers of health care in Europe. Patience is a virtue.

 ____x____

I received two significant emails today that got me excited; which I am taking as one of the unique ways God is encouraging me to pursue what He has prepared for me. 

1.   A patient with chronic pain from the United States inquired through the Filipino Doctor for a physician who could help him with his pain as he is preparing to spend his retirement in Dumaguete City. I hope I will be able to practice what I have learned from my fellowship on pain management. Most importantly, that I can make a difference in the life of this patient and his family.

2. The most exciting of it all, is knowing that a Sillimanian based abroad, is interested in starting a community palliative care program. I have committed to help her in this endeavour. Based on this first exchange, she wanted to start by educating the students and the Silliman community about what palliative care is and its goals. 

_____x_____

Julius and I are currently in the "medical process" of finding out if we can have children or not. We have been married for almost three years and there is no sign of a baby yet. Hopeful.

____x____

People and circumstances may delay it but truly they could not stop it.

Instagram

Discovery

fascination

curious

Its my 33rd

Other people would want to keep it a secret but NOT me.
I love April 20. I appreciate the date. I am thankful that there is such a date.

Its not about the big celebrations but the joy of having people remember me in this crazy, hurried world - that  IT IS MY BIRTHDAY!

There are only two birthday parties that really stood out in my memory.
One, is on my 7th birthday, when I had a big children's party at the backyard of my grandparents house in Butuan City. But that is not what made the day special, its because of that extra birthday cake that my Tito Dongkoy and Tito Honey had for me. A rectangular buttercake with white icing and green trimmings on the side. We enjoyed the cake in the evening with 3 or 4 of my childhood friends around. Yayang, Honey and the other two... I wish I had kept that picture taken in the sala of the house that I called home for the first nine years of my life. I was told that the house is no longer there.The street of Del Pilar is no longer the same. 
Second, is on my 18th year, in MSU, a generous gift from Tita Mila and Tito Lando. Classmates from summer class were present, and I distinctly remember, being worried, that food would run out. I don't usually have classmates on my birthday. They did sang songs -"harana."

My parents were not with me on these dates. =(
Its far too complicated to  write. For now.
Daddy, Mommy and Mama have died already. 
My sister, Wela, who was born on April 19, 364 days after me, has a baby of her own.
Papa has a family of his own with four more kids.
...

There will always be lessons.
 




...
I started the day singing "Happy Birthday to me...." and my husband joining "Happy Birthday to you...."

...
Patiently waiting.


  

Clinic Hours

My husband would have preferred for me to have the usual out-patient clinic hours that other physicians keep -  the nine to five thing with lunch break in between and the occasional after office hours consultations. Instead, I am keeping a twelve noon to nine in the evening clinic from Monday to Saturday. It is unconventional but it does serve its purpose(s).

The hospital I am affiliated with is trying to up-build her emergency and ambulatory care services. Based on the patient census, this is the time wherein most patients and their families would come to the ER for consultations; and they are not necessarily emergency cases. Most of the time, its either their preferred physicians are no longer holding clinic for the day or has reached a limit in the number of patients to be seen for the day. Or they just do not want to wait, period. The "OPD-ER Extension Clinic" will decongest the ER of the non-emergency cases- somehow discipline the clients about emergency cases vs ambulatory cases. 

This schedule has also allowed me to have late mornings, spending it with my husband over brunch in most days of the week. I can also schedule errands/other appointments in the morning;  and starting this June, I can hold classes in the medical school in the morning. The morning is also spent catching up with other administrative work for the residency training program.

Since I have always believed that there is always a time and a season for everything, I am pretty sure that there will be more reasons for me to keep this schedule in the days to come. And yes, my husband has come to accept this schedule and has also found ways to "complement" my schedule.  

 

definitions

Palagaylay - is a term that I first came to understand when I started my post-graduate training at Silliman University Medical Center in Dumaguete City. It could mean dilly-dallying, dragging your feet or delaying.

And it is something I wanted to do after a week of hospital work. ",)

The TroubLe with Being A NewBie

The truth of the matter is, even after 3 years of residency, another year of post-residency and a year of fellowship training; in this profession that I have grown to love and (sometimes hate), I am a newbie. I have just started seeing my 'OWN' patients in the outpatient department just this year. I have met many patients from all walks of life and in various forms, for I am in primary care after all. The mantra of womb-to-tomb, treat the disease AND the illness, the family is my greatest ally in patient care, etcetera - all that, I believe that I have learned by heart. 

Even if I have my own share booboos;  I still like to think that I don't have any problems with asking help from the other doctors about certain things or accepting my own limitations and mistakes in some aspects of disease management.

There is this adult patient who came in with a long-standing skin lesions, that I referred to Dr.GNG - only to find out that, if I had asked if a skin biopsy was done before, I would have known then that it is leprosy. There is this 19-year old, with amenorrhea, if I had been more specific in my abdominal exam, I would have known that she is pregnant even without a test. The list can go on, and it's just been 45 days!!!!

Family would often think that being a doctor would make me automatically financially rich especially now that I have finished my diplomate exam and fellowship training. I have also been invited to join the faculty of the medical school. "Consultant." Nice to hear. I am quite proud of what I have achieved but right now it did not do much in improving my bank account. Nope, I am not forgetting that money is certainly, not everything.  But it would be nice if it will help me afford some of life's luxuries.

In the current state that I am in, I feel that my capacity to practice what I have trained for and apply what I have learned is limited by the same (some) people who were once my mentors and by the bureaucracy that I am a part of.

It can be tiring when almost everyday, I try to let other doctors and the staff understand what are my competencies. It seems that the certifications that I have earned through years of toil are not enough for me to be granted that admitting/clinic privileges.

In my understanding, this is how the system is working- we have the EXECOM composed of department heads who convene to decide on whether or not one gets to have the clinic space or the admitting privileges. From the information that I have gathered, there seems to be the hesitancy in granting me that privilege because of my being a Family Medicine specialist and that I therefore belong to the OPD only plus, I might usurp patients! These are perennial issues and it would be such a waste of time and effort if I go around educating every single consultant what the specialty is about.

I would be doing a great injustice to patients and their families if I will treat them for something that I know so little about. This is just one of the reasons why a specialty society has a set of competencies that needs to be mastered before becoming certified (well, at least, in PAFP).

In a resolution submitted by Sen. Manny Villar during the 14th Congress (http://www.senate.gov.ph/lisdata/80747294!.pdf), he made mention that the doctor:patient ratio was at 1:28,000 when the WHO placed the ideal ratio at 1:10,000. How could I possibly usurp patients with this statistics?! 

Do I need to emphasize that I am responsible and capable of providing comprehensive health care to every individual seeking medical care, and that I can arrange for other health personnel to provide services when necessary; that I can accept everyone seeking care whereas other health providers limit access to their services on the basis of age, sex and/or diagnosis; that I care for the individual in the context of the family, and the family in the context of the community, irrespective of race, culture or social class; and that I take personal responsibility for providing comprehensive and continuing care for my patients. (http://www.globalfamilydoctor.com/publications/Role_GP.pdf) Do I have to, really?


I feel lost. I need to take a stand and treat matters more aggressively. I need to make my domain known. There is much to learn for a newbie like me and the whole world to explore.

++++++

We cannot allow efficiency, bureaucracy, competition, or technology to divert us from keeping our covenant to be there for our patients from first contact to last resort. Advocacy for our patients and for our unique role is central to the future we share with our patients. (http://www.stfm.org/fmhub/FULLPDF/APRIL01/2001-33-4-273-277.pdf)

Shout Out for 2012: Joshua 1:9

"Have I not commanded you? Be strong and courageous. Do not be terrified; do not be discouraged, for the Lord your God will be with you wherever you go."

 Thank you to the Silliman University Church Service today for this reminder. I am truly blessed.

++++++++++

 The year 2012 started with a challenge - how to pack all the materials things that I have accumulated during my fellowship year in Manila without earning the ire of my patient husband - and I failed. I had to pay a considerable amount of money to Cebu Pacific for the excess baggage. Countless times has my reminded me to send some of these things ahead of time but I procrastinated. Yes, I have to admit that I really am a Hoarder and I hope to make every effort to improve.

++++++++++++

I have been told by those who have come before me that I will face the considerable task of making palliative care be known, understood and accepted in Dumaguete City. I had to prepare myself; and I knew, even at the beginning, that could not do it possibly do it alone. It is in the moments of hesitation that I became more conscious of the people and circumstances that God has presented to me. 

++++++++++

 The most basic virtues still apply - patience and perseverance, humility and love.

 

Dear Manong

Dear Manong,
 
Thank you for staying with me during the entire duration of my fellowship year at PGH. Your sacrifice is so much appreciated. I know how difficult it must be for you to be "idle" when you are so used to working. Your humility and patience is beyond words.
I will always remember you sitting in one of the benches at the back of the OPD building, being pestered by the notoriously big mosquitoes of PGH; while waiting for me to finish my patient's rounds.
During the waiting periods, you must have memorized the floor plan of the nearby Robinson's Place like the back of your hand. How you have discovered little shops/big sales and places to eat inside that mall... Mangoong, Hongkong noodles....
I admire you for finding ways to make your time productive - going into training for small/medium enterprises at E.Rodriguez in Quezon City. You braved the afternoon traffic so you could pick me up right on time.
Our space here in Makati is in order because of your organization skills... You have surprised me many times with a clutter-free work table.
Metro Manila is not so scary for me for you have accompanied me to places that I used to see only in the papers or on TV. The rackets with the TV networks and motorcycle shows, the Walk this Way and The Stamp Tour...
How your face beamed during the graduation and How you uttered a prayer of thanksgiving... even on that late afternoon  after the exit exam.

You have made the stay in Manila much more bearable by agreeing to stay; and not venture into some faraway ocean. Thank you for allowing me to be selfish of your attention.

The year has been tough but you have softened the blows.

I will always thank the heavens for sending you to me and that I belong to you.

I Love You.

Yours aLways,

Manang

My Julius I. Samares ^-^

 

Regrets

12 11 2011

The stay in Manila for the UP-PGH Fellowship Training in Supportive Hospice and Palliative Medicine has been financially tough for my husband and I. The reality is, the income that we are earning, when spent in Dumaguete City is far more rewarding than when spent here in Metro Manila. Dumaguete City is not the boondocks but we can get around the city just by walking or talking the pedicab; and it would not take us forever to get from one place to another. We have the convenience of cooking our own food rather than go for “dine in” or “take out;” Not be crammed in an apartment with many restrictions. But don’t get me wrong, with almost a year done here in Manila, I am grateful for the people we have met, the places we have visited and the events we have attended. The fun and excitement of discovery is something that cannot be bought or even exchanged.

A.      A. On Moonlighting and Relieving

Among the many experiences I gained here in Manila was the opportunity to go into relieving/moonlighting duties. Straight from passing the physician licensure examinations, I went to residency training in Surgery then Family Medicine. My idea of moonlighting/relieving/racket stemmed from the accounts of friends and seniors. The monetary compensation was good and you have the opportunity to do 2-3 duties. The downside is, well, the travel time and there is no “permanency.”

On three occasions (2 at the BoomLand Kart Track for a Motorcycle Race and 1 WiLLing WiLLie Anniversary at Smart Araneta Coliseum), I was able to work with STAT Med – an ambulance service with its own team of EMTs.  I had fun and the pay was just enough at P2500 for 8-10 hours of work with free meals. But, according to my companions who seem to be “perennieals” in the moonlighting/relieving seen – the pay is just small. That is okay with me, though, because they allowed my husband to tag along and I get to see the “artistas.” Happy na ako dun.

The other thing is my not so nice experience with the racket at Slimmers World which I ‘inherited’ from one of my companions. The schedule is on Tuesdays and Thursdays, 6-8 o’clock in the evening for P8000 which translates to about P500/duty. The work is not that tedious –physical examination for those wanting to enroll in their fitness program with a few consults here and there. I shared this duty with a resident – she takes the Tuesdays and I do the Thursdays.  Before I accepted to take this job, I knew for a fact that there was always a delay in giving out the cheque, about two weeks late, and if you will not follow it up with the assistant manager/accounting, it may take longer than that. I always hear Aliza complain about the delay. In our case, the cheque is placed under the name of the resident, because the management would only want one name. Logistics, I suppose.

December 8, 2011 – on this fateful day, I have come to realize that I have had enough of the delaying tactics; being treated like ‘second’ class, not being compensated for what I have studied and trained for. “Cge, kahit hindi sa pina-trainingan ko, kahit sa paging doctor na lang…”   I am a specialist, a diplomate member of the largest medical specialty society in the Philippines. I thought it is about time to stand up for my ‘rights.’ Having said that, I do remember enjoying the duties that I had and fondly thinking that it is all well with me if there is a delay in the handing out of the cheque; so, I could just forget about it and place it under savings. The problem now was I did not give them the two-week notice; I just did not show up. At siyempre nagalit sila. I just said I am sorry. Simple; rather than risk saying something that is not called for.

However, when I learned from Loida, that our October and November salaries have only just been processed last December 6, 2011…. Grrrrrrrr! What are these people doing with our time cards of the last two months??? I felt really bad and quite frankly, I regretted not saying this to their face. Abuso na ito! Wala po akong ma-recommend na doctor po sa inyo kasi nakakahiya ang pasahod niyo at na-dedelay pa.

B.     B.  BPI Express Deposits

No matter how advanced the technology is, it still needs a good head to be able to operate it =)

I was eager to show my husband how to make a deposit on an automated teller machine but I made the mistake of not arranging the bills properly without the “kunot.” The machine ended up “eating” most the bills and was not posted to my account. To state the obvious, “syempre;” my husband scolded me for my carelessness and impatience – “Why didn’t I wait for morning to do the transaction..?”

I immediately sent an email to the bank and posted in twitter… in less than 24 hours, I received a call from a bank representative and promised to settle it in 3-4 banking days. And Promise Fulfilled.

Lesson Learned.

Roaming and Eating Around

November was a busy month - both on the home front and at work.

 There was the going home to Dumaguete City for the elective and research matters.

Morning Snacks

The UP-PGH DFCM Post-Graduation Course at the Hyatt Hotel and Casino....

Happy Birthday, my Love (November 16, 2011)!!!

The Weekend Birthday CeLebration for Julius; and his wish to savor the Crispy Pata at Buddy's Restaurant-Kakatong Branch.
How could I possibLy resist that face?

The Crispy Pata was 9/10 on the NRS... but the quantity was just too much for both of us to finish. We had the left-overs for breakfast on the following day.

The truth is, we have been going to Buddy's for almost two months now - after going through the "ChicBoy" phase.

Doctor Ellen and Sir Lims, both of whom my mentors while I was reviewing for the diplomate board examinations.

Along with other doctors, I got invited to lunch at Mangan. I had this for dessert -the bibingka and the puto bumbong!

The Pinoy Christmas Scene

Julius and I paid the entrance fee of 10 pesos so we could get into the trade fair at SM MegaMall Building B Megatrade Hall 2 - The Buy Pinoy Exporters Fair.
 
Julius got so excited when he found out that there was a booth catering to the "how to make the fabric softener and dishwashing detergent...."  He had been talking about it for months already where he could possibly learn how to do it.

 We were there on the second and on the third day.
The second day was to buy some kakanin that we could bring to our DGroup meeting at CCF , St. Francis Square. It turned out to be a "Sweets Festival, " with our cassava cake and leche flan, completing the Goldilocks cathedral and apple pie. We met new companions, too - Juvy and Alfred and Maricel.

The third day was for Julius and his seminar/demo on the fabric softener and dishwashing liquid. He is having some business ideas now. i hope this will push through in God's own perfect time.

TAkoyaki Balls for me!

Julius would always pick me up from the hospital in the afternoon. Robinsons Place in Ermita, Manila has become our go-to place before going home (along with the rest of PGH staff!)



And this is what we usually have----

The Green Mangoes at Mangoong for him

But, on the weekends... SM Megamall Food Court is our place.

The Megastar was around during this time - attending the launching of some brand of cooking ware.










It is still the "mangoong" for him... and I have just recently discovered the NYFD french fries and dips...
... next time it will will be the garlic sauce or the pepperoni or...

On the MRT Platform at Buendia station; I thought it was Ayala station already - sowi, manong!

And this is us, while waiting for my most favorite mode of public transportation  - the train.


Fellowship training is about to finish; graduation day, December 15, is just around the corner -
I am thanking the Lord now for allowing me to live and experience Metro Manila; not aLone but with my husband.

At Mass. General, palliative care changes patients' lives - The Boston Globe

At Mass. General, palliative care changes patients' lives - The Boston Globe

ENCOUNTERING PALLIATIVE CARE: The Supportive Hospice and Palliative Medicine Fellowship Experience

                 On my third year of Family Medicine Residency training, I was given the option to undergo a 2-month rotation in the University of the Philippines-Philippine General Hospital (UP-PGH), Department of Family and Community Medicine (DFCM). The budget skimping, the Manila traffic, the dialect change and being alone (and getting lost) in a big city could not deter me; for I was bent on learning what I can from the country’s top university and training hospital.

                I had many learning points in the other sections of DFCM (Wellness, and Community Medicine) but I was most excited of the three-week Supportive Palliative and Hospice Care (SHPC) rotation.The “newness” of the subspecialty intrigued me. My understanding of it was so limited- taking care of the dying, home visits, doing something when many say there is nothing available. I wanted to find out if this is the type of medicine that could have been the best option for my Mom who had late-stage cervical cancer.

                And yes I did find out. If I had known it before, if somebody could have told us, Palliative Care would have made my Mom’s last days more comfortable and dignified.

As I was finishing my Residency training, I have come to realize that on many patient encounters - the long-staying Lola in Room 337, the mestizo Lolo, whose children are all living abroad and is being taken cared of by his longtime “yaya”, the mother of three adolescent children who has brain tumor, the repeated admissions of an elderly COPD patient, the dyspneic mother who had metastatic breast cancer to the lung, the advanced hepatic cancer middle-aged father with encephalopathy, the school-aged child with leukemia,the little babies in the nursery born of multiple congenital anomalies); Palliative Care would have made a big difference among these patients’ lives and in their families.

                I was therefore delighted that Silliman University Medical Center Foundation, Inc (SUMCFI) has given me the chance to undergo the one-year post-residency training in Supportive Hospice and Palliative Medicine at UP-PGH, the only fellowship training program for Palliative care in the country. In the absence of any other academic specialist programs in the country, it is the national academic center of the medical specialty field in the Philippines.

The SHPM Program

It was this year(2011), when the Section underwent a name modification to Supportive Hospice and Palliative Medicine (SHPM), as a specialty field and to make it more consistent with the international designation of the discipline. The term Supportive Hospice and Palliative Care (SHPC) could then be appropriately used to refer to the clinical practice. The goal is to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies, and is not limited to cancer cases, but all other serious illnesses.¹

The fellowship training involves weekly case management meetings and didactic sessions with service meetings for research and training. There is the prospect of interacting and teaching the rotating Family Medicine residents (1 month each for Junior and Senior Rotations) and fourth-year medical students (2 weeks) through the case and journal reports, and grand rounds. Weekly multi-disciplinary conferences are also being attended in cooperation with the other subspecialties such as medical oncology, surgery, radiation oncology, rehabilitation medicine, psychiatry, dietary and the social services.The clinical care includes the in-patient and out-patient care and consultation services and the community home and hospice care services.²

The total in-patient referrals in a month can reach to as much as 80-90 patients. However, this number is still below the estimated number of patients who need SHPC in the 1,500 bed UP-PGH, since the delivery of care is still hindered by limited awareness, resources and support. Approximately 80 outpatient clients are seen per month. The program holds out-patient clinics at the SHPM Center at the Outpatient Building. There is also an extension clinic at the Cancer Institute (CI) of UP-PGH to make care more accessible to patients with cancer, especially those being seen by other oncological services. There are approximately 40 patients, living within the 5-kilometer radius of PGH, who are enrolled in the Home Care program. The Community outreach services include service-oriented activities with nearby partners such as Madre de Amor in Laguna and Missionary Sisters of Charity in Tondo, Manila. 

Other Related Activities

Along with four other fellows (3 are graduates of the UP-PGH and 1 is from Ospital ng Maynila), we were able to participate in different activities and events in various capacities that help promote the different avenues of cancer awareness, bereavement care as an essential component of palliative care, international hospice week celebration, palliative care awareness and education.

Every third week of January, the National Cancer Consciousness Week is being celebrated. In UP-PGH, the celebration was spearheaded by the Cancer Institute and the different subspecialties. Activities included a parade in and around the hospital premises, an entertainment program, various symposia and a drawing contest for the pediatric cancer patients.

We became involved with the Philippine Cancer Society as volunteers through the encouragement of our consultant, Dr. Rachael Marie B. Rosario, who is the Executive Director.

Last July, a bereavement program was organized as an annual activity called “PAGGUNITA.” This is a necessary service for the families whose loved ones have died under the care of the SHPM. Psychosupportive care and counseling were provided especially for those identified with complicated bereavement. One of our consultants, Dr. Agnes Bausa-Claudio, is seen here sharing her personal experience. Part of the activity was an exercise on guided imagery.

The World Hospice and Palliative Care Week Celebration on October 4-7, 2011 was a big event. It was an event that showcased the importance of hospice and palliative care as a model for quality, expert and compassionate care for those with life-threatening and life-limiting illness like cancer, and end-stage heart or kidney disease. The activity was announced during the Flag Ceremony, continued with a parade inside the UP-PGH premisesand an entertainment followed. The culminating activity was the Hospice Summit wherein lectures were given on topics such as pain and other symptom control, care of the dying and care for those with cancer and non-cancer illnesses. The event was well attended by nurses, social workers, students and physicians from other specialties.

A pose with the PGH Director, Dr. Jose Gonzales and the Section Head, Dr. Manuel Medina, Jr, Dr. Rachael Marie B. Rosario, and Hospice Nurse Luningning Siarez.

Almost Done

                A year of SHPM fellowship training is about to end but it does not mean that I should relax. There is so much work to be done. My SHPM mentors have always reminded me that the practice of palliative and hospice care will not be easy; obstacles abound but the passion remains to strive for “improving the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.”³

The SHPM Fellows of 2011: (from right to left)

Jeromel Lapitan, M.D., Aliza Macaraya-Pangaibat, M.D., Djhoanna Aguirre-Pedro, M.D. Rowena Marie T. Samares, M.D., Barbara Amity Flores, M.D.

References:

1.       SHPM Service Document (SVC 04202011-1). SHPM Clinical Services: Guide and Summary of Operations (2011)

2.       SHPM Academic Document 122010-1

3.       Definition of Palliative care by the World Health Organization. http://www.who.int/cancer/palliative/definition/en/