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We knew these long term symptomatic relief (quality of life) offered by total joints surgery for quite sometime already. But why isn’t it given as an option to osteoarthritic patients 65 years old and above is not clear either.

This study (” Joint Replacement Surgery in Elderly Patients With Severe Osteoarthritis of the Hip or Knee“) by doctors at Beth Israel Deaconess Medical Center in Boston, Massachusetts and published in the Archives of Internal Medicine (Vol. 168 No. 13, July 14, 2008) said so in their conclusion.

Conclusions: Elderly patients who had hip or knee replacements for severe OA took several weeks to recover but experienced excellent long-term outcomes. Physicians often do not discuss joint replacement surgery with elderly patients who might benefit.

So how many physicians actually give the option of Hip or Knee Surgery to patients with severe osteoarthritis?Or even discuss the option to their patients? Is it the cost?The knowledge about the surgery?Outcomes?

If ever you need information on this, the author will freely discuss this options with you, their physicians.

Filed under: Opportunities for physicians in practice, Perspectives in orthopedic training | Comments Off

Although rare, wrong site surgery happens even to the most able and busy OR team such as in this hospital. Imagine the horror of both the OR team and the patient discovering the closure stitches in the normal side after the procedure. But thats another story.

What I’m a bit surprised is how the hospital administration managed to “rectify” the error and came out with better policies to prevent future incidents like this to happen. Their CEO even blogged about it, so the whole community would know about the lapses, the steps taken to correct it, and prevent further “errors” to happen in the same way.

I can help but wonder if most of our health institutions here in our country have the same attitude towards wrong site surgery and medical errors. A universal protocol for wrong site surgery has been existing and updated regularly for quite sometime already. The American Academy of Orthopedic Surgeons (AAOS) also had its recommendations to reduce surgical sites error in orthopedics. Most of the stories I hear in our country from the gossip tree end up in long, expensive court duels. And even with the pay off, none of the parties learned anything (but money and pride) from the mistakes which should have been preventable in the first place!

Not to be over simplistic about this but parallelisms can be drawn between mistakes like this one and that of mistakes done on people you care of. Admission is a braved act. Facing the consequences is an even braver act. But taking actions to prevent such errors from happening is a mark of a true caring physician. That is how we deal with people we care. To us physicians, that would be our patients.

Filed under: Deeper look at the orthopedic practice, Personal insights into the practice of medicine, Perspectives in orthopedic training | Comments Off

1. Start young, start at home. How young? Nobody knows. But ss soon as the kid discover that phenotypic sex have different biological needs, parents can introduce gender friendly concepts. Remember that most gender biases apparent in the adult life can be traced to the person’s childhood.Most of them proved to be very difficult to change.The formative years has the greatest “stick on” knowledge than any of the stages in a child’s life. It is important that the child understand the difference between sexes and gender and how one is related or how to be “sensitive” about it.
2. Start in school. Education perhaps has the single most effective way of combating future threats of gender issues aside from the family.This is more important to a child person who’ s family dysfunctional . This is probably the best area to introduce gender awareness concepts. Sex segregation in this stage is often a result of a misguided awareness by some educators themselves. This is passed on to their students. Parental reinforcement then becomes an essential tool.
3. Quality and productivity driven medical school and specialty programs. This is a very controversial issue and often the most debated upon. Thee issue is not about depending one’s gender from another, or gaining points for that matter. Qualifications and productive outputs measures who is best suited for a job description. No giving in or pluses to the gender. If the program do cultivate a culture of “gender insensitive workforce”, it is the taint of the program and not the trainees themselves. If the training gets more sex a than b, the only reason verifiable is because their evaluation and qualification process allows (or disallows) them to and thus cultivate such culture. Change the policies to implement more gender sensitive workplace. No excuses.
4. More role models. Perhaps one of the more effective “enticing methods” by the few who braved to the opposite sex dominated specialties. Most of the applicants interviewed for a particular gender dominated job alludes there persistence to role models entrenched in the workplace itself. The domino effect of such roles models often determines the number of gender wanting to gain access to that workplace.
5. Educate the patients lounge. If you can’t do it for yourself, get someone else more comfortable to do it for you. We get patients we deserve, in one way or another. The quality physicians do not stop at treating their patients only. They educate too. As a physician, we are in a powerful position to create an impact, just like we do when we harbor negative issues on it!
6. The last but the most important of course, is to educate ourselves. You can never teach someone else gender awareness without you being “aware” of it in the first place. We all knew what is gender sensitive and what is not. Sometimes we just do what is easy and our patients take cues on our actions. And there’s no denying actions speak louder than words!

Filed under: Personal insights into the practice of medicine, Perspectives in orthopedic training, The Blog Rounds | Comments Off

I love the outdoors ever since I was a kid. In fact, I spent most of my childhood summers in the highlands driving water buffaloes and riding horses uphill with my cousins! So when a friend invited me to climb Mt. Apo one day, I answered with a resounding “Yes!”. Never mind that it was 20 years since I last set foot on a dirt path. Forget it that I’m terribly out of shape for the summer’s race-to-peak craze. The temptation to beat the trekking odds is there. And the chance to be on top, no matter how amateurish and hard it will be, is downright exciting. I’m not the kind of guy who shun opportunities. “Count me in! When are we climbing?“

It was visibly elated to know that despite the hundreds of others worthy of such “luck” I have been accepted to a residency program of my choice. Knowing you’re not “brainy and in shape”than most of the applicants, you’d jump at the slightest hint of acceptance. Coming from a well respected center, this is not the type of opportunity you think about twice. Indeed I jumped at the opportunity, not knowing where to put my ass around so many icons and pillars in the world of orthopedics. I am putting forth my best show- “to belong”. I immersed myself in the “cloak of invincibility” and forgot what’s coming…

“Mind over matter” is no gainer.
I have to prepare for the climb of course, even if I got so little time to do so. The stubborn and stupid in me believed I can shape up for this climb in two weeks. “Two weeks is better than no preparation at all” I said. I have climbed hills in the past, but not mountains. “I guess thats enough?!”.

I tried to amass orthopedic tidbits so that in endorsements I can answer and in pre-ops, I have something to blurt out to show everyone I know something. This “critical mass” is all, but voluminous widget- a disorganized heap of ideas that I rarely knew worked in reality or in patients. Often, I never understood the wisdom and experience of my more senior residents and consultants no matter how much I read. Some of these “experiences” I think, were never even supported by an RCT! So the egoistic me thought I’m ready to wield a scalpel just because I’ve read Netter two days ago.

“I know Kung Fu!”- Neo, The Matrix
In a short time, I read so many things about trekking and mountaineering, more than improving my fitness and stamina. “I knew mountaineering!” The brain can accommodate such information explosion , but not our body-physical fitness and stamina especially. Physical fitness and stamina can only be achieved through disciplined training. Two weeks of training (as I learned later), didn’t even raise my heart beat. In this kind of treks, if you don’t have discipline, no time is ever enough preparing.

Bingo! I started cutting skins and pounding bones, to my salivating happiness. At long last, my dream of healing people while cutting them, became a reality. Ironic as it is, but thats the way I think the art and science of orthopedics is learned. I am a surgeon now-or at least thats what I’d like myself to believe. “I cut, ergo I heal”

“Come on! Stop trying to hit me and hit me”- Morpheus, The Matrix
So the apprentice in me, eager to prove he can conquer a peak despite the obvious half hearted preparation, went on with the the climb. Barely a hundred meters from the jump off site, we went into every sort of obstacles. I was carrying a back pack heavier than what my body can endure. I packed in so many useless stuff without really asking the more experienced climbers. It is such an agony to hike with a heavy pack full of useless gadgets and clothes. I was darn too tired dragging my ass through the trails and obstacles. Which made me drink my water supply fast and inched in thirst before the next water refilling stop. Obviously, my fitness and conditioning was well below minimal for this trek. It was a cycle of recurring mistakes and lessons after all. Even if I read all about it and I knew it even, theres no substitute for experience in the wilds. And the worlds of the older and more experienced climbers rang with so much wisdom.Looking back, I left it to luck for us to survive.

Then the morbid realization came after I encountered my first ever mortality.Fifty six year old female, with perfectly controlled DM, a cardio clearance, post hip replacement, found dead in her ward bed, from a silent MI, the night before the patient is to be discharged. The patient gave me a token gift- a handsome polo and a tie the day before and a tight, cheerful hug. “Salamat doktor sa pagopera mo sa akin!“What went wrong? What the heck did I miss? I read and studied books and journals for this case! And this was not even an eventful procedure! At two AM, I was devastated mulling over the reasons for such unexpected demise. Then a consultant told me, he had a similar case before and he noticed that such age group is prone to “silent’ death post op. I gnash in agony.

“Don’t think you are…Know you are!”
After luckily surviving the inordinate trek and making it to the top of the Philippine’s highest peak, it is then that I realized how lucky I am to survive a journey with all my ego and stupidity at the forefront rather than wits and fitness. There is more to lessons learned on your way up, than the vast emptiness of the so called “peak”. So what now? Here I am standing on the tallest place in my land. I could barely see a thing because of the fog. There’s not much place to go around the peak. It will be crowded soon because all other climber will have to stand on this peak too. And this peak would just be another jump of point to some other peaks. There so many other peaks to conquer, treks to make and obstacles to hurdle. “I’m afraid of heights”. This sudden realization, of the fear being alone in the heights rather than falling itself, sent a chilling message to my heart. I have to go down.

Surviving residency is not just”luck” for residents. It is a given. The moment you entered the training halls of “cutting and pounding”, you have to “learn the craft” and make it to the top- which is your practice. Surviving the training is one thing, learning from mistakes during this training, is another. It is such a folly to dream of “the peak” without having to take a hard look at where you’ve been, and on whose shoulder your standing. The vast empty place you call “top” is nothing without “the craft” learned on your way up. It is here where you realize so many stupid things you did on your way up. You see butt holes in your ego, anecdotes in your reasons and immaturity at best, to your personality. More importantly, it is here at top, that you realize wisdom of “bone cutters from ages” who told you something about it, but did not so learned in haze.

So I’m taking the “jump”!
My learning has just started. Somehow I felt, it was just a beginning of a climb, to another mountain perhaps. It will be a another long arduous journey. Surely I’d be more careful now, with the lesson learned and wisdom of I gained from ages. I will need this wisdom on my way down. And on my next climb, my journey here would be nothing if have not learned something…

Looking back, I am yet into another journey-my professional practice. The realization of the wisdom of my mentors before, stuck into the ages of my wits. I am also an educator right now. That though perhaps, like the resident in me before, its very hard to see the wisdom of experience from seniors and educators and then fit them into what I read , into what I do. Surely, the experience is there for some reason. And in our journey to better serve our patients and community,we’re only half prepared if we don’t learn from those mistakes.

Filed under: Ideas and concepts for physician education, Perspectives in orthopedic training | Comments Off

I would be a leap of faith just to believe I can be where I am today, but my family just made it all possible.

“Our family is everything to me. No matter how remote my actions and decision are before, today and in the future, you’ll find a “connection” between those actions and you, my family” -R.A., an excerpt from a letter to his mom and siblings, during the “hard times” of med school.

Third sibling in a family of four, the eldest of the boys, a father’s pet and the family’s nightmare, I am cut for an outrageous fate. Fate, it seems, is full of ironies.


The passing of a beloved father
My dad died when I was just eight years old and my family was plunged into an abyss of compounding problems fit for a telenovela.

And so goes the story of my re-education.

A cut for survival
It was surviving that was central to the family’s agenda. So, a “cut” is made in all the basic needs of the family- food, shelter, education, for us to survive.

It was education that was hardly hit, thanks to EDSA revolution back then. A sibling in college, another one entering college soon and a younger brother in elementary- all surviving and being supported by a single working mom. The loss of our dad has had the ripple effect in no time. But there were signs of disasters waiting to happen.

The grim reality
“You gotta have a scholarship in high school or you’ll not going to any school at all” this grim reality my mom told me with tears welling in her eyes. “We can’t afford to send you to school”. These words, sunk into the deepest recess of my brain and bled my heart to no end. It was a cut my mom made to ensure the survival of our family. And though, I sense the simmering helplessness and agony in her, she has shown a firm and decisive role to govern her family through the hard times.

“Why me? Was it because I was the third or was it because I was expendable to the family?” At a young age of 12, I knew a storm of hard ships is coming our way. But this was just the beginning. And I was one of the hardest hit.

One step at a time.
So, while gnawing in pain and agony for the luck I got, I took it on as a challenge. “I will loose nothing in this uphill battle. I have no way to go but up.”

My dad wanted a doctor in the family and this was his plan for our eldest sister early on. But he did not lived long enough to even see my sister step into college. The dire financial chaos my family is in only dampened the spirits of my sister to even enter premed. She went into accountancy instead.

Meanwhile, I was inching my way though high school scholarships. The initial taste of success emboldened me to “I want some more” type of aggressive academic greed. Daunting the challenges were at those times, I stood my ground and leaned on the “walls” of my family. If I was victorious , that is because I was so darn proud of my family. We were beginning to shatter all the gloomy expectations for our family

Undaunted and victorious over the challenges given to me in high school, I trained my gun next on college. Opportunity then knocked when UPCAT applications came into my mailbox. “A scholarship and a thick stomach is all I need” I jokingly told my mom and sisters. “You got to be nuts” said my sister. “Even if you get inside UP and get a scholarship, will you be able to survive on that alone, through college in a far away place? Away from us?” They’re afraid I’d land with the “great thud” when I hit the ground of failure.

“Give me just a year. If I fail, I’ll stop at my wishful thinking and go back here…” My family knew that with my initial success in high school, I am virtually unstoppable. So I got my way. Though afraid of what I might get into, they supported me all the way through, hugs and tears included. I am embarking on a path no one else in my family had gone into. So the benchmark is, unknown.

The Ebb and Flow Cycle
So that series of “one year” came and lead into another… and another. My family and especially my mom was an inspiration. She never spent a dime on my tuition fee, that is because I felt, she has had enough of her share of hardships. So I made it a point my mom would be proud of me, and she be proud of her self. That despite having to bring up all four ostensibly ambitious children, her hard work did pay off in thousand folds. So every year during my college, she has to travel from our place to my school, climb up the stage and receive an honor in recognition for growing up four fine and ambitious children, proud of their mom, proud of their family. It was a memento of her marvel for survivorship.

It was like these since then, the same story repeated through med school and even training. I, haughtily pursuing my medical career and my family giving the turbo charged after burners in times of chaos. I was busy carving a path for my career, and my family asphalted it for me.

Whether my decisions would run for and contrary to their wisdom, they embrace me and hug me though my journey. How I became a doctor despite all of these, is another story to tell. But my family is pivotal to all the decisions I made in the past.

I stood my ground through years. But I have shoulders to stand on- my family.

Filed under: Ideas and experiences as a tool for medical students, Personal insights into the practice of medicine, Perspectives in orthopedic training, The Blog Rounds | Comments Off

For most of us, the mentor-stimulus for learning is a unique experience. Our “receptors” for learning may accept signals from nice, approachable and likable professors. The feel-good- mentor attitude is irresistible.

But I learned most from the hard hitting, no holds barred tor-mentors. Not that I liked getting hurt or being hit upon for me to learn. But squeezing something positive from such “despicable challenges” always give me the “high”. Even if it was just for survival.

That’s what I think happened in these snippets of paradigms shifts during my college days.

“You got a 0.5 grade for your term paper?!” Grinning, my friend Joselito added “that’s higher than 1.0! You’re amazing!” and then he burst out in laughter. Already red in shame, I grabbed my paper Joselito was waving in air inside our classroom. I went into cold sweats and then froze humbled on my chair. “A 0.5? How the earth can that be?“

“That was for you’re ink Mr. Tito! To give credence to your ink! You wrote a reaction paper instead of a concept paper, you *@#$!” This scumbag professor just didn’t remembered my name right. He also insulted me in front of our class. Judging from his snicker, he was visibly satisfied with my agony. I grimaced in anger while wishing the earth will crumble and I can smash the face of this fag.

“How many times do I have to remind your weightless nut brain? You wrote a concept paper while I was asking for a reaction paper!“ So you get another 0.5 for your ink! Thats a 1.0 on a scale of 40 points!

Getting a 0.5 on two term papers and zero on the other two are not just pranks and whimpers. It is sabotage! For that I hated English and Communication as GE courses in Pre Med.

And then wished my bike would run over that darn professor.

That wish never came. I never had the chance to smash the face of that prof, nor I was able to wreck his neck. For some miraculous reasons, I did finish the course without having to take removals. On the last day of our our class (which was also a mini speech competition with chocolates and free cinema tickets as prizes), he walk straight to me and told me

“You were one of my most improved students. I never thought I could turn such charcoals into diamond snippets that you are right now, speech wise. You owe yourself some chocolates and a movie! Thank that 0.5 you nut brain!“

Just like that…

But I have this copycat habit of emulating some mentors in an attempt to incorporate their traits while forming my true self. Let’s face it, we take the values and personality we like and junk the others we deemed “crazy”. And mentors, are icons whether we like it or not.

“Is that him? He looks like a bodybuilder to me than a professor.” I whispered to my seat mate. “Good morning!” came the booming voice over the classroom speakers. “I am Dr… and you are entering blah blah” The tall, muscled guy sounded like he’s going to mince us one by one. “…nobody said med school is easy. And being in the premier state university, you are expected to excel. So study harder…” The cool, smooth voice of this professor is surprisingly boring and frank. He means business and he is a no fun fare teacher. “He’s definitely making sure I’m par the slot I got in this premier medical school, or he’ll kick me out!”

“Hell no! I wouldn’t want him to do that! Not ever!“

“I want to be like this professor.” No, not his macho image nor his stern look. His frankness and no holds barred attitude is worth emulating. I thought he was a surgeon. But he is not. He devoted his time after med school to learn how to make medical students learn. On a very young age, he’s quite making an impression. “You flunk any of the exams. You better study harder.” So coming in to his office means you’re in trouble. At least for the time being.

For one whole semester of listening to his human anatomy and dissecting cadavers to no end, I am both scared and emulative of this professor. His brutal frankness scare the wits out of my brains. On the other hand, I liked his habit of telling the truth first and only. No dicing. When he talks, I make sure all my ears, including my brain, is listening. Even if I can only absorb a handful of medical information.

But his frankness is coupled with fairness. “I only record and calculate what scores you give me. You do the studying I do the grade calculations. Plain and simple.”Making sure you reflect the “results” you store in, is his concern. “You are actually grading yourself”. He told us in one didactics.

For the next 5 years I marked my medical school days with attitudes I first stumbled with this professor. Frank, cool and fairness. “Keep your medical life simple. Study hard and you will get what you deserve.

Though medical life is never simple as I’ve learned later, the attempt to simplify it was a fulfilling exercise nonetheless. I had paradigm shifts.

These mentors were part of my paradigm shifts- changes in perspectives that saw the positive in every opportunity that knock in, scary and the not so scary. They were my windows to the new world.

Mentors or tormentors?

Filed under: Ideas and experiences as a tool for medical students, Perspectives in orthopedic training, The Blog Rounds | Comments Off