Thursday, November 20, 2008

My Classroom's Online

In this Firefox tab is Multiply's blog interface, while in another tab is my classroom. There are around sixty of us taking a common subject - Introductory Economics (Econ 11) - the class being composed of a variety of individuals ranging from the fresh high school graduate, to a paramedic somewhere in Cebu City, to the IT Systems Administrator somewhere abroad. Our professor is literally chillin in the City of Pines that is Baguio.

On the showbiz and celebrity side, some of our schoolmates are actually kapamilyas (ABS-CBN Television Talents) or kapusos (GMA Talents). We were informed that Senator Loren Legarda is also part of the UPOU, taking a degree in Environmental Studies.

We are all part of the University of the Philippines Open University, or UPOU.

The UPOU has been called "Open" because the often-heard UP saying that "learning is not confined in the four walls of a classroom" is literally implemented in this Constituent University of UP. It is truly self-directed study, which is kept in check quality-wise by the structured system of UP. While we are almost 90% of the time not together in a classroom, we are still required to meet ijn online study sessions at least four times for the semester, and in learning centers near us for our proctored/supervised examinations.

I for my part am rather motivated in browsing through the written modules for Introductory Economics. The last time I was taught this subject was in High School, where we never went beyond the Supply and Demand curves in brief in our Social Science subject. My enrollment as a non-degree student seeking nothing more but credit units in Econ 11 is also in season, what with phrases like "Economic Slowdown" or "Upcoming Recession" making their way into our newspaper's front pages.

Of course I don't expect to start talking shop when it comes to the money market, among other things. All I'm doing is trying to gain a fundamental understanding of the world of Economics in all its complexity. :-)

Monday, November 17, 2008

Yuppie MD, with a Twist

Back in medical school, our teachers always told us to be the best possible doctors that we can be, and to aim to become a "five-star physician" in accord with the World Health Organization model of the same name. I'd like people to use that model to understand my present job, what I do for that job, and what I'm looking forward to in the long term.

The Classic Q&A

Case in point: during friendly conversation initiated between myself and someone I haven't met before, it is but natural for both of us to ask each other (or sometimes, volunteer) what we do for work. Mine is easy to relate to - or so I thought.

Upon mentioning that I am a doctor, the next question for me becomes either "What hospital do you work in?" or "What's your specialization - internal medicine, surgery?"

If I happen to be in a light social situation when asked that question, I would simply reply that I just graduated from medical school, and that I am aiming for a career in Internal Medicine, or even Family Medicine. That is my standard, run-of-the-mill reply, which saves time in small talk. I use it whenever my work circumstances do not really matter in my relationship with the person who asked. It may not be an accurate answer, but it is not a lie either - note that I simply said that I just graduated, and that I am aiming for a career in IM or FamMed.

However, if there is the luxury of time, and the person I'm talking to has a little background info on me (or is sincerely/necessarily interested in my occupation), then I answer with the full details: I work with the UP Econ - Health Policy Development Program, or HPDP, as a Health Policy Fellow.

I started work with the HPDP last Wednesday, November 12, and I'm fast beginning to like what I'm doing.

Am I still a Doctor?

After giving my HPDP answer, some would awkwardly ask if I still "heal" people/patients. My straightforward answer is Yes. Being a registered Physician at the Professional Regulations Commission (PRC), I am a holder of a Philippine Medical License, and that allows me to practice medicine - to see patients, to interview and examine them, to arrive at a diagnosis of their illness, and to prescribe/perform the appropriate treatment. In case the question of my medical practice still persists, I refer the inquisitor to my short stint as a Resident-on-Duty at the Ospital ng Muntinlupa, where I worked at the medical wards and at the Emergency Room.

There actually is what I'd like to refer to as the Doctor Stereotype. Because most of us are acquainted with the doctor being a 30ish to 40ish white-coated healthcare professional working in a clinic or hospital, it is easy for the general public to think of the doctor in terms only of a Clinician, or a physician that sees and treats individual patients. I'm also one of them clinicians, in the sense that I am capable of and legally licensed to practice General Medicine.

But I have decided that I can't limit myself to clinical practice. I'm not saying that clinical practice is just that - something that is limited. No, I have the deepest respect and highest regard for the expert clinicians - doctors who heal individual people. Their training is very technical and rigid, because they literally are entrusted with individual lives.

The Five-Star Model

The WHO Model of the Five-Star Physician envisions a physician to be 1) a clinician, 2) an educator, 3) a researcher, 4) a manager, and 5) a social mobilizer each at some point in his career, or perhaps be a combination of any of the five at the same time.

The doctor stereotype everyone knows is at least #1; if s/he belongs to a training hospital with a medical school, s/he can also be #2 and 3; if s/he is part of administration, s/he can also be #4. Sometimes when there's an advocacy, or in the case of the practitioners of Community Medicine, #5 comes into strong play.

Health Policy Fellow

HPDP Health Policy Fellows (HP Fellows) can either be medical doctors or not, but all the same they work under a United States Agency for International Aid (USAID)-funded project that helps the Philippines' Department of Health come up with health policies that seek to improve healthcare in the country, in general. Think of the HPDP as a "think tank". In my work as an HP Fellow, initially the educator, researcher, and social mobilizer roles come into play:

Educator, because when HP Fellows provide technical assistance to their assigned Department of Health (DOH) agencies, we make new concepts (or rediscovered ones) available for use. We give this knowledge to our agencies not as the classic classroom teacher, but all the same we still impart new concepts.

Researcher, because in the course of our work, we need to turn to scientific literature to have hard evidence as the basis for our policy recommendations.

Social Mobilizer, because our work results in policies that are bound to be used for programs and projects on a public health scale.

Multiple Levels of Care

To drive home the point, allow me to use the example of one of our HPDP Consultants - Mario M. Taguiwalo.

Let's say that an expectant mother dies of severe hemorrhage on the delivery table. Who's at fault? It's may not be just the Obstetrician who attended the delivery. The patient may have not availed of pre-natal check-ups, which makes the Primary Care delivery system also at some fault. And higher up, perhaps it's the lack of funding for the Primary Health system that's causing the inability to make pre-natal check-ups available. The bottomline is there are multiple levels of care in our health system.

In the clinical scenario above, I may not be the clinician (Obstetrician), but I'm part of a team who is analyzing the policy factors surrounding the scenario - the systems, so to speak. And in doing my work, I hope to contribute towards a future wherein the above mortality would be avoided, on a larger scale.

Monday, November 10, 2008

Is your Prescription (Rx) Computerized?

With the license to practice medicine comes the responsibility of communicating directions (medical orders) to the appropriate health professionals who participate in the care of a patient. These include but are not limited to other physicians, nurses, midwives, physical & occupational therapists, and pharmacists. In outpatient or office clinic practice, the pharmacist (or pharmacy assistant, as the case may be) is the one most communicated with by way of the Prescription Order.

While there is formal training in the subject Pharmacotherapeutics as to how one should write a Prescription, the actual practice of individual physicians do vary somewhat, depending on their clinical experiences while in training, and even in actual medical practice.

When it comes to patients, the Prescription does matter a lot - because it is tangible proof that the doctor cares for the patient, and wants something to be done regarding the illness. Which is why as early as clerkship (4th year Medicine Proper), I took to heart the tip of one of my residents in the Philippine General Hospital. She told me not to use medical shorthand (such as, "1 tab PO BID x 7d"), but to spell out my instructions in plain English (same instruction: "take one tablet by mouth two times a day, for seven days") or even in Filipino/Tagalog, on a patient-to-patient basis (translation: "uminom ng isang tableta dalawang beses sa isang araw, sa loob ng isang linggo").

Yes, some colleagues have lightly joked that I'm being too obsessive-compulsive in writing my Prescription instructions in Filipino. But I'm not changing the way I do it - I find that patients comply more when they understand.

Lately I've taken on a relatively new trend - issuing computerized/typewritten Prescriptions. I first saw such Prescriptions last May 2006 when I rotated at a Family Practice Clinic in Houston, Texas. Little did I realize that locally, they were also already doing it - at least in the bigger medical centers/hospitals. Now that I am licensed to write my own Prescriptions, I decided to give it a try.

A little academia: in the book Goodman & Gilman's The Pharmacological Basis of Therapeutics (Hardman and Limbird, Eds., 2001), there is an entire Appendix dedicated to the "Principles of Prescription Order Writing and Patient Compliance". In it, authors Edwards and Roden stated the obvious: "The clear communication of a prescription order to other members of the healthcare team and to the patient is a vital step in drug therapy."

Regarding typing Prescriptions, the same authors wrote: "All prescriptions should be written in ink or typed ... as erasures on a prescription easily can lead to dispensing errors or diversion of controlled substances" (emphasis supplied).

I set out to write this blog post because earlier today, a patient of mine approached me for a prescription of Phenobarbital, an anti-epileptic drug. In summary, she needed a new Prescription for her previous one was already completely dispensed (Phenobarbital being a controlled substance, the local pharmacy is strict on counting the amount dispensed). After her consultation with me, I decided to give her a computerized Prescription for her medication.

A few minutes later, I received a phone call from the local pharmacy, verifying if I indeed wrote the Prescription. I appreciate the fact that they do conduct such verification, for the drug in question is a controlled substance. However, what perplexed me was when the pharmacist/pharmacy assistant mentioned that his basis for verification was not the drug per se, but the fact that the Prescription was computerized.

As I earlier pointed out, the textbooks are quite clear that Prescriptions should either be written in ink, or typed. Is a computerized Prescription not better than a handwritten one in terms of medical errors avoided, and eye strain? My handwriting is the classic so-called "doctor's handwriting" - not so clear. Again it was nice of them to call, but I think pharmacists/pharmacy assistants should be oriented that so long as a computerized/typewritten Prescription bears the handwritten signature of the physician, it should be accepted.