No Smoking

Here in California, there is a bill pending in the state legislature that would empower a landlord to prohibit smoking within the rental premises. Over the last 20 years, cigarette smoking has dropped drastically in the US due to higher taxes that make the product more expensive, more inconvenience as it is banned in restaurants, government offices, public transportation, zero advertising on television plus a barrage of warnings that detail the many evils the habit brings.

In the Philippines, there are four million Filipino youths who smoke fully one fifth of the total youth population. This is because many provincial governments rely on tobacco revenue for their continued existence and US producers aggressively court this giant market with free samples and clever gimmicks while making sure, of course that the traditional politicians look the other way with generous contributions.

From my perspective as a physician, there can be no filthier habit than smoking. Lung cancer, obstructive lung disease, coronary artery disease, osteoporosis, respiratory infections, oropharyngeal cancers are all directly related to smoking. While there are many who smoke in order to avail of the anorexiant properties of nicotine especially during these days of ridiculously high food prices and there quite a few who smoke to ward away the multitudes of hemorrhagic-fever-bearing mosquitoes, the adverse effects overwhelmingly negate whatever salutary benefits that smoking brings.

Let us follow California. Let us respect those who choose to smoke but let us make them bear the costs that their polluting habit brings. Raise taxes, prohibit smoking in most public venues and ban advertising. We need to plant rice, not tobacco.

Road Trip

Perhaps the longest period of time I was unable to post an update. Before we decided to complete the road trip across America that we began with a trip from Brooklyn to San Antonio, TX in 1991, I decided to back-up my files and photos. Found out my DVD drive was out of order so I called Dell and they sent me a replacement part in 48 hours. After the drive was reinstalled, I realized that all my files were wiped out! Whenever I would get internet access in Texas, New Mexico, Arizona and California, I would contact Dell but all efforts have so far proven futile. Talk about a disaster.

We’ve been on the road though. Spent one night in Flagstaff, AZ which became our staging area for our Grand Canyon expedition. I had been warned about the canyon before and I agree that it is the most impressive natural site in the United States. I don’t know of anything grander and henceforth, I will reserve the use of the adjective only to describe the canyon, it is that grand.

Spent 2 days in San Diego, attending a Filipino unity event and a Gawad Kalinga builders summit. With all the problems in the Philippines, GK remains one of the few sustainable private projects that deserves our complete commitment and support. There was GK supporter Kuh Ledesma and to prevent any conflict with the other Diva, I had my photo taken with her.

Visited classmates from Medical School who tried practicing in the Philippines before making the tough but practical decision to relocate in the US.

Gas prices rose 50 cents in a week and even food has become significantly more expensive. In Los Angeles and Orange County, home prices saw a 21.7% drop in the first quarter (Las Vegas registered a 25.9% fall). If it’s getting bad here, how much worse will it be in the Philippines? We buy oil the same way everybody buys it, at $128 a barrel. Already, the peso has fallen to 43.92 to a dollar, it was PhP40 to a dollar 2 months ago, and looking at what’s going on, the Filipinos are being distracted by a corporate power struggle over the power company, American Idol, speculation regarding the elections in 2010 while rampant smuggling and corruption and generalized low productivity prevail.

It was also with sadness that I learned about the death of longtime labor leader Crispin Beltran who must have had a CVA while repairing his leaky roof and fell on his head. And one bishop even instructed his priests not to conduct Catholic services for a man, however imperfect who spent his life for others. Sure makes your sorrow deeper.

These are not precisely hopeful times.

Blog Rounds: The Doctor's Family

The Doctor’s Family is the topic for the week. This from the host:

Some guide questions as follows. Remember, you are not limited to the guide questions. These are just questions for you to ponder on. But I’m sure you have your own creative way of expressing your thoughts!

What was your family’s role in your decision to become a doctor? Did they encourage you? Did they discourage you?

Was there a doctor in your family that influenced you to take the same path?

How did your family show their support during the time that you are still pursuing your training? Did that support continue after the training and when you started your practice (knowing how little a starting doctor earns)?

For those who have shifted gears and turned to another profession, how large was the family’s influence on that decision?

If you are single, do you think that this is because of your pursuing medical studies and training?
If you are married, at what age did you get married? Did you marry a fellow doctor? Or somebody in another profession? At what stage of medicine — in school, clerkship/internship, residency/fellowship or when you were already practicing? Did medicine enhance or hinder your relationship with your spouse and children?

What family decisions have been altered because of your obligations to Medicine?

What career decisions have been altered because of your family’s needs?

What is your current priority?

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All my close friends know that the very first time I saw this classmate in Medical School who would turn out to become my best friend and wife, I went to her and told her that I was going to marry her someday. I don’t want anyone to think that I was some kind of Lothario, we went out a total of three times that first year of school. Lunch at the now defunct Cosa Nostra, supper with a group of friends before the Christmas break and one real date before we adjourned for the summer.

It was always clear to both of us that we needed to focus on our studies if we wanted a ticket to the real learning ahead. We never bothered to apply to any of the local residencies because we wanted to begin living on our own resources as soon as we could. We knew we could never be truly autonomous in the Philippines and fortunately, we matched to the same hospital in Brooklyn, NY. As soon as we had an employment contract, we got married. 18 years ago, May 26.

Many say, training in the Philippine General Hospital is toxic, with all the poverty and disease and frustration in treating patients amid rudimentary facilities. Kings County Hospital in Brooklyn was the second largest county hospital in the US with a 90% AIDS rate in the medical wards in 1990. My wife and I look back often and remember that we were very happy during all this training. All those years were very happy ones.

We decided to stay on in a sparsely populated town in the Oklahoma panhandle because we felt it was the best place to raise our children. Safe and quiet, where most everyone knows you. Our daughters would be out there playing until 9 in the evening.

It was difficult bringing our kids back to the congestion, heat, violence, corruption and mosquitoes but we felt a more important lesson was to be learned. We saw older, successful physicians and it no longer became sufficient to raise Harvard graduates, live in a gated community nestled in an exclusive golf enclave, own a Bugatti.

Family teaches you what matters. The brevity of our lives makes it vital that we begin as soon as we can to find meaning through serving the never-ending line of people in dire need.

Blog Rounds: Mentor / Tormentor

“There were teachers, and there were mentors. We all knew there was a difference. Whether it was your basic medical science lab professor or it was the department chairman, we had our favorites.

On the other hand, there were those who loved to torture us. Why do they create greater impact? Deeper wounds, maybe? Or do they really?

The theme is your favorite mentor and/or tormentor during medical school and training. They may be the same person, or not. You may have several favorites. Most importantly, share your experiences with these people, and the reason why they have created an impact on you as a doctor and as a person.”

One person stands out for me. See, medical school and residency hardly even count. Much like practice and play before the real business of treating patients, committing mistakes, breaking the news of an unexpected death of a close friend and patient to a distraught family who will never understand, getting slapped with lawsuits, having to be available every hour of the day, every day of the week and spending many sleepless nights wondering if any patients will show the following morning to pay for the nurse, the receptionist, the rent, the utilities, the insurance premiums, the medical supplies, the equipment lease.

There is no practice involved in private medical practice. It is a painstaking process that requires total commitment and focus. Required anatomic equipment include nerves of steel and a cast-iron stomach. Rewards may be great but certainly no country for the faint of heart.

I was a newly-minted gastroenterologist who had to work in a medically underserved area in the Oklahoma panhandle, population of 10,000. He was a blue eyed surgeon who spoke impeccable Spanish because his father was from Puerto Rico. Even if his expertise was in laparoscopic procedures, he saw them all and did them all. He delivered babies, took care of neonates, set fractures, removed cerumen and excised ingrown toenails, circumcised, took x rays, met patients with migraine headaches at the clinic at midnight and gave them shots of nubain and promethazine. His patients loved him.

He owned two planes, one of which, the Cheyenne picked me up in Dallas for that fateful interview. His well appointed home was perched atop a cliff, his wife was strongly protective, ever-resentful of the little amount of time her husband had for his family on account of his vigorous work ethic.

He had a way with patients, he made them feel as if he spent an inordinate time with each of them even if he would get to see close to a hundred patients in a day. Naturally, others got envious. He was accused of being too aggressive, performing unnecessary procedures and downright unethical behavior. Even then, working closely with him, I found all those charges baseless. I tried hard to get him back to the local hospital where he had been barred from practicing. I drew the ire of many of the old white guard here especially since I was a young, foreign upstart but it did not matter. Here was an injustice that needed to be corrected.

After close to 10 years, he was able to perform an operation at the Guymon hospital. The clinic was doing very well, I was working seven days a week and would never complain if there was an endoscopy that needed to be done in the evenings because my salary was based upon my productivity. I don’t remember taking a day off in 2 years.

We found a discrepancy in how the collections were being tallied. The irony is, I never really got to talk to him because he became strangely defensive and hired lawyers to placate me. One of them became the head of FEMA and the other lawyer came from the firm of the Attorney General of the State of Oklahoma.

I was eventually sued for libel for a million dollars and I had to counter-sue and he ended up being ordered by the court to pay me a large amount of money, not a single cent I would get to see because he filed for bankruptcy and he left town.

Talk about pure torment--but to this day, I am grateful to him. He showed me the ingredients of a successful medical practice: availability, compassion and competent medical care.

I continue to hope that I can one day coax him out of his self-imposed exile and return to the tiny town in the panhandle where your best dreams come true.

Tita Inday

My Tita Inday died today. A wonderful person who graced our lives when we lived in Brooklyn. I would pick her up in Astoria in Queens at 5 in the morning on Mondays and make our way through the Brooklyn-Queens Expressway and drive her back on Friday evening. Throughout those exceedingly busy work weeks, she stayed with us and cooked unforgettably delicious meals and took excellent care of our first child.

Long before her cancer and her dying made it easy for us to gloss over her failings, I would tell my relatives that the Tita Inday I knew never uttered an unkind nor an uncharitable comment against anyone despite having endured her own share of unfaithfulness, disloyalty, ingratitude. I am grateful I had the chance to tell her last Christmas that I did not have a single unhappy memory of our time together in New York.

We would make our way to northeast Philadelphia on weekends every chance we got to scour the magnificent clearance racks in what was then the largest outlet mall in the US. Most, if not all of her salary went towards thoughtfully made purchases for her family. It made me and my wife very happy to know that she was happy to be with us. We would have been privileged to have let her continue to stay with us but taking care of her own grandson naturally took precedence. Tita Inday had a clear understanding of what duty was all about.

When she was diagnosed with colon cancer, I could not help speculate how easy it would have been for me to screen her in my clinic and how much my other children would have learned from her kindness and how obese my wife and I would have become if only she remained with us but that is the way life is. You make your choices and for the good ones among us, you live your life for others.

Tita Inday was an Assumptionista. Her father was a talented golfer from Bacolod who helped establish one of the first law schools in the Philippines and who was also a successful publisher. Her mother was a prominent leader of the Catholic Womens League in its formidable days. At her wedding, Judy Araneta and Precy Lopez were part of the entourage. My Tita Inday may never have attained the early promise of her bright social stature but at the end of our lives, who really cares?

She was gentle, she was kind, she was generous and she kept her Faith. Rest now, Tita Inday. May we meet again.

Practicing What We Preach

Do we physicians practice what we preach? Do we eat little saturated fats, exercise regularly, stay away from nicotine? The average life expectancy in the US is 78 years. It is 70.5 in the Philippines. The difference is mostly due to the scandalously high infant and maternal rates prevailing in our country. In other words, a Filipino physician in his or her 40’s has roughly the same chances of living up to 80 as anyone living in the US. If we could only provide more potable water, vaccinations, inexpensive antibiotics, anti-tuberculosis medications, prenatal care, obstetric support we would be able to live as long as those who reside in Andorra.

What is my point: anyone reading this entry is statistically set to live beyond the age of 75. Of course it would help to lose a little weight, keep an eye out on our lipid profiles, glucose and PSA levels, submit to Pap smears, mammograms and colonoscopies but the important consideration remains that we live lives that are fulfilling and meaningful. How often have we seen nursing home residents with advanced dementia, abandoned by their relatives and totally oblivious to what is going on around them?

It is not simply a matter of living long. What is more important is living well and being able to share our blessings with others. Much like passing the baton in a relay, we must strive to lengthen the lead we bequeath to those who follow us.

If we should preach any particular message, it is that we neither live nor die for ourselves alone.