Looking for an inspiration to lose weight. Here’s something I found in one of textbooks.

Risk of certain cancers appears to increase modestly (relative risks generally in the 1.0–2.0 range) as body mass index (BMI) increases beyond 25 kg/m2. A cohort study of >5 million adults included in the U.K. Clinical Practice Research Datalink (a primary care database) found that each 5 kg/m2 increase in BMI was linearly associated with cancers of the uterus, gallbladder, kidney, cervix, thyroid, and leukemia.*

Made me want to exercise and eat less for a moment.

* Pg. 444, 20th Harrison’s Principles of Internal Medicine.

Day 31 of #100DaysToOffload. Find out more about it here.

The point of having an external rotation is to be like a sponge and absorb as much scientific knowledge and appreciation as much as you can. However, in those surreal moments, my interactions with fellow, I have also picked up a thing or two about life as a fellow and in general.

• When asked about what fellowship would you like to pursue, I still find it difficult to answer.

• Get into a government hospital and enter as a lateral entry for fellowship.

• The oldest that went into fellowship in PHC is 39 years old. This was comforting.

I was thinking that age was factor in the training. Likely to be a great factor, but determination and commitment is also key.

• Take the days, one day at at time while in fellowship. When you enter a fellowship training, you are undergoing a system of training. It is you who will adjust to the training and not the other way around.

Fellowship training is grueling. To survive, take it one day at a time.

• Do not forget to treat patients and charge appropriately. If they don’t have money, treat them anyway. Money will just be a blessing many folds over.

It is refreshing to here this even in higher institutions.

• I’ve rarely received “thank yous” or even praises on good performance while on residency training. While in the short stint I have here in PHC, I received some good comments. And it builds me up be better.

While certainly, I overhear negative comments or exortations from seniors to their juniors, it is always meant to build up “character”.

Thank you Lord for all of the interactions.

Day 30 of #100DaysToOffload. Find out more about it here.

The Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock (CULPRIT-SHOCK) trial was designed to test the hypothesis that PCI of the culprit lesion only, with the option of staged revascularization of nonculprit lesions, would result in better clinical outcomes than immediate multivessel PCI among patients who have multivessel coronary artery disease and acute myocardial infarction with cardiogenic shock.

Clinical Question: Among patients who had multivessel coronary artery disease and acute myocardial infarction with cardiogenic shock would PCI of the culprit lesion only than among those who underwent immediate multivessel PCI result to better outcomes?

P: Patients were eligible for the trial if they had acute myocardial infarction with cardiogenic shock. Additional eligibility criteria were planned early revascularization by means of PCI, multivessel coronary artery disease (defined as at least two major vessels [≥2 mm in diameter] with >70% stenosis of the diameter), and an identifiable culprit lesion.

Criteria for cardiogenic shock included a systolic blood pressure of less than 90 mm Hg for longer than 30 minutes or the use of catecholamine therapy to maintain a systolic pressure of at least 90 mm Hg, clinical signs of pulmonary congestion, and signs of impaired organ perfusion with at least one of the following manifestations: altered mental status, cold and clammy skin and limbs, oliguria with a urine output of less than 30 ml per hour, or an arterial lactate level of more than 2.0 mmol per liter.

Exclusion criteria were resuscitation for longer than 30 minutes, no intrinsic heart action, an assumed severe deficit in cerebral function with fixed dilated pupils, an indication for primary urgent coronary-artery bypass grafting, single-vessel coronary artery disease, a mechanical cause of cardiogenic shock, the onset of shock more than 12 hours before randomization, an age of more than 90 years, shock with a noncardiogenic cause, massive pulmonary embolism, known severe renal insufficiency (creatinine clearance, <30 ml per minute), and other severe concomitant disease associated with a life expectancy of less than 6 months.

I: Either PCI of the culprit lesion only, with the option of staged revascularization of nonculprit lesions, or immediate multivessel PCI. In all the patients, PCI of the culprit lesion was performed first, with the use of standard interventional techniques. In patients in the culprit-lesion-only PCI group, all other lesions were to be left untreated at the time of the initial procedure. In patients in the multivessel PCI group, PCI of all major coronary arteries with more than 70% stenosis of the diameter was to be performed. This included efforts to recanalize chronic total occlusions during the acute phase; the recommended maximum dose of contrast material was 300 ml.

O: PCI of the culprit lesion only (with the option of staged revascularization of nonculprit lesions) was superior to immediate multivessel PCI with respect to a composite end point of death or renal-replacement therapy at 30 days. The difference was driven mainly by significantly lower mortality in the culprit-lesion-only PCI group

Day 29 of #100DaysToOffload. Find out more about it here.

Today is the day of accreditation for the Internal Medicine department. Sending out good vibes to my fellow residents and consultants.

What I see in workspace right now.

Day 28 of #100DaysToOffload. Find out more about it here.

Imagine a sick doctor. Imagine her coughing. Imagine her having a runny nose. Imagine her having febrile episodes. Imagine her down with her illness.

Now, imagine her in front of you, working with you, communicating with you.

And you, you just had to ask yourself, “What the fuck is she doing here anyway?”. Rage, rage, rage against the dying of common sense.

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55-word short story #3 #55wordshortstory

Day 27 of #100DaysToOffload. Find out more about it here.

Today, marks the third time that I’m on solo duty.

Wunderbar!

I will survive.

Day 26 of #100DaysToOffload. Find out more about it here.

Whether you believe in God or not, some simple truths are hard to come by.

The person who is trustworthy in very small matters is also trustworthy in great ones; and the person who is dishonest in very small matters is also dishonest in great ones.

• Luke 16:10 ( New American Bible)

Something I try to live by. And I believe this verse still holds true today.

Day 25 of #100DaysToOffload. Find out more about it here.

I was to receive a patient in that particular room. This was the room when I last saw you breathing, crying, gasping...

When I saw chart number of the room, every vivid memory came flashing back, flickering a memory of you. I just couldn’t enter. I’m probably not ready yet to enter that room.

I’ll visit you sometime. I promise.

Day 24 of #100DaysToOffload. Find out more about it here.

The advantage of being a graduate of the community engaged medical education allows me too appreciate that health is a by-product of its determinants. We were exposed and immersed to the social and harrowing realities of health.

The World Health Organization defines Universal Health Coverage means that all people have access to the health services they need, when and where they need them, without financial hardship. It includes the full range of essential health services, from health promotion to prevention, treatment, rehabilitation, and palliative care.

The same is also related to the 3rd goal of the Sustainable Development Goals which is Good Health and Well-being.

Of course, these goals are lofty, ideal and needed. However, in a utopic world with an infinite or nearly infinite resources, the best healthcare delivery system without cost to its users would exist. I have my reservation on our provisions of the Universal Health Act in our country. I feel we are not ready. There is no clear roadmap or an attempt to disseminate information regarding it. What is made honestly clear is the money – the incremental increase of contributions for direct contributors of the Philhealth fund. Other than that, I know nothing more.

A review of RA 11223 otherwise known as the Universal Health Act revealed to me several things:

1. PhilHealth shall implement a comprehensive outpatient benefit, including outpatient drug benefit and emergency medical services in accordance with the recommendations of the Health Technology Assessment Council (HTAC) .

2. PhilHealth shall provide additional Program benefits for direct contributors.

The amount necessary to implement this Act shall be sourced from the following:

a. Total incremental sin tax collections;

b. Fifty percent (50%) of the National Government share from the income of the Philippine Amusement Gaming Corporation (PAGCOR);

c. Forty percent (40%) of the Charity Fund, net of Documentary Stamp Tax Payments, and mandatory contributions of the Philippine Charity Sweepstakes Office (PCSO);

d. Premium contributions of members;

e. Annual appropriations of the DOH included in the GAA

f. National Government subsidy to PhilHealth included in the GAA

1. Within ten (10) years from the effectivity of this Act, only those who have been certified by the DOH and PRC to be capable of providing primary care will be eligible to be a primary care provider.

The above list are the issues I think Philhealth or the DOH or both should address in the soonest possible time. I feel there is no transparency from the end of Philhealth. For instance, how much contribution is collected in a quarterly or annual basis from the direct contributors and the billions that PCSO and the other sources of funds for the UHC. Very promising, right? Sounds delicious.

Dr. Dans was right, in my opinion. He commented regarding supply and demand. The demand from the Philhealth fund must be lower than the the available supply of funds. At at least 100 million Filipinos and spending 1,000 for outpatient care would require 100 billion pesos. This does not take into account the hospital expenses that a Filipino might make when admitted in a hospital.

One article pointed out that nearly half of Filipinos are unsure if they can pay for their hospitalization if they get sick, 40 percent of 1,350 respondents from various parts of the country expressed uncertainty on their capability of paying medical bills. It also revealed that 37 percent of respondents had to use their savings while 25 percent sought the help of their relatives to pay their medical bills. What this means, the objective of UHC is daunting. Financial hardship is really an elephant in the room and let’s just say, the Philhealth coverage is not enough to cover half of the medical bill.

And there’s also the failure of the Philhealth to give due benefits to its direct contributors. Equity is not synonymous to dole outs. Money is earned hard in our country. Think about the workers, the daily wage earners who contribute and your average drunkard, slacker, and addict. Each have the right to access to care, agreed and they must receive competent and compassionate care.

Lastly, it is 2022. The law was passed last February 2019. Granting the pandemic has stalled this act. A concrete phasing, format, plan and milestone. What again was set in stone was the collection of dues. Sending a wrong message, not of social justice but of, when you work hard, we will milk you harder of your money. Disappointing. Frustrating for the individual working 2 to 3 jobs just to make things meet.

We might not be ready for this. We might just end up worst that when we started.

A clear, strategic, year-on-year rollout chronology towards achieving the vision for UHC should be laid out in a transparent manner for all stakeholders namely healthcare providers, local government units, people. Reforms should start with generating clear demand for primary care through patient empowerment and incentive schemes for providers. Focusing on chronic diseases like hypertension, diabetes, dyslipidemia will have impacts on health financing and patient load in the tertiary or apex centers. This can drive the necessary motivation for the public sector to build capacity, and similarly attract the private sector to participate and coordinate.

By committing to a clear plan of action, the DOH and Philhealth can galvanize confidence amongst all stakeholders, public and private, local and national, and across government. Clarity of vision will be essential to deliver on the promise of UHC in the Philippines.

As for my future plans, I intend to be a primary care provider for adults. I believe as a general internist I could help more people. I believe the mechanisms for primary care providers are not yet set and clear. Until, there are clear guidelines, we are at a limbo for now. As a general internist, I hope to be able to manage common adult problems and refer to specialist if need arises.

Day 23 of #100DaysToOffload. Find out more about it here.

Reference:

1. https://www.who.int/health-topics/universal-health-coverage

2. https://lawphil.net/statutes/repacts/ra2019/ra_11223_2019.html

3. https://www.philstar.com/business/2019/07/05/1932014/philippines-healthcare-unaffordable

There are days when I remember you: when I'm down and tired, when I'm in a reflective mood, Or when I just feel blue.

The comfort, the advice or just the way you made me feel secured. No more hugs. No more goodbyes. No more talks during breakfast. Happy mother's day Mommy. I miss you!

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55-Short Story #2

#55WordShortStory

Day 22 of #100DaysToOffload. Find out more about it here.