Driving instructor to me

 "Sir, disiplina lang kita sa accelerator, no?"

Farm-to-table

 

Heroism

S, my former intern, now a physician in a public hospital in Batanes, asked me about a patient. Difficult case—a young woman who might need dialysis soon. Reassured her that her management was spot on: a trial of diuresis to relieve pulmonary congestion and hyperkalemia. Asked her how she was doing: S is married, has a son, contemplates on specialty training, until the pandemic hit. She spent the past two years serving as a doctor to the barrio. S called me “Doc”—a telling sign that one has spent enough time outside PGH. “I’m proud of you, S!” I said, on the other southern part of the country, a proud former-IM resident. Doctors serving the underserved are heroes. 

"Lose weight"

New stethoscope, a Littmann III, olive-green with smoked screen finish, arrived by mail last week. Ordered it online from an Australian company. Design is unique; nothing quite like it. Saved money, even with shipping cost. Lost my stethoscope (same design) last year while doing rounds at Cancer Institute. 

My first patient for this stethoscope: Auntie Nanic (Nancy), mother's cousin who lives with us. Heard faint wheezing on the right lower lung field. Gave her a worried look. "HALA, ANO INI, AUNTIE?!" Laughed out loud—Auntie Nanic has hypochondriac tendencies. Reassured her it was nothing to be worried about. 

"What should I do?" Auntie asked. 

"Magpa-payat." 

Advice not related to wheezing (which eventually disappeared when I listened again), but sound medical instruction, nonetheless. Fear is a powerful motivator, especially for relatives. Been telling her to cut down on rice. Now she limits herself to 1.5 servings. 

The command to rejoice

Copied the verses sent in advance by Kuya Vance; these will be discussed in tonight's Bible study. Thank You, Lord, for Your Word. 

Ps. 32:10-11

Many are the woes of the wicked, but the LORD's unfailing love surrounds the man who trusts in him.

Rejoice in the LORD and be glad, you righteous; sing, all you who are upright in heart!

Prov. 3:5-6

Trust in the LORD with all your heart and lean not on your own understanding;

in all your ways acknowledge him, and he will make your paths straight.

1 Thes. 5:16-18

Rejoice always, pray continually, give thanks in all circumstances; for this is God’s will for you in Christ Jesus.

Phil. 4:4.
Rejoice in the Lord always. I will say it again: Rejoice!

Footage

 

Scenes of hospital wards are regularly shown on TV. Wards 1 and 3 of the Philippine General Hospital have been converted to areas dedicated for COVID-19News on COVID-19 patients. But there was a time when these were the very places where we did teaching rounds with clerks and interns. On the tables in corners, we chatted and charted with colleagues. 

The worth of human touch

"What is a physical examination worth?" Paul Hyman, MD reflects on his answers in his perspective piece, The Disappearance of the Primary Care Physical Examination—Losing Touch.[1] 

As our primary care practice has pivoted to telehealth and the physical examination has been ripped away from me, I find myself reflecting on what value the examination has. It is clearly needed at times to make a diagnosis. But I now realize the other ways I use the examination to advance care and its significance to my own well-being. It is a means through which I pause and physically connect with patients, I demonstrate my knowledge and authority, and is a tool I use to persuade patients and reevaluate their narratives.

Performing P.E. helps him as a physician, not just his patients.

The examination, though, is more than a tool that informs diagnosis and treatment. I now realize its value to me. The quiet moments when I am listening to a patient’s heartbeat and breath can be centering, similar to the part of a meditation where one refocuses on one’s own breathing. Abraham Verghese has commented extensively on the role of the physical examination as ritual and its importance to patients; he also has observed how this ritual brings physicians satisfaction through human connection. Only now have I come to recognize the examination as a ritual that is restorative and brings me calmness and confidence.

This resonates with me.

In an admission of my own insecurity, the physical examination remains one of the few domains where I maintain a sense of professional skill and authority. I have never been much of a proceduralist. The mainstay of what I offer to patients is the ability to listen to them, to use critical thinking skills, and to offer my knowledge and experience. But those skills are sometimes challenged in a world where patients research their own health and develop their own medical narratives. The physical examination remains a place where I offer something of distinct value that is appreciated.

But, as I wrote in a perspective piece, these are still good days to heal. 

Online interactions cannot completely replace actual human interaction between the physician and the patient, but through these remote meetings, we can able to offer communication bridges. With telemedicine, these are still good days to be a doctor. But I still wish for better days ahead when the pandemic is over, when I can talk to my patients face to face, hold their hands, and celebrate our shared humanity.

---

[1]Hyman P. The Disappearance of the Primary Care Physical Examination—Losing Touch. JAMA Intern Med. Published online August 24, 2020. doi:10.1001/jamainternmed.2020.3546

Dr. Karen sings

Learned last night that Dr. Karen Senen has passed away. She wrote in Facebook:

I have long been thinking of singing this song ["The Warrior is a Child"]. 

It is very personal to me because as a neonatologist I often find myself in situations where I have no other option but be the bravest person in the room. And it is never easy because I know that deep inside... I am terrified. 

The current pandemic has placed our youngest colleagues, the residents and fellows, in the hospital frontlines. Our beloved frontliners, we the consultants, recognize your bravery... your grit... your passion for serving others. We know that you fear this disease. We thank you for choosing to face the battle each and every day inspite of the fear. We want you to know that we will always support you and guide your every step... comfort you and see you through every trial. 

The Lord is our strength. We will get through this.

Doctors dying

My creative non-fiction piece, "To Be Afraid Is Human," will be published in an anthology by UP Manila. It starts with a quote from Merrill Moore's Les Savants Ne Sont Pas Curieux:

Doctors must die, too; all their knowledge of
Digitalis, adrenalin, henbane,
Matters little if death raps again—
Once he may be forestalled, but their great love
Or little love of life is merely human:
Doctors must die like other men and women.

Shadow play

Shadows cast by plants that shade the living room from the sun. Marbel afternoons are stifling, but the foliage makes them bearable. 

Trees in Lola's backyard in Banga

Yesterday, dropped by Lola's house in the next town. Pruritus and ear discharge not troublesome. Advised her to take her meds. Saw young cousins, bored by the prolonged vacation. Spent some time in the backyard, under the shade of the old chico tree. Can you identify the other plants?

Confused

“Friday na ba subong?”

“Daw Thursday pa lang man.”

Days blend into each other—the comforts and frustrations of the unemployed.

Camus may well have been writing about the Philippines

 Revisiting Albert Camus's The Plague. 

[Dr. Bernard Rieux] had examined the old man and now was sitting in the middle of the dingy little dining-room. Yes, despite what he had said, he was afraid. He knew that in this suburb alone eight or ten unhappy people, cowering over their buboes, would be awaiting his visit next morning. In only two or three cases had incision of the the buboes caused any improvement. For most of them it would mean going to the hospital, and he knew how poor people feel about hospitals . . . As for the "specially equipped" wards, he knew what they amounted to: two outbuildings from which the other patients had been hastily evacuated, whose windows had been hermetically sealed, and round which a sanitary cordon had been set. The only hope was that the outbreak would die a natural death; it certainly wouldn't be arrested by the measures the authorities had so far devised. (p. 58) 

TWSBI Eco (White) is working now!

Sean fixed my first TWSBI Eco two days ago. Frustrated because I couldn't pull the stuck piston up, I retired the pen many years ago, previously condemned inside the plastic box I reserve for spare parts. I love TWSBI pens. Sturdy, charming, with a sizable ink capacity; they're also affordable. To make up for my "loss," I bought a Diamond AL 580 (1.1 mm stub) and, later, an Eco Rose Gold (medium nib). These pens have served me well. From time to time, however, I would open the plastic box and attempt the restoration of my original Eco, which I bought at the TY Lee Pen Store in Taipei. I used tweezers. I soaked the insides with silicone grease. My fingers hurt. I ended up doubly frustrated. 

Sean, a dentist/oral surgeon, loves to tinker with things. I tossed him the defective Eco. "Can you fix this?" I asked.

He opened his toolbox and got to work. He worked his magic. My Eco worked! It just needed a bit more lubrication.  In exchange, I gave him the Diamond 580 (I am downsizing; I don't need too many pens.) Pleased, he reminded me, "You should care for your pens, Manong."

Reading Toni Morrison for the first time

Hilton Als on Toni Morrison:

When she looked at you and addressed you by your Christian name, she made it sound like a promise, one that stood on the side of everything that was juicy, smart, black, amused, yours. In the old days, when ladies were “colored” and she herself was just a child, she had learned from those ladies, probably, the same eye-rolling, close-mouthed look of incredulity that she employed when she recounted a glaring error of judgment on someone else’s part, or something stupid someone said or didn’t know they were about to say. After she gave you that look, you never wanted to say anything dumb again, ever. If she took you in as a friend—and this was rare in a world where so many people wanted her time and felt they had a right to her time, given the intimacy of her voice—she was welcoming but guarded. Then, if you were lucky enough and passed the criteria she required of all her friends, which included the ability to laugh loud and long at your own folly, and hers, too, she was less guarded, and then very frank: there was no time for anything but directness.

Also: 

As she described this or that, she drew you in not just by her choice of words but by the steady stream of laughter that supported her words, until, by the end of the story, when the scene, people, weather, were laying at your feet, she would produce a fusillade of giggles that rose and fell and then disappeared as she shook her head.

Finished The Bluest Eye, the first novel she wrote. Like Oprah, I feel I've been enhanced by her language. 

I enjoy watching her interviews. Her voice is soothing. Mavis Nicholson's 1988 interview with her is one of my favorites.

Lounging around

Screenshot from The Spirit of the Beehive, film by Victor Erice. 

What's the perfect posture for reading? I can read in bed, in a chair, with a table, in bright or dim light. I can't read in a moving vehicle. I get nauseous. Good thing there are podcasts.

Tarps and COVID-19

Saw this in my feed. So Pinoy in many respects: 

• the graduation photo
• the tarp with three fonts: Monotype Corsiva ("Congratulations"), Arial (the girl's name), and the serif below
• the papaya tree
• the use of the middle name
• the color scheme (pink in white)
• the iconic Philippine countryside

It's the first time I'm hearing about Zarraga, some 16 km north of Iloilo City. Seems like a charming place to visit. Also COVID-free. 

Tourists in Bangkok

PGH Med Onco goes to Bangkok

Posing with medical oncologists from Japan!

"The books you read are the books you can easily bring with you."

Patrick Rhone, who owns the defunct Minimal Mac, now blogs at Rhoneisms. He published his reading plan for 2019. These are some of what he wrote. I have a few comments below.

Read more paperback books, specifically mass-market sized ones. The books you read are the books you can easily bring with you. And, especially in the winter months here, every coat I own has large enough pockets to easily slip one in.

My Kindle holds 90 percent of the books I've read for the last three years. Occasionally I bring a paperback or even a hardcover. This is the exception rather than the rule. I read more books because of my Kindle.

Replace boredom with books. In the check out line, in the waiting room, while my daughter is in her classes. Assuming I’m good about having a book within easy reach per above, I’ll fill these sorts of times with reading one.

Absolutely. The more I read, the less time I spend in social media, the happier I become. Reading books offers a peaceful distraction, encourages critical thinking, fosters concentration, and cultivates a special relationship reader and author. I read long works through this method (Tolstoy's Anna Karenina, Calvin's Institutes, Charnock's Doctrine of Regeneration, for example). 

Bias towards fiction. If you look over my reading list of the past several years, you’ll notice I tend to bias towards non-fiction. The reason is that I’m a curious learner and reading non-fiction fuels that. That said, every time I do read a fiction book for escape and entertainment, I always feel like i should do so more often but then fall back into my habits. The truth is, I read fiction a lot faster and enjoy the escape when I allow it. Therefore, I’m going to intentionally bias towards it and see what happens.

I read anything and everything. I'm biased toward fiction, almost as a default. Fiction allows me to delve into another human's imagination, which I enjoy. Over the years, however, I've discovered some gems in the non-fiction department. William Finnegan's Barbarian Days (on surfing) and David Remnick's biography of Muhammad Ali (on boxing) are some of them.

Read more classics (including ones I’ve read and would like to read again). Not the least of the reason being that many of these are easily available in a smaller, mass-market size where recent paperback are less so (in general, these are trade-sized).

I'm intentional in the classics I read. I'm biased towards works of Christian classics, especially the those of the early church fathers, including Puritan writers. Thomas Watson, Jonathan Edwards, and Stephen Charnock captivate me. St. Augustine uplifts me. There's John Calvin, of course. The language they use is beautiful, almost poetic. They may seem daunting. I admit that they need some getting used to. But my heart is stirred to more love for God, and my eyes look to heaven. They're worth your time!

The 14-day quarantine: last day

Woke up to thunder and rain. Afternoon nap done. There goes my day. 

Used to love rain as a child. Didn’t fancy it too much when I lived in Manila, when it meant leptospirosis, flooding, and higher Grab fees. 

Last day of quarantine today. Yesterday Sean dropped by to hand me food. Greeted him from an open window. He lost weight and looks more like me. Durian was moist, sweet, heavenly. Devoured everything in minutes. Room smelled like coffee and durian. No anosmia! Called mother about durian. She said, “Let me know if you want some more.” My family gets excited about tropical fruits—perks of living in this sun-soaked piece of paradise. 

Outside my window: trees swaying, soil soaked in watery goodness. Amazing is God’s creation. I feel artistic but can’t get my words out. 

Meditated on life of prophet Samuel and Psalm 23. “Surely goodness and mercy shall follow me all the days of my life, and I will dwell in the house of the Lord forever.” Spent the morning thinking about this. Prayed for friends and family and myself—career directions, and so on. 

Plan for tonight: watch some episodes of Scams (Japanese series) and Occupied (Norwegian series), pack things, write some emails.

Visit to the Reformation Museum

Got to see John Calvin's handwriting! I was so thrilled!

Geneva tour

Walking tour in Geneva, Switzerland with Harold, after the poster presentation at ESMO Immuno-oncology Conference.

New Life

Best karinderya in town!

"Flowing"

At Auntie Cecil's farm in Banga, South Cotabato

In the vicinity of Crawford Market

I felt like I was in a movie!

Garden

Lovely exteriors, Taj Mahal Tea Place, Mumbai

Tea

At Taj Mahal Tea House, Mumbai. Loved the ambience here.

Staff at Lalit Mumbai

The 14-day quarantine, days 3-5

Work, meaningful work, is the antidote to boredom. Must remind myself to quit anything that bores me. 

Yesterday: spoke to friends and family. Tito Bong, my father's close friend, called me up. Felt like talking to Tatay. In many respects they sound the same. Told me that Tatay's gift of charming people rubbed off on me. Everyone knew and liked him, Tito said. In malls and restaurants, people were charmed. Heartwarming story: Tatay and his bike gang passing through chapel named after San Isidro Labrador. Tatay told Tito Bong, "Lance would be angry if I named him Isidro, so I used 'Isidore' instead." Tito said Tatay was always proud of me. I miss him every day. 

Worked on papers. Made me forget I'm in quarantine.

Metro Manila now in MECQ. Government listened to doctors this time, but I feel this is temporary. Doctor-friends relieved but pessimistic. Note to self: limit social media engagement. Atmosphere is anger and hopelessness. Must pray for wisdom for our leaders, who don't have much of it. 

Huge PhilHealth scam irks me. How can thieves do this to poor patients who can barely afford to pay for transpo to clinic, let alone their chemo meds? The depravity of human nature. Trusting that justice prevails in the end. God is just and merciful.

Technology makes quarantine bearable. Tita Mavis's essay on Marguerite Yourcenar intrigues me. Got myself a copy of Memoirs of Hadrian. Tita Mavis on English translations of French work: 

None of the books now available in English reveals anything of the quality and clarity of the French. English and French are not negative-positive images of each other, but entirely different instruments. The two languages cannot be made to work in the same way. A French sentence, transcribed exactly as it stands, means an English sentence with five words too many.

With barely a grasp of French, I'll make do with the English translation.

Gateway of India

Maharashtra, Mumbai, India

I think it's going to rain today

Current LSS: Audra McDonald's I Think It's Going to Rain Today. She's right on two counts. First, kindness is overflowing, despite humanity's depraved nature. Second, I think it's going to rain today.

Broken windows and empty hallways
A pale dead moon in the sky streaked with gray
Human kindness is overflowing
And I think it's going to rain today

Scarecrows dressed in the latest styles
With frozen smiles to chase love away
Human kindness is overflowing
And I think it's going to rain today

Lonely, lonely
Tin can at my feet
Think I'll kick it down the street
That's the way to treat a friend

Bright before me the signs implore me
To help the needy and show them the way
Human kindness is overflowing
And I think it's going to rain today

Kolkata Airport, India

Keep your things safe

ECQ is not yet over

Ate Lei sounds the alarm on increasing COVID-19 cases, reaffirms importance of physical distancing and wearing of masks, and empowers the public--"you are our first line of defense." The advice is firm and compassionate. Listen to her.

Dr Lei Camiling-Alfonso, technical specialist for the Philippine Society of Public Health Physicians, says the Philippines is far from return to normal. Camiling-Alfonso took part in the 'Frontliners for ECQ' online press conference on Saturday, August 1, 2020

This, too, shall pass

The 14-day Quarantine, days 1-2

Day 2 of quarantine. Cloudy day. Rained all evening. Rooster’s cry woke me at 5 am. Could hear it over closed windows. Turned off the aircon. I get cold easily—an inconvenience in places with snow, but not a problem in Marbel, where it feels like an oven most days. Opened my email, wrote replies. Still dark outside. Before daybreak is the best time to get things done.

Last night, spoke with a couple from Dormitories Christian Fellowship over Zoom. DCF people are the best—bright minds, kind hearts from provinces meeting in the country’s best school. Or so we think. Among my dearest friends are DCFers. Call was a welcome distraction from the monotony of quarantine. Been itching to be productive all day. Getting the hang of online consults. With video, I could see facial reactions at least. So much of doctor-patient communication is nonverbal. Face-to-face consult, in the flesh, is still the best. Ended the call with my heart encouraged by their faith in the Lord. Miss talking to patients. Hoping to start a clinic here soon. Waiting for approval from a telemedicine provider. Doing remote clinics while locked in hotel room—why not?

Mavis Gallant—Tita Mavis, we call her—keeps me company. Paris Notebooks is delightful. They don’t print this anymore. Found a copy from Powell’s Books (Portland, OR). Delivered in post office last February but I picked it up few days ago. So worth the trip. Mother will reprimand me for risking exposure. Miss getting nagged. Tita Mavis writes she was neighbors with a med student. I love her more now.



Arrived in Mindanao last July 30. Flight was okay. Lady at NAIA checked my documents, stamped them. Remembered A Very Secret Service: “tamponner!” Man at PAL check-in counter asked, “You’ve been abroad, Sir?” He saw my Japan visa. Memory of cancelled trip. Will have to content myself with watching documentaries of Japanese old people. Might rewatch Kimi No Nawa. Throughout trip, wore N95 over surgical mask. Also: face shield. Felt like I had cataracts. Too much? Old med school roommate Bryan Jay wore complete PPE. Better safe than sorry.





Plane was 80 percent occupied. Fascinated by kids on board—they didn’t give a care to this world’s problems. Childlikeness, a virtue. Teared up as I remembered God’s goodness to me throughout all my years in Manila. Couldn’t wipe my tears lest I risk getting COVID. Tears dried on their own. Wala muta. Brothers tell me I’m a sosyal crier.



Nanay texted me, “Welcome home!” Auntie Net: “See you in 14 days!” Manong quite envious he was left behind. Sean asking if everything was okay, he’d bring me a coffee maker. I have the best, kindest, most generous brothers. Filled out some forms. Light snacks on designated seat in LGU bus. Driver started small talk, greeted everyone “good morning” in Hiligaynon. Sounded like one of my father’s friends. Felt like home, at last.





At Koronadal City Health Office, got tested. Old lady told me she remembered a speech I gave in high school. Someone from high school announced, “Amo ni ang valedictorian namon.” There went my wish for anonymity. Everyone calls me “Dok” now. Even the receptionist and the man who brings meals to my door. A small world.

Poignant scenes: six or seven-year old boy, before going to the rest room, asked if I could watch over their bags. Mother was away, interviewed by health care worker. The kid acted like an adult; he’ll reach places. In contrast to many kids these days—downright irresponsible, waiting for their overly doting mothers to feed them, while they play on their gadgets. Could be forgivable they had a book. But gadgets? Disastrous.

Another: old people asking the nurse, “Can we feed our dogs?” “Where can we hang our clothes?” “Can I walk around the garden? I have a fence and I live alone.” Nurse told us, “Be creative with your time.” Encouraged us to record Tiktok videos. So eloquent and heartwarming, with a reassuring voice that remind me of ninangs who sniff me during beso-beso.



Now settled in small hotel. Sean arranged for accommodation. Internet connection is good. Books keep me occupied—Thomas Watson, George Saunders, Tita Mavis, and maybe Hilary Mantel.