Medical Anecdotal Reports

Medical Anecdotal Reports
for the Development of

Holistic, Professional and
Compassionate Physicians
in the Philippines
Volume 2
Reynaldo O. Joson, MD
2014
140
Medical Anecdotal Reports Volume 2

Table of Contents
Table of MARs by Year Reported
Table of MARs by Issues and Topics Discussed
Preface of Volume 2 of MARs (2014)
Preface of Volume 1 of MARs (2013)
Introduction
12
Medical Anecdotal Reports (see Tables of MARs)
14
111
Epiloque
Appendices
1
Medical Anecdotal Reporting as a TeachingLearning Activity in a Clinical Department in the

Philippines [Abstract] (presented in the 4th AsiaPacific Conference on Problem-based Learning in
Health Sciences in September of 2004)
113
List of surgical residents of OMMC Surgery who

have written MARs from 2004 to 2014
External Anecdotal Feedback on the MAR in 2005
114
118
Feedback on the MAR Project by Surgical

Residents in 2006
Feedback on the MAR Project by Surgical
Residents in 2012
Feedback on MAR Volume 1 (2013)
Introduction of MAR Volume 1 (2013)
131
Epiloque of MAR Volume 1 (2013)
133
About the Author
135
3
4
5
115
124
130
139

138
Year
No.
Title
Reporter
2014
2014
2014
2014
2014
2014
2014
2014
Routine Post-Operative
Instructions on Sexual
Activity After an
Operation. A Taboo?
Safety of Hospital Staff
2014
Preventing Euthanasia
2014
10
2014
11
2014
12
2014
13
Seeing Hope and

Appreciating Beauty of
Life Through a Patient
with Stage IV Breast
Cancer
Reflections on Patient
Care and the Makings of a
True OMMC Surgeon
Grace Under Pressure
Stepping Up To Be a
Senior Resident
Good Intentions Without
Proper Decisions Is
Hopeless
A Lesson of Forgiveness
The Bridge to a New

Stone
Respect the Relatives
Decision on Their Dying
Patient
Challenges Due to Closure
of the Operating Rooms
Managing the Operations
of My Patient in a Limited
Budget
Page
Onofree L.
OConnor, MD
14
Voltaire Samson
Dela Cruz, MD
18
Glen Mark
Macatiag
Gervacio, MD
Rembo M.
Aguda, MD
Romeo Cagauan
Abad, Jr., MD
22
Sheena Shayne
Panes SiapnoFeliciano MD
Princess Beverlie
Correa Co Oracion , MD
33
Marco Antonio
Elepao Sanico,
MD
Glenn Pablico
Villanueva, MD
Lucas Riel B.
Bersamin, MD
John Alexis
Dingal Canlas,
MD
Marienelle Recto
Maulion, MD
Eugenette
Bernardo Saluta,
MD
42
25
30
37
46
52
56
59
64

Year
No.
2014
14
2014
15
2014
16
2014
17
2013
18
2013
19
2012
20
2012
21
2005
22
2005
Title
Reporter
Page
A Heart-Breaking, Best
Option for a Relative
Thou Shall Not Fear
Surgery
Disrespect From a Civil
Servant
Mark Balceda
Velez, MD
Owen Parma
Lizaso, MD
Allain Abad
Alvez, MD
69
The Hurdles of
Transferring a Patient to
Another Hospital
Towards Patient Safety
in Surgery: My
Departments Principle
Managing a Colleague
Patrick Jovan
Concepcion
Gagno, MD
Ariel T. Celzo,
MD
80
Jenny Vi. H. de
Castro, MD
87
Respecting Relatives of
Patients in the Refusal
for Treatment
Being Humble
Shouldnt Mean Losing
Self-Confidence
Cell Phones,
Connecting Lives
Alma Jawali
Lucero, MD
92
John Lloyd F.
Fonte, MD
94
Janix M. de
Guzman, MD
97
23
Challenges in Hospice
Care
Reynaldo O.
Joson, MD
103
2004
24
Valentines Day
Hazel Z.
Turingan, MD
105
2004
25
Long Life Span of

Patients with Thyroid
Papillary Carcinoma
and Balancing
Conservative vs Radical
Surgery in Cancer
Patients
Reynaldo O.
Joson, MD
109
73
77
84
137
Past Chief, Division of Head and Neck, Breast, Esophagus, and Soft Tissue
Surgery, Department of Surgery, Philippine General Hospital (July 13,
1994 - 2000) (Acting Chief 1992 1994)
Program Director, Education for Health Development in the Philippines

(1989 -) http://edhedephi.tripod.com
Issues and Topics Discussed
Page
Project Director, Medical Anecdotal Reports, Ospital ng Maynila Medical

Center Department of Surgery (2004 2014 )
What are the things that physicians can learn from

interactions with their patients?
14
Author- Scientific Papers > 100; Scientific Books/Primers/Course Packs

> 80; Published papers =50 (4 - international; 47 local);(9 from 2000
to October, 2006); research awards >16 (1976 October, 2006) [Last
updating: December 2012]
The Medical Anecdotal Report as a feedback and

evaluation Tool
How should physician-surgeons prepare for and
manage situations which require them to perform a
grace under pressure action?
18
How should junior resident-physicians prepare

themselves for the day they will become senior
residents, particularly a Chief Resident?
How to avoid and manage conflicts in department
assignment of patients for inpatient admission
25
What should physicians do to patients whom they have

gone the extra mile to assist and who eventually do not
come back for the agreed treatment plan?
How to give advices on physical activities (inclusive of
sex) to patients after a surgical operation
What are the strategies that can be used for patients
who openly defy physicians recommendations and
decisions and insisting on their wants with an
accompanying threat, expressed or implied?
What are the concepts of euthanasia and its associated
issues in the practice of medicine?
Why should junior resident-physicians cherish and
nourish the learning they get from their senior resident
-physicians?
Why and how should physicians control or manage
their mindsets and emotions when dealing with
patients?
What are the implications of a temporary cessation of
services in a hospital and how should hospital
administrators manage them, particularly, in
mitigating the negative effects?
33
Author Websites [https://sites.google.com/site/rojosonwebsites] = 207

[as of December 26, 2013]
Contact information:
rjoson2001@yahoo.com
09188040304
4
5
6
Details of ROJosons Biodata:

https://sites.google.com/site/rojosonwebsites/rojoson-curriculum-vitae
7
8
9
10
11
12
136
22
30
37
42
46
52
56
59
Appendix 7
About the Author
Issues and Topics Discussed

13
Page
How should physicians manage patients with limited

budget?
How should surgeons manage patients who are their
relatives and who have a major medical disorder whose
treatment is within their surgical specialty practice?
What should surgeons do to manage patients who are
anxious and afraid of a surgical operation?
What should physicians do when they are disrespected?
64
What should physicians know about Transfer of Patients to Another Hospital Types, Reasons, and Policies?
How does the Department of Surgery of Ospital ng
Maynila Medical Center remind staff of patient safety
in surgery?
How should physicians manage physician-patients?
80
20
What is informed refusal and what is informed

consent? How should physicians manage these?
92
21
How to differentiate and use humility, meekness and

self-confidence as good character traits of a physiciansurgeon?
Should physicians give their cellphone number to their
patients?
What are the challenges in hospice care?
94
14
15
16
17
18
19
22
23
24
25
How should physicians in specialty training (residentphysicians) respond in terms of a decision to quit or not
to quit training if they develop a major medical
disorder?
Long life span of patients with thyroid papillary
carcinoma and balancing conservative vs radical
surgery in cancer patients
69
73
77
84
87
97
103
105
109
Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg

Doctor of Medicine (MD), Univer sity of the Philippines College of
Medicine (1974)
Master in Hospital Administration (MHA), UP College of Public Health
(1991)
Master in Health Profession Education (MHPEd), UP National Teachers Training Center for Health Profession (1993)
Master of Science in General Surgery (MSc Surg), UP College of
Medicine (1998)
Faculty, UP College of Medicine (1985 2014 : Retired Professor 5); Clinical Professor (June 2014 - )
Consultant, Department of Surgery, Ospital ng Maynila Medical Center;
Philippine General Hospital; Manila Doctors Hospital; Medical Center Manila
Past Chairperson, Department of Surgery, Ospital ng Maynila Medical
Center (2001 July 11, 2009)
135
Please give me feedback particularly on the following:

1. Usefulness of the book in the advocacy for the development of
holistic, professional, and compassionate physicians in the
Philippines.
2. How the surgical residents and I fare in terms of English writing
skills in the context of a physician who are expected to write
technical medical reports, not literary prose.
Thank you very much.
Preface of Volume 2 of the MARs (2014)

Please read the Preface to Volume 1 of the MARs (2013) first and come
back here.
.
I retired from the Department of Surgery of the Ospital ng Maynila
Medical Center on February 1, 2014, the day after I reached the
compulsory age of retirement of 65 from government services.
From February 1, 2014 up to December 2014, the Project MAR which I
started in 2004 is still being continued by the current Chairperson, Dr.
Hazel Z. Turingan. For this, I thank her.
With regards to the publication of the MARs, after the publication of
Volume 1, I pledge to continue even after my retirement. Thus, this
Volume 2. I have pledged to myself that I will publish all the MARs
written, submitted, and that I can retrieve, from April 2004 to November
2014. The total number is about 1700 MARs. With 25 MARs per volume,
I will be publishing at least 60 volumes. I hope to finish this gigantic task
before I die.
From 2015 onwards, if the Project MAR continues, I hope the leadership of
the Department of Surgery will assign somebody to publish the MARs.
My pledge is only up to 2014.
I like to end my Preface for Volume 2 with acknowledgment of the
following people and institutions:
The Residents of the Department of Surgery of OMMC

The Consultants of the Department of Surgery of OMMC
The Don Go Peng Kuan Foundation
North Texas Association of Philippine Physicians
Mr. Alfredo Chua
Dr. Catherine Co
My family (Jackie, Lance aka Rey and Therese)
Thank you very much for the support.

Email: rjoson2001@yhaoo.com
Cell No.: 09188040304
134
Preface of Volume 1 of the MARs (2013)
Epilogue of MAR Volume 1 (2013)
In April 2004, I started a project which I named Medical Anecdotal Reports

or MARs for short, in the Department of Surgery (Surg) of Ospital ng
Maynila Medical Center (OMMC) [OMMCSurg]. The MARs was an
additional innovative teaching-learning activity that I had designed for the
Department during my term as Chairman from 2001 to 2009. The MARs
was operationally defined as a brief written report on an actual medical event
that involves an actual patient seen by a surgical resident or trainee. The
medical observation must have an impact on the surgical resident as a
physician in terms of insight gained and which he/she thinks is worth sharing
with colleagues as this may help improve patient care and may be useful for
the knowledge management system of the Department. In essence, the MAR
is a reflection paper and writing it is a reflective learning activity for the
surgical residents or trainees.
As mentioned in the Preface, I started actively developing this book in June

2013 using a framework that approximates the key processes of Medical
Anecdotal Report. By today, October 29, 2013, five months after, I am
done with appending my insights or thoughts, perceptions, opinions and
recommendations (TPORs) to 23 Medical Anecdotal Reports (MARs)
written by the surgical residents of OMMC Surg. In my original plan, as
seen in the Preface, I said I will put 15 to 20 MARs per volume. I decided
to put in 25, at least in this first volume, as there are still a lot of MARs to
cover, over 1400 MARs written from 2004 to 2013. In subsequent
volumes, I hope I can maintain the number of MARs at 25 per publication.
From April 2004 to June 2013 (the time of this writing), the objectives,
policies and implementing instructions on the MARs have been continually
refined. Below are key information on the MARs.
As to objectives, the MAR is primarily a learning activity in the
development of holistic, professional, and compassionate physicians among
the surgical residents of OMMCSurg. The second objective is to enhance
the residents English writing skills. The third objective is to reinforce the
Departments knowledge management system through the issues raised and
resolutions made in the MAR activity.
As to policies and implementing instructions on the MAR, each resident is
required to write and present one MAR a month, except in January and
December, the respite period. A template is used for the writing and
presentation of the MAR which consists essentially of a one-page paper with
narration followed by insight and categorization of the latter into physical,
professional /ethical, and psychosocial domain. For every presentation of a
MAR, at least 2 residents are required to react with a consultant moderating
and facilitating discussion. Feedback and discussion cover both the contents
and the technical writing of the MAR. At the conclusion of each MAR
presentation and discussion, resolutions are made on measures to be adopted
by the Department staff in enhancing the development of holistic,
professional, and compassionate physicians as well as in improving the
system of care, not only of the Department but also of the entire hospital.
(Note: The history of the MAR can be seen in the following website:
(https://sites.google.com/site/medicalanecdotalreports/history-of-mar-inommc-surgery).
I included two of my personally written MARs to make a total of 25 in this

first volume, the rest of the 23 were by my surgical residents. The reason
for inclusion of my MARs is to bring out the value of role modelling on my
part.
There are 48 surgical residents who have written MARs from 2004 to 2013
(see Appendix 2). In this first-volume publication, I just picked out 23
MARs from 23 residents. The selection was done by convenience (readily
available in my files) and I made it in such a way that there was at least one
MAR per year from 2004 to 2013 and no two MARs per resident. In
subsequent volumes, the MARs of the other surgical residents not included
in the first volume, will be published. Thus, all the MARs of the 48
residents will eventually be published.
The main objective in the publication of the MARs is to advocate the
development of holistic, professional and compassionate surgeons and
physicians. I hope all the MARs in this first volume have somehow
brought out these values. Just to cite some examples, the MAR of Dr.
Turingan touches on holistic physician. The MAR of Dr. Velazquez, on
being a professional physician. That of Dr. Bersamin, on being a
compassionate physician.
In this first volume of the MARs, I included the feedback gotten in 2005,
2006 and 2008 (See Appendices 3 to 5). I plan to include feedback on this
first volume on the second volume. Thus, I would like to request all
readers of this first volume to send me feedback through email
(rjoson2001@yahoo.com) or through the online site
(https://medicalanecdotalreportvolume1.wordpress.com). The second
volume hopefully will come out by mid-2014.
Since after presenting a formative evaluation paper on the MAR project in
133
This book has an online version

(http://medicalanecdotalreportsvol1.wordpress.com).
Go to the Contents page
(http://medicalanecdotalreportsvol1.wordpress.com/contents) and click
on the links for each page, MAR and article you are interested to see and
read.
In some of the MARs, there are recommended online links for further
readings. Thus, for those reading the hard copy of this book, they may
have to go online in they want to pursue the recommended supplementary
readings.
I wish every reader Happy Reading! If you have any concerns,
questions, and feedback, which I welcome wholeheartedly, please dont
hesitate to communicate with me through my email
(rjoson2001@yahoo.com) and /or cellphone (0918-8040304).
the 4th Asia-Pacific Conference on Problem-based Learning in Health

Sciences in September of 2004 with the findings of usefulness of the MAR
in improving trainees competency in biopsychosocial management of
patients, I have been wanting to publish the MARs into a book. I feel a
book on MAR will be appreciated by both medical and non-medical
readers, not only because of the uniqueness of the MAR as a training
method for physicians but also because of the extremely valuable
competencies (holism, professionalism, and compassion) it is developing.
These competencies are being constantly sought by patients and medical
teachers alike from their physicians and physician-students respectively.
Meanwhile that a book publication has not yet been done, the MARs have
been posted in several websites since 2004 by both the surgical residents
and myself. In 2005, I asked the help of Dr. Elvie Razon, who spent
clinical clerkship in OMMC and who was known to be a good writer, to
edit the 2004 MARs. Thereafter, Dr. Nolan Aludino, a surgical resident,
created a website (http://omsurg-mar.tripod.com) and posted the MARs
edited by Dr. Razon and also the MARs written by the surgical residents in
2005 and 2006. After 2006, the MARs have been scattered in the online
General Surgery Journal of the individual residents.
As mentioned earlier, I have been wanting to publish the MARs into a book
since 2004. However, I was bogged down by the search of a good design.
I have been looking for a design that will approximate the key processes
involved in making and presenting the MAR by the surgical residents, that
is, presence of an insight-triggering event followed by reflection and
writing of insight and then feedback and discussion by readers and
listeners. In addition, I have been looking for a way in how to make the
MARs useful to the readers, both medical and non-medical. Initially, I
thought of just a compilation of the MARs with editing of the grammar and
syntax. This was essentially what happened to the 2004 MARs. I wanted
to go beyond that. For the past 9 years, I have been experimenting on the
design. I used websites to simulate the book. Honestly, I was having
difficulty deciding on the design.
Finally, in June 2013, 7 months prior to my compulsory retirement from

OMMC on January 31, 2014, I decided to have the following action plans
to have a book on the MARs published:
1. As of June 2013, my estimate is that I have about 1,400 MARs (April

2004 to June 2013) to deal with in publishing a book on the MARs.
2. I will be publishing by volumes with 15 to 20 MARs per volume.
First volume should be out by November 2013. Subsequent volumes

will be out in 2014 and thereafter (I can continue to write after January
31, 2014).
132
3.
4.
5.
I will be using the Internet to complement the book. Websites will be

created to host the MARs of the residents. The websites will contain
the original MARs written by the residents.
In the book, there will be minimal editing of the grammar and syntax
by yours truly on the MARs written by the residents. The MARs
published in the book can be compared with the original ones posted in
the websites. The comparison will allow readers to evaluate the level
of competency or degree of enhancement of the surgical residents in
their English writing skills as a result of the MAR activity.
At the bottom of each MAR that was written by a resident-reporter, I
will add a personal insight with a subtitle of ROJosons Insight
(TPORs). TPORs stands for thoughts, perceptions, opinions, and
recommendations. My insight will be limited to what I perceived as
actual and/or potential issues identified in and/or deduced from the
narration and insight of the residents. I will give my insight guided by
the following envisioned objectives of the MAR: development of
holistic, professional, and compassion physicians; improvement of
system of care in the department and in the hospital. I will refrain as
much as possible from commenting on the technical writing of each
resident-reporter.
I hope that with the abovementioned design, I will be approximating the

processes involved in making and presenting a MAR by the surgical
residents. The published MAR of a resident is my trigger for an insight. I
reflect and write my personal insight on the MAR of the resident. I can have
insight to his/her insight. I share my insight to the readers of this book for
feedback and more discussion through my email address:
rjoson2001@yahoo.com. With my insight directed and focusing on the
development of holistic, professional, and compassionate physicians and
improvement of system of care in the department and hospital, I hope to be
able to give to the readers something they can use in their setting, as a
patient, a medical learner or physician-student, a medical teacher or as a
hospital administrator. I hope that my thoughts, perceptions, opinions, and
recommendations (TPORs) will be able to motivate non-medical readers to
advocate for physicians who are holistic, professional and compassionate. I
hope my TPORs will be able to motivate the readers who are medical
learners to become holistic, professional and compassionate physicians and
surgeons. Lastly, I hope my TPORs will be able to motivate the readers
who are medical teachers and hospital administrators to adopt the MAR
activity for their medical learners. All these three hopes that I just
mentioned are my ultimate goals in painstakingly publishing this book.
Only you, the readers of this book, can give me information on the impact
of this book. I will wait for your feedback in my email
(rjoson2001@yahoo.com) or through the website in which these MARs are
published (http://medicalanecdotalreportsvol1.wordpress.com).
10
Introduction of MAR Volume 1 (2013)

There are 25 Medical Anecdotal Reports (MARs) contained in this first
volume, 23 written by the surgical residents of the Department of Surgery
of Ospital ng Maynila Medical Center and 2, by yours truly. Surgical
residents, in the context of this book, are those licensed physicians who
are pursuing on-the-job training to become specialists in general surgery. In
each of the 23 MARs written by the surgical residents and minimally edited
by yours truly, I added a personal insight with a subtitle of ROJosons
Insight (TPORs). TPORs stands for thoughts, perceptions, opinions, and
recommendations. My insight were limited to what I perceived as actual
and/or potential issues identified in and/or deduced from the narration and
insight of the residents. I gave my insight guided by the envisioned key
objectives of the MAR project, that is, development of holistic,
professional, and compassionate physicians.
There are two ways of going through the MARs. One is by year of
reporting of the MARs, chronologically from 2004 to 2013. Second is by
issues and topics (not titles of MARs) that I, as author of this book,
identified and discussed in the TPORs portion of the MARs of the surgical
residents and also in my own 2 MARs. (See the two sets of Table of MARs
in the first few pages of this book.)
The Table of MARs by issues and topics will be useful to readers who want
to look for information on specific topics upon opening of the book. It will
also be useful for readers who will use the book as a take-off point for
group discussion on specific topics. Based on the issues and topics
discussed, I categorized the MARs into 3 groups, namely, Making of a
Holistic Physician, Making of a Compassionate Physician, and Making of a
Professional Physician. This will not only help the readers identify the
theme of each MAR; it also gave me a better basis (I think) for the
sequence of presentation of the 25 MARs in this book.
In the Appendices, I included the following for historical value:
1.
2.
3.
4.
5.
Medical Anecdotal Reporting as a Teaching-Learning Activity in a

Clinical Department in the Philippines [Abstract] (presented in the
4th Asia-Pacific Conference on Problem-based Learning in Health
Sciences in September of 2004)
List of surgical residents of OMMC Surgery who have written
MARs from 2004 to 2013
Feedback on the MAR Project by Surgical Residents in 2006
131
Appendix 6
Feedback on MAR Volume 1 (2013)
Dr. Daniel Ong, a neur osur geon affiliated with J ose Reyes Memor ial
Medical Center (JRMMC), asked for an extra copy of MAR Volume 1
(2013). He said he would ask the Department of Surgery of JRMMC to
adopt the MAR for its residents.
Dr. Edgardo Penserga, a gener al sur geon, sent in the following SMS
after receipt of the MAR Volume 1:
At this point, I like to disclose that I did not hire a copy editor to check and
edit the grammar of the residents and even myself as the author of this
book. This is in consonance to my envisioned design for the book to
approximate the processes of the MAR. As mentioned above, the second
objective of the MAR is to enhance the English writing skills of the
surgical trainees. I purposely included this as another objective for the
MAR because of my personal observation that majority of Filipino
physicians, which include me, are not good English writers, even in writing
technical medical reports. With every resident writing 10 MARs a year and
50 MARs in 5 years (the duration of the surgical training), with the regular
feedback on the English grammar and syntax by colleagues and faculty (me
included), enhancement of the English writing skills is expected. I
mentioned in my action plans above that there will be minimal editing of
the MARs published in the book because I like the readers to evaluate the
level of competency or degree of enhancement of the surgical residents in
their English writing skills as a result of the MAR activity. Please give me
a feedback through rjoson2001@yahoo.com on how the surgical residents
who wrote the MARs fare in terms of English writing skills in the context
of a physician who are expected to write technical medical reports, not
literary prose. Please do the same for me as the author of this book. We
admit we are not excellent in English writing. We are contented with being
good in writing non-literary prose as long as we use English grammar
correctly; we are easily understood; and we continually improve.
I like to end my preface with acknowledgement of the following people and
institutions:
The Residents of the Department of Surgery of OMMC

The Consultants of the Department of Surgery of OMMC
The Don Go Peng Kuan Foundation
Dr. Elvie Razon
My family (Jackie, Lance aka Rey and Therese)
Thank you very much for the support.

Email: rjoson2001@yahoo.com
130
11
Introduction
There are 25 Medical Anecdotal Reports (MARs) contained in Volume 2,
23 written by the current and past surgical residents of the Department of
Surgery of Ospital ng Maynila Medical Center and 2, by yours truly.
Surgical residents, in the context of this book, are those licensed
physicians who are pursuing on-the-job training to become specialists in
general surgery. In each of the 23 MARs written by the surgical residents
and minimally edited by yours truly, I added a personal insight with a
subtitle of ROJosons Insight (TPORs). TPORs stands for thoughts,
perceptions, opinions, and recommendations. My insight were limited to
what I perceived as actual and/or potential issues identified in and/or
deduced from the narration and insight of the residents. I gave my insight
guided by the envisioned key objectives of the MAR project, that is,
development of holistic, professional, and compassion physicians.
tions, No Disability, No Lawsuits. These goals I believe are not just noble
aspirations but goals that all surgeons in training and in practice should
strive for.
I believe that at the end of each ones 5 year residency training in the
OMMC Department of Surgery, these Medical Anecdotal Reports would
remind us how much we have learned along the way in terms of being a
competent surgeon, reinforcing professionalism and ethical values, and of
the importance of recognizing each and every person as a human being.
There are two ways of going through the MARs. One is by year of
reporting of the MARs, chronologically from 2014 to 2004. Second is by
issues and topics (not titles of MARs) that I, as author of this book,
identified and discussed in the TPORs portion of the MARs of the surgical
residents and also in my own 2 MARs. (See the two sets of Table of MARs
in the first few pages of this book.)
The Table of MARs by issues and topics will be useful to readers who
want to look for information on specific topics upon opening of the book. It
will also be useful for readers who will use the book as a take-off point for
group discussion on specific topics.
Unlike in Volume 1 where I categorized the MARs into 3 groups, namely,
Making of a Holistic Physician, Making of a Compassionate Physician, and
Making of a Professional Physician, in Volume 2, I forego with such
categorization. The primary reason is that it is not easy to make a definite
categorization for majority of the MARs as the elements of holism,
professionalism, and compassion cannot be felt in an isolated form but in
combined and integrated form in the contents of each MAR (narration and
insight of the residents and my selected insights).
In the Appendices, I included the following for historical value:
1.
2.

Clinical Department in the Philippines (presented in the 4 th AsiaPacific Conference on Problem-based Learning in Health Sciences in
September of 2004)
List of surgical residents of OMMC Surgery who have written MARs
12
129
Appendix 5
Feedback on the MAR by Surgical Residents in 2012
Eugenette B. Saluta, M.D. (Incoming Year Level 1 in 2012)
Back when I was still rotating as a clerk in the Surgery Department of
Ospital ng Maynila, I had already encountered Medical Anecdotal Reports
from the surgery residents. At first I thought they were a nice way of giving
others a glimpse on the day to day lives of surgery residents and thought
nothing much of it. But now as a Surgery Pre-Resident, I am beginning to
understand what the Medical Anecdotal Reports stands for.
A Medical Anecdotal Report as defined by the Updated Policies and
Procedures on Medical Anecdotal Reports (Dr. Joson, 2012) is a brief
report on a medically-related event encountered by the reporter which
provided an impact on the reporter, which is worth sharing with his/her
colleagues for the promotion of good patient care. It is further
systematically classified whether the insight gained is Physical, which
involves the processes of diagnosis and treatment of a medical condition;
Professional/ Ethical, which involves the handling of the patient; or
Psychosocial, which involves empathy for the patients medical condition.
As trainees in the art of surgery, we oftentimes are burdened by patient
loads and long hours that we unfortunately become jaded to our patients
sufferings. They become mere problems that we need to solve. But the
Medical Anecdotal Report I believe somehow allows the surgery residents
to see a lesson in every encounter with a patient. This reminds them that
despite the unpleasantness of a certain situation, there is a lesson that can be
learned and applied later on. As surgeons, we should all strive for continued
quality and excellence in our every work. Thus, every encounter should be
treated as a new learning experience whether it is a novel technique in
doing a routine procedure or a way of gaining the cooperation of a difficult
patient.
3.
4.
5.
6.
7.
from 2004 to 2014

Anecdotal Feedback on the MAR in 2005
Feedback on the Volume 1 of the MARs (2013)
Online Links
This book has an online version (http://

medicalanecdotalreportsvol2.wordpress.com).
Go to the Contents page (http://
medicalanecdotalreportsvol2.wordpress.com/contents)
and click on the links for each page, MAR and article you are interested to
see and read.
In some of the MARs, there are recommended online links for further
readings. Thus, for those reading the hard copy of the book, one may have
to go online for the supplementary readings.
I wish every reader Happy Reading! If you have any concerns, questions,
and feedback, which I welcome wholeheartedly, please communicate with
me through my email (rjoson2001@yahoo.com) and cellphone (09188040304).
Surgeons of course should have excellent decision-making skills and

technical skills but our bedside manner to our patients still matters. The
patient-physician relationship could not be overemphasized. And empathy
towards others suffering as recorded in the Medical Anecdotal Reports
only confirms that we doctors are still human, capable of compassion and
understanding.
The Medical Anecdotal Reports also reminds each surgery resident the
ultimate goals of the department: A Live Patient, Minimized Complica-
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13
MAR Title: Seeing Hope and Appreciating Beauty of Life Through a

Patient with Stage IV Breast Cancer
Reporter: Onofree Larroza O'Connor, MD
Year Reported: 2014
NARRATION:
My patient was a 38-year-old female diagnosed with rhabdomyosarcoma
of the breast, left, post modified radical mastectomy (surgical removal of
whole breast with axillary dissection and removal of lymph nodes) more
than two years ago, here in our institution. She underwent radiotherapy
after surgery at Jose Reyes Memorial Medical Center. She was relatively
well until July 2014 when she experienced pain all over her body and
episodes of difficulty of breathing and shortness of breath. It was then
that she was diagnosed with stage IV of the disease with metastasis to her
lungs and bones. Although progression of this disease was expected, I
was still saddened by the bad news.
learning should not go to waste and can be utilized in creating

policies for the department, including guidelines in clinical diagnosis and
treatment.
Medical Anecdotal Reports are important to remind us that patients are
there not only to be cured, but to share in our experience as doctors. By
getting to know our patients, we know not only their illness, but also their
story, their lives, and we use all of these to improve in our work as
surgeons. Medical Anecdotal Reports are what remains of our patients, the
memories they leave behind even after they have been cured. It just goes
to show that even if our patients return back to their normal lives, we have
taken and kept a part of them. Through Medical Anecdotal Reports, we
have obtained something from them which can be used not only to reflect
on our performance as surgeons, but also to improve on how we can cure
future patients. Indeed, Medical Anecdotal Reports are a simple yet
meaningful way of knowing our patients and learning from our patients by
reliving our experience as their doctors.
She came to me one day seeking consult to relieve the unbearable pain. I
referred her to Anesthesia for pain management and advised the family to
support and make her as comfortable as possible. I also primed the
patient and the family that she was suffering from a terminal illness and
that any time soon she might leave her loved ones behind. She cried at
that moment, perhaps due to both physical and emotional agony but I
encouraged her to stay strong. I also talked to my co-residents about how
we could help the patient and her family during this trying time.
Although we knew that she was wasting away, we did everything that we
know was best for the patient. I did not consider her as a patient who
would be gone soon, but as a human being full of hope and enthusiasm to
extend her life, at least for a few more days or weeks, or even months.
What made the difference in her situation was her attitude towards her
disease. She knew and accepted the fact that she was severely ill and
decided to stay happy and grateful with what was left of her. She had a
positive outlook toward life and death. Although her body was so weak
and in pain, her mind and spirit were so strong and alive that she was able
to tolerate the surgery and radiotherapy and overcome her disease.
Currently, the patient would consult regularly for her pain management
and maintain that positive outlook. I would be delighted every time I saw
her because she reminded me that everything has a purpose. That despite
what we are going through right now, there is hope as long as we live and
every day that we are alive is a reason to be grateful.
14
127
Appendix 5
Onofree L.OConnor, MD. (Year Level 3 in 2012)
As medical practitioners, we should be constantly reminded not to treat
patients just as mere cases, as operative procedures we tally and keep track
of, or as numbers to complete a census. The dangerous side of being a
doctor is forgetting that patients are human beings. As humans, we impart
experience and through that experience, we touch other peoples lives. As
surgeons, we touch our patients lives by healing them, by curing their
physical illness, by using our knowledge and hard-earned skill to restore
their bodies to their best possible condition. When we look at it this way, it
seems that our patients have the better end of the deal. However, what we
dont see is that we as doctors also gain something from them, just as much
as they get something from us. Aside from honing our skill, these patients
touch our lives just as much as they have touched ours. They give us an
opportunity to learn, to improve in our craft, but also to remind us that we
are human, that we have emotions, and are capable of compassion. Every
patient is different, and every patient brings something new and contributes
to our experience as surgeons. Medical anecdotal reports are an avenue for
collecting these experiences with our patients and putting them to good use.
By presenting them, we learn from them, and by learning from them, we
improve as healers and agents of the medical field.
A Medical Anecdotal Report (MAR) is defined by the Updated Policies and
Procedures on Medical Anecdotal Reports (Dr. Joson, 2012) as a brief
report on a medically-related event encountered by the reporter which
brought a significant impact to the reporter, that is worth sharing with his/
her colleagues for the promotion of good patient care. It is further
systematically classified whether the insight gained is Physical, involving
the processes of diagnosis and treatment of a medical condition;
Professional/ Ethical, involving the handling of the patient; or Psychosocial,
involving empathy for the patients medical condition.
During my first year as resident surgeon, I regard the MAR as just small
sharing of personal experience with a special patient to our fellow resident.
However as I coursed through my residency, making more MAR every
year, I then realized that we are reporting more than just an experience, but
also learning. That was when I realized that MAR is not just a mere storytelling but a learning experience not only for us surgeons of this institution
but for medical interns too. Often times, Dr. Rey Joson would say that every patient is unique and many times we learn something from them. This
126
INSIGHT:
This patient made me realize more how precious life is. That no matter
what the circumstances are, to always be thankful for the opportunity to be
alive. The patient had two options: 1) to be consumed and surrender to
negativity or 2) to accept the situation and make the best of life. She chose
the latter, and became an example of somebody who never gave up and
thus served as an inspiration to all the people she encountered, myself
included.
By accepting her condition and remaining positive, she was able to overcome the disease and see the beauty of life in her own perspective, which is
unique. That no matter how hard it was, she would find a reason to get up
and live the best she could. It made me realized that everything that
happens in life is an opportunity to grow and be an inspiration to others.
She taught me to take difficult experiences in life as opportunities to further
strengthen and prepare me for all the challenges that I will encounter in my
chosen profession.
Being a resident for five years in the Surgery Department taught me and
developed in me the knowledge and values that a doctor must have that I
will carry with me wherever I go innovative knowledge to be excellent
and to render quality and up-to-date management for my patients.
As a doctor, it is my responsibility to be physically, emotionally and
mentally prepared to accommodate and manage these patients who have
placed their trust on me. I learned to be grateful and appreciate my
profession more because of the patients whom I practiced and applied my
skills and knowledge on.
I am also thankful for the team and department that I work with. If not for
them, I am not where I am now. They have been my helping hands,
colleagues, friends, and mentors, who have trained me and shared the
burdens with me, especially in dealing with patients with terminal illness.
These people taught me that everyone is accountable to each other and that
we have a responsibility to make each others lives easier and better.
Being a doctor, however, is not all about skills and knowledge. We also
have to be compassionate in dealing with the patients and keep in mind that
we are not just treating the disease. We are treating a human being.
This Medical Anecdotal Report is the last one that I am writing as I
complete my training in December 2014. As I pursue a step ahead, I will
always look back to where I was founded. I will carry with me the
15
professionalism, compassion, integrity, respect and excellence that the

Department developed in me. We are a team whose members are accountable to each other. I am a better person because of the all the people I
have encountered and the experiences that I have gone through. And I am
and will forever be grateful.
ROJOSONs INSIGHT (TPORs):
What are the things that physicians can learn from interactions with
their patients?
There is a myriad of things that physicians can learn from interactions

with their patients.
Patients are the best teachers of physicians not only in how to hone their
knowledge and skills in the practice of medicine but also on how to understand and live their lives to the fullest.
The great medical educator William Osler once said, medical education at
its best begins with the patient, continues with the patient, and ends with
the patient. Nobody disagrees with William Osler. His statement is true
as far as medical education is concerned.
patients, colleagues and every person I am able to encounter during work,

inside and outside the hospital. Not only did it develop my writing skills
but also, teaching myself not only to hear but to listen to my fellow
residents MAR and apply the insights that they were able to share. Most
importantly, the MAR taught me discipline. We dont write the MAR for
the sake of presenting one. From one of my MAR, we do our work fast,
correct, relevantly complete and appreciated. I have a hard time putting
my experiences into words, but I always take extra time and effort to do it
right, putting into mind the objective of this MAR- development of
holistic, professional and compassionate physicians.
Lastly, I appreciate that the MAR has evolved in its own way. In time, the
MAR has moved from sharing it to residents in the Department, then to
students rotating in the Department, to colleagues through the
Yahoogroups and now worldwide through Facebook. I only recommend
that we residents, who are sharing our MAR be diligent in posting. We
have to be reminded that this is not only for us but also it may help other
physicians who are able to read these anecdotes. Also, diligent and
efficient posting would help in the compilation of the MARs for the
project of compiling it into a book.
I too agree with William Osler. However, I want to expand the concept
and scope of patients being physicians best teachers. Physicians see how
patients behave when they are sick; when they are well; when they face
death; and during their last moment of life. Physicians also see the background of all these events. As a result, they learn to understand life more
and how to live their own lives to the fullest.
The two big categories of learning that physicians are getting from their
interactions with their patients should promote the development of a
holistic physician.
My concept of a holistic physician is a doctor of medicine (MD) with the
following characteristics:
A compleat physician who is highly skilled and accomplished in all
necessary and desired aspects (physician-individual-family-healthproblem-solver; physician-community-health-problem-solver; physician-manager; physician-teacher-learner; physician-researcher).
An MD with systems approach in the management of a patient, that is,
looking simultaneously at both the parts and the whole of the patients
body and person and all the internal and external factors that may
influence the patients well-being.
16
125
Appendix 5

Sheena Shayne P. Siapno, MD (Year Level 1 in 2012)
On September-October 2009, I was a rotating junior intern of the
Department of Surgery in Ospital ng Maynila Medical Center. It was then
that I first heard about the MAR. I often hear this, uttered by the
residents. Curious as I am, I asked what the MAR stands for. That
resident answered, Medical Anecdotal Report. My inquiry stopped there
and no further questions was asked.
An MD administering comprehensive and total care of a patient, that

is, covering all aspects of health (physical, psychological, and social
well-being), throughout the continuum of care (promotive, restorative,
supportive and preventive phases) and with management of the external health-determining factors (social, cultural, religious, economic,
family and community).
An MD who serves not only as a biopsychosocial health counselor but
also as a life coach.
Below is a diagram that I made to illustrate the characteristics of a holistic

physician.
Then on September 2011, I had my pre-residency in this department. Now,

I just did not hear about the MAR, I was now able to listen to residents
presenting their MAR. I did not fully understand what the MAR was for. I
just knew that they shared their own anecdotes, and their learnings from
such. However, these anecdotes opened the surgeons day-to-day activities
to the listeners/readers. It showed how they were able to deal with their
patients and colleagues in the hospital or in other places where they were
able to encounter them.
Come November of last year, we were able to experience writing our own
MAR. Before I became a part of this department, I thought that writing the
MAR was that easy - think about an experience and put it into writing. But,
when the time came that I was doing it, it was not superficial as thinking
about an event in your hospital life. It was picking the experience which
had the impact in you and at the same time, you know that it was worth
sharing. It was more than superficial-digging deep into your emotions
regarding that experience and how it taught you some lessons.
The Medical Anecdotal Report (MAR) is unique to the Department of
Surgery. The history of which, is unknown to me, but enough to say that it
started in 2004. It has become a part of the Departments weekly activities,
wherein during our conferences, assigned residents present a written report
on medical events which they experienced. These experiences are those
which have an impact on them as physicians, and from which, arises
insights that they were able to realize. These insights are then categorized
into physical, professional/ethical and psychosocial. (Details of
categorization is stated in PROJECT: MEDICAL ANECDOTAL REPORT
2012, Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg).
Link to Reporters Original MAR:

http://ommcsurgerymar2014.wordpress.com/2014/12/24/oloconnors-mar14-10-seeing-hope-and-appreciating-the-beauty-of-life-through-a-patientwith-stage-iv-rhabdomyosarcoma-of-the-breast
In my 12-month stay in this Department, the MAR project has developed

me not only to write a report but to reflect on myself every time I deal with
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17
MAR Title: Reflections on Patient Care and the Makings of a True OMMC
Surgeon
Reporter: Voltaire Samson Dela Cruz, MD
Year Reported: 2014
Appendix 4
Feedback on the MAR by 15 Surgical Residents in 2006
What do you like least in OMMC Surgery MAR and why?
NARRATION:
It was way back in the beginning of the year when I first met my patient.
He was a 53-year-old male, who was admitted in our sister hospital and
was referred to our department for Complete Intestinal Obstruction. During
my interview with him I learned that he was once a highly respected
kagawad in their area. But ever since he felt the symptoms of his
condition, his body not only weakened but also his spirit. I told him and his
relatives that we would do all that we could to treat his condition. I then
immediately facilitated his operation and performed an Exploratory
Laparotomy with Sigmoid Loop Colostomy on him. Since a rectal mass
was discovered during his operation, I advised him that he still needed to
undergo chemotherapy and radiotherapy before we would be able to fully
remove the mass. I gave him his needed referral requirements and sent him
home.
A full 8-months after his operation, I was in the Emergency Room (ER)
aiding my juniors in the management of the patients. I received a text
message from the patient that he was coming over to discuss his operation.
It had been a long time and so it took me a while to remember, who this
person was.
When he walked into the ER, I immediately knew that he was my patient,
who I had sent to another hospital for treatment. Though my patient has a
built of a giant, he appeared like a child eagerly telling me his progress in
treatment. He even told me how one resident from the other hospital
berated and walked out on him when he said that he would return to our
institution for the definitive procedure. He told me that he was greatly
impressed with the level of personal care we provided during his earlier
stay and thus he would like to come back again.
I was silenced for a moment as I felt humbled with his words. I thanked
him, facilitated his clearance, and performed the resection of the mass with
the aid of our Colorectal Consultant. After the procedure, he was up and
about in no time. As I was giving him his discharge instructions, he eagerly
asked me when he would return to me for the taking down of the remaining
protective ileostomy. Once again, I felt humbled for the great trust this man
had laid on me. I then told him that I would no longer be around for his
next operation. I told him that as long as the surgery residents remain, he
would still be taken care of when he returns.
18
Residents still need to improve on English written skills.

Became a routine.
English composition skills of many are painful to the ear. After 3years of
MAR, they havent improved since they just let others edit their
compositions as needed.
Its nice to share experience but its difficult to make because its hard to
make a literary form.
Doing it on a monthly basis. mostly I ran out of interesting stories to tell.
Sometimes, I ran out of stories to share because it is done on a monthly
basis.
Having to squeeze out a story when there is nothing interesting to write
about. Being creative is tricky when one is out of material for inspiration.
In the hospital we have so many experiences regarding patients, but

formulating a topic is somewhat difficult.
The technical writing I guess because Im not a good writer. I have some
hard times putting my feelings and ideas into words.
Recommendations:
Open discussion to the medical students for insights and reactions,
furthermore, a MAR from their experience as a medical clerk in the
hospital.
Encourage everybody to make it a habit to prepare their MAR days before
the expected presentation and avoid cramming so as to produce good
compositions.
We have some of our MAR posted at the ward. I suggest we pick up
some MAR that was presented this year and post it in our hospital lobby
(tarpaulin).
We should fast track the publication of the MARs.
I like to see our fruits of labor (MAR) be published.
123
Appendix 4
What do you like most in OMMC Surgery MAR and why?
It helps me see things from a different prospective. I was able to learn things
based on my experience and the experiences of my co-resident.
It gave me the opportunity to share my stories and insights about it to other
residents.
MAR gives me the opportunity to express myself and share some stories
about my life as a doctor. This helps me in becoming a well-rounded
person.
It is a piece of writing wherein one is given the opportunity to reflect on the
psychosocial aspect of our profession. The sharing of emotions that exhibits
the humane facet of the mechanical world of surgery. It also brings the
consultants and residents to a carefree moment during conferences thus
building camaraderie between us.
Its an effective way of learning insights from the different levels of surgery
training from Level I to level V residents including the consultants. Each
anecdotes presented in the MAR is viewed differently by each members of
the Department and each member has an opportunity to express their views
during the open discussion.
MAR serves as a very effective training tool for us residents, not just for us
to discuss, analyze, and interact with one another the clinical aspect of our
training. It also help us to polish our attitudes, stimulate us to change toward
good behavior, serve as a constant reminder to avoid mistakes. It is also an
effective tool to polish our grammar and sharpen our writing skills.
It helped me realized that treating patient is not only by giving medicine but
also understanding them as well and also it helped to express my own
experiences to my co residents and listen to their own stories as well.
INSIGHT:
The question seemed simple enough. Why do you want to go into
Surgery? My answer back then was fairly straightforward, why not? I
was confident enough in the dexterity of my hands and know well enough
in anatomy not to go into surgery. I would soon learn my lesson that these
are not enough. Throughout my five-year stay in the Department of
Surgery of Ospital ng Maynila Medical Center (OMMC Surgery), I had
learned a lot. Here are the lessons I have learned in my training:
I was taught the different techniques in performing operations as well

as the most important aspect in surgery - decision-making. Surgeons
need to make immediate, rational, decisive actions in order to save a
patients life and that is what is inculcated to me by the Department
through the Benefit-Risk-Cost- Availability Assessment Plan. You do
not simply pick a management plan and stick to it because that is the
only thing you know. The department encourages you to learn and
seek ways to better serve your patients.
The Department has also taught me the value of ingenuity. Despite
our not so stellar facilities in the hospital, we are pushed to be creative
in our management. We might not provide the ideal set-up but we do
know what we can provide and when and where to refer in order to
help our patients.
The Department has also taught me the value of respect. It does not
mean however, that we lose our individuality in following our seniors.
This is the only surgical training department that I know that feels
more like a family than a strict, rigid hierarchy. But we also do not
forget to value our seniors and consultants opinions. There is a
reason why they have already reached their status. Their suggestions
to us of course are value added with the weight of their experience.
Lastly, the Department has taught me the importance of establishing a
good patient-physician relationship. It will foster a harmonious
management of your patients condition with the added benefits of
minimizing complaints if ever your original plan accidentally does
not push through. And most importantly it keeps our humanity intact.
Ours is a very busy, laborious field. It is easy to become robots,
spewing out orders, carrying out our procedures. But knowing the
value of maintaining rapport with our patients enables us to slow it
down and remember that our patients, are humans. We should strive
for the best optimal care for each and every one of our patients.
There are other lessons that my training in OMMC Surgery has taught me.
Now as I walk in the hallways, I feel that I am truly blessed to be part of
our Department. I will truly miss the department conferences, where each
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19
of our actions are scrutinized in order to mold us to become competent

surgeons; our consultants, for providing wisdom in our diagnostic and
surgical queries; and most of all to the surgery residents, for being a second
family to me. Hopefully, when I step out the hallways of our hallowed
institution, I could truly become the surgeon that the Department can be truly
proud of.
The Medical Anecdotal Report as a Feedback and Evaluation Tool
The above article is a Medical Anecdotal Report (MAR) of Dr. Voltaire de la
Cruz written on his last 2 months of training in the Department of Surgery
of Ospital ng Maynila Medical Center (OMMC Surgery).
The MAR is a teaching-learning tool as well as a feedback and evaluation
tool of the OMMC Surgery since 2004.
Through the MAR, the trainees gain insights or learning through reflection
and analysis of the event. They experience all aspects of physician-patient
biopsychosocial interaction. They are given opportunities to be expressive
and to polish their written communication skills. Through the MAR, the
faculty are able to observe and evaluate the cognitive and affective levels of
competency of the trainees.
Appendix 4
What do you like most in OMMC Surgery MAR and why?
It gives us the opportunity to express our actual experiences in managing
and interacting to our patients. This is a good training ground for us to
develop our physician-patient relationship. It is also nice that we are
required to report it thru e-mail and thru actual presentation. This way
others may learn and vice-versa the reporter also learns from them based
on their comments.
The narration of the experience of the surgeon.
The thinking process, wherein you are looking at your experience as a
whole, not just the good side but also the bad side and learning from it.
It helps me express my thoughts and emotions as well as enriched my
vocabulary in writing narrations about patients and their management.
Learning what others are thinking that they usually fail to share.
Learning from the success stories of others as well as from others
mistakes (not to commit them), MAR opens the eye to a number of
perspectives on a similar scenario, mostly from the reactions from the
audience after presenting a MAR.
In the narration part of the MAR, we can see an anecdote in which Dr. de
Cruz was able to elicit a patients delight, which is one of the targets in the
training program of OMMC Surgery.
The thing I like most about MAR is that it is an avenue to for me and for
the other MAR writers to share our experiences which would otherwise
not be considered as informative in other for a. It breaks down barriers in
such a way that we can share emotions felt, the feelings involved in being
a doctor. Through this form of sharing, other persons will learn from our
experiences. What would otherwise be a personal or intimate lesson
becomes a lesson shared for others to digest.
In the insight part of the MAR, we can see a narrative feedback and
evaluation of the personal learning of Dr. de la Cruz as well as the training
program of OMMC Surgery.
As the saying goes experience is our best teacher. MAR gives us the
opportunity to make a reflection of our own experiences in dealing with
our patient and everybody in the hospital. Then we learn in the process.
The achievement of the abovementioned objectives of the MAR is clearly

seen in the MAR of Dr. Voltaire de la Cruz, particularly on the feedback and
evaluation aspect.
Such is the beauty of the MAR that Dr. Daniel Ong, a neurosurgeon, and Dr.
Edgardo Penserga, a general surgeon, said in response to receiving the
Volume 1 of the Medical Anecdotal Report in 2013 that the MAR should be
part of the curriculum of all surgery training programs.
20
It is through this project that we, residents are able to share our
experiences that eventually become venue for self growth, personal and
training wise. Moreover, MAR developed our English and literary writing
skills.
121
Appendix 4
Reactions to 29 Statements
Key: SA Strongly agree; A Agree; UnC Uncertain; D Disagree; SD
Strongly Disagree
SA A Un D SD
Statements on OMMC Surgery Medical Anecdotal
C
Reporting (MAR)
Through the MAR, I have improved on my relational
15
skills with my patients, their relatives, my colleagues,
and my superiors.
Through the MAR, I was given the opportunity to be
15
more expressive.
Through the MAR, I was given the opportunity to
polish my written communication skills.
15
Through the MAR, I have improved on my English

composition skills.
The MAR can serve as an evaluation tool of students
learning.
Through the MAR, the cognitive domain of
competency of the students can be evaluated.
15
Through the MAR, the affective domain of

competency of the students can be evaluated.
The MAR has contributed to my discipline in terms of
following instructions and formats.
The MAR has contributed to my discipline in terms of
submitting my report on time.
15
Overall, I am satisfied with the MAR of OMMC

Surgery.
I recommend we maintain the MAR but we should
keep on refining to make it more effective and
efficient.
14
120
Below are recommended links for further readings on the MAR:

https://sites.google.com/site/medicalanecdotalreports/history-of-mar-in
-ommc-surgery
http://omsurg-mar.tripod.com
http://medicalanecdotalreportsvol1.wordpress.com
15
15

http://ommcsurgerymar2014.wordpress.com/2014/12/26/vsdelacruzsmar-14-10-reflections-on-patient-care
15
15
1
15
21
MAR Title: Grace Under Pressure

Reporter: Glen Mark Macatiag Gervacio, MD
Year Reported: 2014
NARRATION:
Appendix 4
I was having a conversation with my intern who was on her last day of duty
while waiting for patients at the Emergency Room. My junior was with me
when her phone rang. I didnt mind her at first but my attention was caught
as she uttered my name. Then after her phone conversation ended, she told
me that the senior resident from the Department of Internal Medicine was
requesting a Senior Surgery Resident to do a central line for their patient. I
asked them why it had to be me. It had been three years since I did my last
Central Venous Pressure (CVP) line insertion. I was told him that the patient
was their Cardiology consultant. He was a Very Important Person (VIP)
patient so they had to request for a senior resident. I was really hesitant, not
because I could not remember how to do the procedure but because the
patient was a consultant. He was a highly respected man in his field. A few
minutes after, the senior again called to inform us that all the materials were
now ready. I just smiled, shook my head and said, Okay, Ill do it.
When I arrived at the Medical Intensive Care Unit, I saw that several
consultants were surrounding the patient. The situation was a little
intimidating. I felt sweat starting to form on my forehead as I was beginning
to do the procedure. My heart was pounding as I worried if I would be
successful in a procedure that I had not done in a long time. It was fortunate
that the circumstances were in my favor and I was able to insert a CVP line
with ease in this VIP patient.
INSIGHT:
Central Venous Pressure line insertion is usually delegated to the junior
members of the Surgery team. I have done this several times when I was in
my first two years of training and felt confident in this surgical competency.
During my intermediate years, I am usually called to help my juniors during
difficult cases. However, as I have narrated above, my composure was
rattled. I felt that it would be embarrassing if I would not be able to insert
the line. I felt anxious that I might need to call on my junior to help me if I
fail to do it by myself. I was concerned that I will lose face with my juniors
in case that happens.
22

Strongly Disagree
SA A Un D SD
C
Reporting (MAR)
The insights and learning acquired through MAR can
15
supplement or complement the guidelines derived
from conventional evidence-medicine methodology in
patient care.
MAR-initiated practice guidelines such as how to deal
with indigent patients, irrational patients,
conflict in management with medical colleagues, etc.
can facilitate training of residents in developing their
relational competency and in their day-to-day
management of patients.
15
MAR is a form of narrative medicine defined as

medicine practiced with narrative competence and
marked with an understanding of these highly
complex narrative situations among doctors,
patients, colleagues, and the public. (Dr. Rita Charon
of Columbian University)
15
Through the sharing of MAR, I can help my

colleagues improve on their patient care.
15
Through the MAR, I have improved on my patient

care as a whole.
15
Through the MAR, I have placed more emphasis on

the psychosocial care of patient and have improved on
this aspect.
Through the MAR, I have become more aware of the
bioethical issues involved in patient care and have felt
improvement in this aspect of my patient
management.
14
Through the MAR, I have improved on the care of the

physical aspect of my patients problem.
14
119
15
Appendix 4
Strongly Disagree
SA A Un D SD
C
Reporting (MAR)
The MAR is a form of learning through reflection.
15
Through the MAR, I can reflect on significant insights 15
derived from patient encounters, acquire learning, and
share them with my colleagues.
Through the MAR, I was able to experience and fully
15
grasp the concept of learning through reflection.
Through the MAR, I have developed the habit to put
14
1
importance on all aspects of physician-patient
biopsychosocial interaction and to analyze them for
insights and my continuous learning.
MAR as a reflective learning tool is a very strong
learning strategy in patient care.
15
MAR as a reflective learning tool has helped me

discover things in patient care that I have not known
or realized before.
MAR as a reflective learning tool has helped
reinforced the philosophies and principles on patient
care that I have held before.
MAR as a reflective learning tool has helped me
change the philosophies and principles on patient care
that I have held before.
MAR as a reflective learning tool has provided me the
stimulus for further learning, research, and
investigations on patient care.
Though frowned upon as a basis for decision-making
in patient management, experience and insight derived
from MAR, when properly used, can serve as basis
for patient care.
15
118
15
15
As Henry Kissinger said, A diamond is chunk of coal that is made good

under pressure. Surgeons almost always face pressure in every decision
that they make. Pressure to help improve our patients, save lives and make
a difference. In coping up with the problems and pressures in our
profession by dedication and commitment, we will emerge successfully
and become valuable, stronger and more capable.
The pressure I felt that day was multifactorial, but it only strengthened
myself, that an ordinary resident like me, put into pressure could be the
best that I could be. It was an overwhelming experience, but also a
humbling one, reminding myself that in this world, we could not be that
superhero whom people look up to, but we could be someone who could
save someone elses superhero - nothing is more rewarding than that.

How should physician-surgeons prepare for and manage situations
which require them to perform a grace under pressure action?
Grace under pressure is a situation in which a person feels nervous but is
able to perform an action well in the face of pressure. The pressure is
usually the anxiety or unpleasant feeling of self-consciousness, that is,
when one feels that he is being watched or observed.
15
14
Pressure in doing the procedure swiftly and accurately built up as the other
consultants from other departments kept an eye on me. The pressure I
experienced pushed me to do my best despite a challenge. At the same
time, I felt honored with the task given to me, when they were not able to
call upon a consultant to perform the procedure. Saving that patient does
not only mean saving the patient himself but saving more lives. I was an
instrument in his healing. He was not an ordinary patient whom we would
encounter every day.
All physician-surgeons will invariably encounter situations in their lifetime

in which they have to perform a grace under pressure action. They have
to be prepared for such situations.
The situations commonly include public speaking and presentation and
doing medical procedures (both operative and non-operative) with an
audience watching. The anxiety pressure is intense and greater if the
audience consists of people whom the physician-surgeons feel are more
superior than they are superior in terms of rank and experience.
23
The strategies in preparing and managing such situations consist of the

following:
1. accepting the fact that they will be encountered one day and
repeatedly;
2. making a resolve to prepare for the encounters;
3. developing confidence in accomplishing the performance of actions
and procedures that may one day be exposed to public scrutiny; and
4. continually controlling and eventually overcoming the anxiety or
unpleasant feeling of self-consciousness through desensitization,
that is, by repeatedly accepting to do grace under pressure actions
until one gets use to such situations and the pressure dissipated.
http://ommcsurgerymar2014.wordpress.com/2014/12/24/gmgervacios-mar
-14-05-grace-under-pressure
24
Appendix 3
Convey to Dr. Guerra that I was impressed and liked very much his
anecdote Beyond Hospital Walls. It is very true that good patient care
transcends hospital walls!! His article coincides perfectly with what I have
always been teaching my students and residents on the ethical values of
personalized patient care. Unfortunately, today, as I saw it in our own
PGH, patient care by some of our doctors has become too mechanical and
the human touch is LOST. I hope more residents will read Dr. Guerras
article and again. Kudos to you for stimulating your residents to come up
with much needed and thought provoking anecdotes like Dr. Guerras.
Antonio Limson, MD
General Surgeon
March 1, 2005
I appreciate very much the anecdote submitted by Dr. R. Chan. It
distinctly shows her unprejudiced attention to details and true compassion
and concern for a patient whether a law breaker or any ordinary patient. I
am extremely hopeful that there will be more doctors like her. May her
tribe increase. My hats off to her. KUDOS to Dr. R. Chan!
Antonio Limson, MD
General Surgeon
May 23, 2005
Thank you for writing to us. Your short e-mail surely tells us that there are
certainly a lot of heroes in the medical profession working quietly to
promote and retain the special values of caring and compassion. I visited
the link that you shared with us, and based on the project write-up, I am
confident, you must have touched a lot of physicians and their patients in
some inspiring way through the insights gained from the reports.
Susan EBL Enriquez
National Coordinator Joy of Caring Advocacy, Biomedis, Inc.
2005
117
Appendix 3
I could not help but feel for the emotional burden that Dr Hazel went
through, to say the least. Because she was only a first year resident then, she
had to follow what was the order. I will not make any criticisms of the
hospital and departmental policy but I believe we should always respect and
uphold ones basic right to refuse a procedure, most of all in death. If we
allow patients to refuse blood transfusions because of their religious beliefs
even if this may mean the demise of our patients, then we must respect
ones religious belief when it comes to, the least of all, an autopsy. If this
was already a Stage IV Gastric CA, would the autopsy have contributed
much to how we would manage a similar case in the future? Or was the
procedure an academic exercise? The pain of losing a loved one was too
heavy a burden to carry for the husband. I also understand why he did what
he did.
The anecdotes on the ileal perforation and Dr. Turingans advanced breast
ca, again focus on personalized and complete patient care and religious
follow up care. This is what we have been trying to teach our residents, and
I hope more and more people will read these articles. Why not compile all
of these anecdotes and make a book. It will serve a lot for young surgeons.
The message of Dr. B. Devesa on family affairs is very timely. DONT
FORGET YOUR FAMILY, even how busy you are. Marc is becoming
guilty of this, he sees us only once in three weeks, claiming hes always tied
up with work. I believe no matter how engaged one is in work, one will
always find the time for certain obligations, like the family!!. Commend
your residents for their excellent and timely contributions.
Antonio Limson, MD
General Surgeon
March 1, 2005
MAR Title: Stepping Up To Be a Senior Resident

Reporter: Rembo Martinez Aguda, MD
Year Reported: 2014
NARRATION:
After doing the rounds in the wards, I went down to the emergency room
(ER) to check on the patients and guide my juniors in the management of
each patient. My junior resident referred a 38-year-old male who was
transferred from a local hospital diagnosed with acute appendicitis with
phlegmon formation. Together with my junior, we did our history taking and
physical examination. I agreed with the diagnosis and the plan to do an
appendectomy. The patient was eventually brought to the operating room.
After thirty minutes, my junior resident called for help and I sent the
immediate senior resident to assess and help in the operation. Less than 30
minutes had passed when she called me and reported her findings. She described a hard, nodular cecal mass with adherent omentum. She also noted
multiple seedings and nodules on the bowel, omentum and peritoneum. At
that moment, she was considering malignant tumor versus tuberculosis. I
went in the operating room and saw the exposed mass. I decided to make a
low midline incision to have better exposure. As I reassessed the mass, I
noted a perforation in the ileal and cecal area. I decided that I needed to
perform a formal exploratory laparotomy, right hemicolectomy and ileocolostomy. I called my senior resident to inform him my findings and
planned procedure. I have started to mobilize the mass when my senior
resident came which brought me relief. There I realized that I was still not
competent enough to perform such a complex operation. I found out that I
needed more guidance and teaching of surgical skills from my senior.
Together with my senior, we performed the operation. Subsequently, we
discharged the patient without any complications. Looking back at the
situation, I realized that being a senior takes a lot of responsibilities and
challenges that I still have to conquer and embody.
INSIGHT:
A surgical training program is designed so that each year level has a required
competency. It means that as a resident go to a higher year level, he/she is
expected to be more competent in handling complex cases and difficult patients. In the said set up, senior residents maintain a relationship to the junior
residents similar to a younger brother. The former should guide and help the
latter in their training. The seniors also teach the juniors their experiences of
the profession.
116
25
In this encounter, I was able to experience being a member of a family

outside our home. During residency, I have experience the comfort of
having someone who would always be there to help and guide me during
my junior years. I also have felt the excitement of being responsible to the
younger colleagues during the senior years.
Being a senior surgery resident entitles you to many privileges but more
responsibilities and obligation. Responsibilities and obligations include
performing major operations, teaching juniors the techniques in surgical
operations, guiding juniors from preparing patients pre-operatively until
post-operative care and attending to administrative issues. These
responsibilities are easier said than done. Being able to perform efficiently
as a senior requires not only enough theoretical knowledge and competent
skills, but tons of hardwork, patience, and understanding. Coupled with
these values, being a senior requires us to step up, ranking high in the
hierarchy, but we should always remember how our Department and the
seniors before us taught us to be humble. We need not gain respect by
acting as the typical senior. An ideal senior instead is one who sees
with competence, listens with perseverance, feels with compassion, heals
with utmost care and deals with his/her colleagues with respect.
Hence, as I go up the ladder of my training, I carry with me these thoughts
and I need not deny that I am having nightmares as I feel the fear of not
being able to play the role of being an ideal senior. The choice is not on
me, so I take this as a challenge to hurdle, not only to finish my residency
but to fulfill my personal goal, and to be able to leave a legacy that my
juniors too, shall learn.
How should junior resident-physicians prepare themselves for the day
they will become senior residents, particularly a Chief Resident?
In the training of physicians, after the physician licensure examination, the
certified physicians can pursue further specialty trainings such as General
Surgery; Ophthalmology; Pediatrics; Internal Medicine; ObstetricsGynecology; Orthopedics; etc. The latter can range from 3 to 5 or even
more years of training. During this time, they are usually called residentphysicians. After the specialty training, they can opt to go for more
training, this time subspecialty training. During this time, they are usually
called fellows such as fellow in Cardiology; Neonatology; Head and Neck
Surgery; Hand Surgery; etc.
26
Appendix 3
I am touched by your efforts to make your residents so aware of their deeper
emotional reactions to the complex situations they are in and the wonderful
people they come in contact with. More so to find beauty in the midst of
destruction, misery and suffering. The practice of medicine, surgical and
non surgical, is a dangerous ground for doctors as it is a field that can make
one feel so powerful, dominant, critical and insensitive to self and others. I
feel embarrassed that you the surgeon has done a sensitivity program
while I have not done my bit to contribute to make our work more humane
and meaningful to others but more so to ourselves. You are an inspiration.
Thank you. You deserve the accolades and recognition.
Connie Salazar-Aleta, MD
Psychiatrist
Feb 16. 2005
Hi! I rarely open my email. Just got to read your anecdotal reports. Kudos!
Its something even we in the field of Psychiatry dont even do. I might just
do that with the psych residents. Thanks for the heart & the inspiration.
Laureen Conanan, MD
Psychiatrist
April 25, 2005
Thank you, Sir, for allowing us to hear the anecdotal reports of your
residents. It gives us also opportunities to re-live our surgical residency
days, to say the least. May we have the kind of humane and compassionate
doctors and surgeons that you are trying to mold, I hopefully wish, fill up
our world.
Randy Abdullah, MD
March 25, 2005
I read the interesting and touching Anecdote of Dr. Rommel de Leon. I
admire his patience and understanding and the incident reminded me of my
days as a young PGH resident assigned to the ER. I met the same
MAKULIT individuals, and yes, parents, too, I just cant recall if I then
demonstrated the same degree of patience as Rommel. Tell him I salute him
and I have to admire you for stimulating your residents to share their
experiences, pleasant or otherwise, or on tragic occasions like the Tsunami
Story of one of your residents, sorry I cant recall his name.
Antonio Limson, MD
General Surgeon
Feb 23, 2005
115
Appendix 2
Department of Surgery
Ospital ng Maynila Medical Center
List of Surgical Resident Staff who have written MARs
from 2004 to 2014
Hazel Z. Turingan, MD
Marlou O. Padua, MD
Redomir P. Roque, MD
Rubi Ann Claire D. Chan, MD
Derrick Chua, MD
Janix M. De Guzman, MD
Maria Cecilia T. Leyson, MD
Oliver S. Leyson, MD
Jose Mario Amado M. Pingul, MD
Nolan O. Aludino, MD
Martin Joseph S. Cabahug, MD
Rommel Q. De Leon, MD
Roderick S. Mujer, MD
Jeffy Guerra, MD
Trisha Daughterty Medina, MD
Benjamin C. Deveza, MD
Harvey Balacuting, MD
Edwin Estonilo, MD
Roberto Gonzales, MD
Michelle Galang, MD
Jonathan Malabanan, MD
Michael Angelo Sunaz, MD
Edelweiz Velasquez, MD
Allan Gabriel, MD
John Llyod Fonte, MD
Alma Jawali, MD
Robelle Joan Peralta, MD
Marlon Caravana, MD
Ariel Celzo, MD
Aristoteles Ilarde, MD
Onofree OConnor, MD
Glenn Gervacio, MD
Voltaire Dela Cruz, MD
Rembo M. Aguda, MD
Jenny Vi H. de Castro MD
Angelica Montesa, MD
Jessie B. Oracion, MD
Romeo C. Abad, MD
Lucas Riel Bersamin, MD
Princess Beverlie Co-Oracion, MD
Marco Antonio Sanico, MD
Sheena Siapno-Feliciano, MD
Glenn Villanueva, MD
John Alexis Canlas, MD
Marinelle Maulion, MD
Eugenette Saluta, MD
Mark Velez, MD
Owen Lizaso, MD
Allain Abad Alvez, MD
Patrick Concepcion Gagno, MD
114
This TPOR will focus on the resident-physicians.

As mentioned, the minimum duration of a specialty training is 3 years. It
can be longer, say 5 years or even more, such as 6 years.
Pertinent to the topic of my TPOR, the resident-physicians are broadly
classified into junior and senior residents. Senior residents are those on the
upper levels of the training period and junior residents on the lower levels.
The resident-physicians can also be more specifically classified in terms of
year level in the training period such as 1st year, 2nd year, 3rd year, 4th year,
and 5th year, that is, if the training period is 5 years. There is usually a
Chief Resident each year who is selected from among the graduating senior
residents to be the head of the team of physician-residents.
In this TPOR, when I use the phrase senior residents, I will be referring
to the Chief Resident and Deputy Chief Resident collectively. I will also
use a 5-year training period as an illustration.
As early as their first year in training, the junior residents interact and are
exposed to their senior residents. As early as this time, in preparation for
the future, they must know the role; associated authorized functions; duties,
obligations and responsibilities; authority, power, and privileges of their
senior residents aside from knowing theirs as junior residents. As early as
this time also, again in preparation for the future, the junior residents must
know the competencies required of the senior residents and start
developing them.
Generically, the training of the resident-physicians is not limited to the
specialty per se or the so-called technical competencies of the specialty.
The educational program is holistic in that it includes also training to
become specialist-physician-teacher; specialist-physician-learner; specialist
-physician-researcher; specialist-physician-community health problem
solver; and specialist-physician-manager (and leader). Generically also,
the training is incremental starting from basic (during the junior years)
progressing to advanced learning and mastery of required competencies
(during senior years).
27
The following table should be used by the resident-physicians in

developing and keeping track of the competencies expected of them during
the entire period of their training.
Specific Competencies
Expected
YL
1
YL
2
YL3
YL4
Technical Competencies (Specialty

required Competencies)
Specialist-Learner
++
+++
++++
YL5
(senior
resident level)
+++++
++
+++
++++
+++++
Specialist-Educator
++
+++
++++
+++++
Specialist-Researcher
++
+++
++++
+++++
Specialist-Community
Problem Solver
Specialist-Manager
++
+++
++++
+++++
++
+++
++++
+++++
Specialist-Leader
++
+++
++++
+++++
Teamship Skill
++
+++
++++
+++++
Communication Skill
++
+++
++++
+++++
Presentation Skill
++
+++
++++
+++++
*YL Year Level

** + to +++++ - from basic or minimum level (+) of competency expected
to achieve to the highest level (+++++)
As early on in their first year of training, the residents should start
developing all the competencies listed in column 1 on their initiatives as
well as using the facilitation programs provided by the department. The
department residency training program should spell this out and specify the
criterion reference for each competency that must be achieved in each year
of the training period. The highest level of competency must ideally be
achieved by the fourth year to the fifth year.
Once a 5th year resident has achieved the required competencies listed
above and knows the role of a senior resident (and that of a Chief Resident)
and its associated authorized functions; duties, obligations and responsibilities; authority, power and privileges; he should be ready and qualified to
assume that position.
28
Appendix 1
Clinical Department in the Philippines
Nolan Aludino, MD
Reynaldo O. Joson, MD, MHPEd, MS Surg.
(Presented in the 4th Asia-Pacific Conference on Problem-based Learning
in Health Sciences in September of 2004)
Abstract
Up to this time, medical anecdotal reporting is used solely in research
methodology discussion and is usually frowned upon when invoked in
patient management. This paper reports on the use of medical anecdotal
reporting (MAR) as a teaching-learning activity in the Department of
Surgery of Ospital ng Maynila Medical Center. MAR is operationally
defined as a brief written report on an actual medical event that involves
an actual patient seen by a trainee. The medical observation must have an
impact on the trainee in terms of insight gained and which the reporter
thinks is worth sharing with colleagues. The insight may come in three
forms, namely: a discovery; a stimulus for investigation and research; and
a reinforcement or validation of previously held philosophy and principles.
Each clinical trainee was required to submit at least one brief MAR a
month, posted in the Departments group email and trainees online
journal and presented in the Departments conference. Formative
evaluation of the MAR showed that it could be used as an evaluation tool
by the faculty as well as a meaningful learning activity by the trainees.
Through the MAR, the trainees gained insights or learning through
reflection and analysis of the event. They experienced all aspects of
physician-patient biopsychosocial interaction. They were given
opportunities to be expressive and to polish their written communication
skills. Through the MAR, the faculty was able to observe and evaluate the
cognitive and affective levels of competency of the trainees.
The full paper can be seen in:
https://sites.google.com/site/medicalanecdotalreports/mar-as-a-teachinglearning-activity-in-ommc-surgery
113
These, in short, describe the framework how junior resident-physicians

should prepare themselves for the day they will become senior residents,
particularly a Chief Resident.
http://ommcsurgerymar2014.wordpress.com/2014/12/24/rmagudas-mar14-10-stepping-up-to-be-a-senior-resident
112
29
MAR Title: Good Intentions Without Proper Decisions Is Hopeless

Reporter: Romeo C. Abad MD
Year Reported: 2014
Epilogue
NARRATION:
I completed Volume 2 of the Medical Anecdotal Reports.
It was really a knock on the conscience to immediately decide what was

the best thing to do for my patient. Unfortunately when I realized I made
a bad decision it was too late. A 74-year-old female came into the
emergency room with complaints of generalized body weakness,
difficulty of breathing and a resolving wound on her right leg. Since the
patient was a diabetic with a wound on her leg, she was triaged to us
(Department of Surgery). We immediately did our history and physical
examination on the patient. Based on our assessment of her right leg, we
decided that no further surgical intervention was warranted and her
medical condition should be immediately addressed. We then ordered the
patient to be transferred to the Department of Internal Medicine. The
Internal Medicine residents also did their assessment but decided that
they would not admit the patient to their department. Instead they would
only actively co-manage the patient with us. Professionally and calmly, I
did raise an argument on their stand but they were insistent. Three days
had passed and seeing the condition of the patient slowly deteriorating in
the emergency room, I again asked a resident of Internal Medicine if her
department still would not take and admit the patient. She said she
already referred the patient to her senior and they still decided that they
would just actively co-manage the patient. Out of pity and rightful notion
that the patient really needed an admission, I admitted the patient to our
Surgery ward. While the patient was in the ward, we managed the patient
the best way we could. We noted that she was also being seen by the
residents of Internal Medicine. But even so, there was still the sense in
me that the patient was not receiving the optimum medical supervision.
Two days passed, the patient continued to deteriorate and later on
expired. Later in the week, I was reminded that that even though I had the
good intentions, I still should have the right decision of not admitting the
patient into our Surgery ward but in the Internal Medicine ward to have a
better medical supervision.
The template and framework that I made in Volume 1 facilitated the

publication of Volume 2.
INSIGHT:
In Volume 2, I decided to maintain the number of 25 MARs that I started in

Volume 1.
In Volume 2 also, I still included two of my personally written MARs to
make a total of 25, the other 23, written by my surgical residents, current
and past. The reason for inclusion of my MARs is to bring out the value of
role modeling on my part.
The main objective in the publication of the MARs is to advocate the
development of holistic, professional and compassionate surgeons and
physicians. I hope all the MARs in Volume 2 have somehow brought out
these values.
I would like to request all readers of Volume 2 to send me feedback
through email (rjoson2001@yahoo.com) or through my cellphone (09188040304).
Please give me feedback particularly on the following:
Usefulness of the book in the advocacy for the development of holistic,
professional, and compassionate physicians in the Philippines.
How the surgical residents and I fare in terms of English writing skills
in the context of a physician who are expected to write technical
medical reports, not literary prose.
Thank you very much.
I hope to come out with the next volume in 2015.
Good intentions without proper decisions are hopeless and proper

decisions without good intentions are distant. Good intentions and proper
decisions should come hand in hand. The hospital offers services of
different medical subspecialties. Every patient should be managed by
doctors most capable of handling them. I admitted the patient to our
Surgery ward out of sympathy. What I learned from this experience was
30
111
numbness on the neck and shoulder pain that would usually occur after a
radical neck dissection. NOTE: In the early years of my practice, my
tendency in dealing with cancer that should be treated with surgery had
been radical surgery. Over years, I have tempered my radical approach. If
the patients tumor can be conservatively removed with adequate margins,
then I do this. If not, I will be forced to perform radical surgery if just to
be able to remove all gross tumor adequately.
should be more aggressive in fighting what I know is the best for the
patient. I should not have succumbed, conceded, or yielded my stand if I
thought it was the best thing to do. I made a decision way short from
what should have been done. It was one of the lessons for me that brick
by brick I am trying to piece up to be wiser and be a better senior
resident in the years to come. In as much I would like to delay or wish
upon the stars meeting the same challenge would not happen, sooner or
later I would be on call in every difficult decision-making regarding a
patient in the hospital. I must prepare myself equipped with lessons like
this so that I can also guide our junior residents in handling such kind of
challenge. I remember one of our consultants saying she was confident
that when we get out from this institution we would be good doctors in
the society. For this to come true, we should be fight what is right.
How to Avoid and Manage Conflicts in Department Assignment of
Patients for Inpatient Admission
Conflicts in department assignment of patients for inpatient admission
are commonly encountered in hospitals, both private and government,
but more common in government hospitals with departmentalization and
residency training programs.
The scenario in a government hospital with medical specialty
departments and with corresponding training programs (Level 3 by Department of Health Classification as of 2014):
A patient goes into the emergency room of the hospital.

A triage has to be done in the emergency room.
After full medical assessment, a decision has to be made on department assignment in terms of continued treatment in the emergency
room and inpatient admission, if warranted.
To facilitate department assignment of patients for inpatient admission

and, more importantly, to avoid conflicts and ill-feelings between and
among the medical specialty departments, inclusive of consultants and
residents, the following are recommended:
110
Policies on department assignment of patients these should be

collegially agreed upon by all the medical specialty departments;
clearly stated in a document; effectively deployed (communicated,
understood, oriented, and implemented) to all concerns, particularly
the consultants and residents; and continually reviewed for
improvement and refinement.
31
Conflict management procedures how to resolve conflicts in the

recommendations and decisions of medical specialty departments on
department assignment; the procedures should be collegially agreed
by all the medical departments; clearly stated in a document;
effectively deployed (communicated, understood, oriented, and
implemented) to all concerns, particularly the consultants and
residents; and continually reviewed for improvement and
refinement.
If the two abovementioned measures fail to prevent and resolve a conflict

in department assignment, there are two more measures to harness if
only to give quality service to the patients.
One measure is to exercise compassion for the patient by the physicians
of the conflicting medical specialty departments. This was exactly what
Dr. Romeo Abad did admitting the patient to his department to break
the standstill - and he did it because of compassion to the patient.
The other measure is to have a hospital policy to provide quality service
wherever the patient is admitted. Department assignment should not
always mean that the physicians where the patient is admitted should be
the one taking full responsibility in managing the patient. It may mean
that the physicians who admitted the patient just accommodated and
admitted the patient to their department so that the quality service can be
continued despite the conflict on department assignment. The physicians
from the other departments involved in the conflict of department
assignment who have roles and responsibilities in the patient
management are expected to continue to provide quality service to the
patient admitted outside their departments.
http://ommcsurgerymar2014.wordpress.com/2014/11/05/rcabads-mar14-09-good-intentions-without-proper-decisions-is-hopeless
MAR Title: Long Life Span of Patients with Thyroid Papillary

Carcinoma and Balancing Conservative vs Radical Surgery in
Cancer Patients
Reporter: Reynaldo O. Joson, MD
Year Reported: 2004
NARRATION:
G. M. from Antique was a patient of mine for her papillary thyroid
carcinoma. In March, 1984, the first time she consulted me at age 63, I
did a total thyroidectomy, wedged resection of the esophagus, resection
of the left recurrent laryngeal nerve with sternocleidomastoid
myocutaneous flap. She had her first recurrence of her papillary thyroid
carcinoma then. The initial operation was done in Antique in 1981 (3
years before I did my first operation on her). Because of an esophageal
leak, I did a pectoralis myocutaneous flap on April 14, 1984 with
subsequent resolution of the esophagocutaneous fistula.. In 1985, she had
a neck node recurrence, which I excised. She had 3 neck node
recurrences thereafter, in 1986, 1988, and in 1991 (she was 70 years old
at this time). In all these recurrences, I just did excisions, rather than a
neck dissection. The last time I saw her was in 1991. I did not see her
thereafter until a relative of hers reported to me on May 5, 2004 that in
2003, GM died of old age in her sleep. Apparently, she did not die
from a recurrence of her thyroid cancer. Attached is a picture given to
me by the relative showing GM celebrating her golden wedding
anniversary in 1992.
INSIGHT:
The long life span of patients with thyroid papillary carcinoma GM
lived for 22 years after her first surgery; 19 years after the first primary
thyroid recurrence for which a radical surgery was done to control the
primary tumor; 18 years after a neck node recurrence. This anecdotal
report on the life span should temper the physicians usual thinking that
patients over 45 to 50 have poor or poorer prognosis. It should help
physicians put into proper perspective when reading published papers
that say old patients have a poor or poorer perspective and therefore,
should be treated with a more radical surgery.
The surgical management that I did shows a balancing between radical
and conservative surgery in decision-making. I did a radical surgery to
control the primary tumor. I did a conservative surgery on the neck node
recurrence. The end-results of these decision-makings were adequate
disease control and acceptable quality of life, one that had no significant
32
109
In addition, the life plan of the resident-physician has to be factored in the

final decision-making on whether to quit or not to quit the training
program. The life plan consists of the plan of the resident-physician
formulated before he got sick which consists of his aspirations with
timelines. It could also be a life plan that has been formulated or adjusted
after he got sick.
Many people have to be consulted. Aside from the attending physicians,
immediate members of the family, supporters and friends, the training
officer and the department chair should not be left out in the consultation
and seeking for advices and help.
In this Medical Anecdotal Report (MAR) of Dr. Hazel Turingan in 2004
in which she described how she coped with the challenges of having a
heart disorder, we see that she did not quit her residency program in
General Surgery at the Ospital ng Maynila Medical Center Department of
Surgery (OMMC Surgery). She finished it in 2004, 3 years after her
heart operation on the Valentines Day in 2001. For sure, the factors that
I mentioned above were considered and were deliberated by Dr. Turingan
in her decision not to quit (namely, average lifespan left long; degree of
disability not too severe particularly after her operation; negative effects
of treatment on her training she took a leave of absence and tried to
come back as soon as possible as indicated in her MAR; financial
resources she was able to cope somehow; and life plan she was
committed to persevere to finish general surgery).
Postscript:
After her general surgery residency in OMMC Surgery, Dr. Turingan
went for a 3-year fellowship in thoracocardiovascular surgery in the
Philippine General Hospital. She is currently (2014) the Chairperson of
the OMMC Department of Surgery.

http://ommcsurgerymar2004.wordpress.com/2014/12/28/hzturingansmedical-anecdotal-report-04-08-valentines-day
MAR Title: A Lesson of Forgiveness

Reporter: Sheena Shayne S. Feliciano, MD
Year Reported: 2014
NARRATION:
A man in his late fifties approached me in the Emergency Room. I spoke
to him, Its already midnight Sir, what brought you here? In a hoarse
voice, pointing to his left arm, Doctor, I need to have a fistula done. I
was supposed to have my dialysis this morning but the nurse in the
center told me that the fistula isnt working anymore. I gave him an
early morning smile and with a relief, I told him that creating a fistula
for him at this time was not that urgent. I instructed him to come back
that morning.
Morning came and it was our conference. Like a child persistently
peeping through the conference door, he signaled that he was already
ready for his check-up. I immediately showed him to our consultant. He
started to be hemodialyzed twice a week 2 years ago. His left
brachio-cephalic fistula was created in another institution but seemed to
be clogged already. Our consultant advised him to have a vein mapping
done to check the patency of the fistula, which he did, revealing
thrombosis of the said fistula. Hence, he was advised to have another
fistula done.
We inserted an internal jugular (IJ) catheter for him, as well, for
temporary access. He was scheduled for the fistula creation the week
after. I was confident that he would be compliant with our management
as he texted me every day updating me regarding his dire need to have a
fistula created, that his operating room needs were already complete,
and reminding me that he really wanted our consultant to be the one to
operate on him.
Two days before his scheduled operation, I received a call from a former
colleague informing me that our patient is currently being hemodialyzed
but there seems to be a problem with the access. I told her to have the
patient follow-up at the hospital and reminded her that we are already
scheduled for the fistula creation. However, I was dismayed as I heard
her reply, Sheena, please dont get mad with the patient. Hes hesitant
to have his follow-up as he already had his fistula done in another
institution. He feels guilty for that and asks me if I could refer him to
another doctor.
I told her that it was still okay for me to see the patient and make
revisions for the IJ if needed and promised not to get mad with the
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33
patient. I really felt bad and informed our consultant about the
deferred schedule. The patient never went back for follow-up in our
institution.
INSIGHT:
As I browsed through pages and pictures of quotes related to
forgiveness, Mahatma Gandhis was most famous, saying The
weak can never forgive. Forgiveness is the attribute of the strong. It
has been almost a month since this happened, and to this moment, I
have been constantly thinking about it every day. Admittedly, I
havent forgiven the patient. I expected too much; I trusted too much.
I was flattered by his words that he would want us to operate on him.
What went wrong? Was my care not enough? Was the schedule too
delayed? Did he think that we are not capable of doing the operation?
No one could answer my question but him alone.
As a resident-on-training, we are lured by every patient coming to us
for operation. Its like a gem when they allow us to operate on them,
because this is how we learn and this is how we hone ourselves. I
thought I was sowing a good plant. I thought that I would reap for a
good harvest, but all my thoughts were a waste. Despite not being
able to operate on that patient, I am still thankful for the experience the experience to forgive. I may not gain extra neurons and strength
for my hands, but I gained a piece of inner peace. Life is easy now, as
I accepted the apology which I never got. It emptied my hands, ready
to reach out for anything new. It opened my eyes, ready to see the
clearer view. It opened my mouth, ready to utter something true. It
lightened my heart, ready to accept you. It changed me as a person,
ready to start anew.
People think that we physicians live good lives. What they do not
know is we had to go through struggles, losses, and pain. However,
going out from our depths has taught us physical, spiritual and
emotional maturity molding us to live a life that is filled with
compassion, loving concern and forgiveness. As physicians, learn to
forgive. Doing so does not make you a loser, but a person just getting
better.
What should physicians do to patients whom they have gone the
extra mile to assist and who eventually do not come back for the
agreed treatment plan?
34
medical disorder, they usually get depressed. They have to control this
depression as soon and as much as possible to be able to make rational
problem-solving and decision-making. At this stage of their physician
training, they should be ready or mature enough to accept any major
medical disorder that come their way. They should by this time realize
that physicians are not immune from diseases. They should not waste
significant amount of time asking the questions why me anymore, why
and how they got the disease, and other questions difficult to answer.
They should go right away to the problem-solving and decision-making
(PS-DM) processes on the treatment of their major medical condition with
their trusted physicians.
In this TPORs, I will not discuss the PS-DM processes on
treatment. What I discuss will be the PS-DM processes on quitting or not
quitting the training program, an issue commonly encountered in residentphysicians who get sick with a major medical disorder.
There are myriad things to consider when faced with the question of
whether to quit or not to quit. The more important things to consider are
average lifespan left; degree of disability now and in the future; and
negative effects of treatment on the training. Other things include
finances and life plan of the resident-physicians.
The general guide on average lifespan left (this should be based on
established statistics for the medical disorder the resident-physician has)
is: if long, dont quit. If short, quit unless there are strong personal
reasons not to quit (such as a resolve to fight it out, a stance of come what
may).
The general guide on degree of disability being encountered now and that
will be anticipated (again, this should be based on established statistics for
the medical disorder the resident-physician has) is: if not significant and
not very disabling, dont quit. If very disabling, quit unless there are
strong personal reasons not to quit (such as a resolve to fight it out, a
stance of come what may).
The general guide on the negative effects of treatment on the training is: if
not too cumbersome and not too extensive and intensive to have a quality
and complete training, dont quit. Otherwise, quit unless there are strong
personal reasons not to quit (such as a resolve to fight it out, a stance of
come what may).
The financial resources of the resident-physician and his supporters are
then considered after the three abovementioned major factors.
107
proceeded to identify the aberrant fibers and ablate them one by one. After
what seemed to be an eternity exactly on Valentines Day I was told that I
now have the heart that I always wanted. I could now do things that I
thought I would never get to do like run, climb, jump and as my senior
residents teased me without end, make love and have a baby without killing
myself. I was given a month to recuperate but I cut my sick leave short and
went back to work after two weeks.
Then, all of a sudden, I unbelievably had what felt like another attack, only
slower this time and not so painful but definitely an SVT, then another. I
went back to my doctors. After several more tests, they confirmed it was
SVT, a slower one going 160 to170 beats a minute. This was not apparent
when I underwent the procedure because it was hidden by the faster ones. I
didnt get my wish after all but nothing changed really, Im still me.
INSIGHT:
The Medical Anecdotal Report (MAR) was created to make the residents
analyze instances in their training that affected them most and brought
change and strengthen their conviction as they treat every single patient
whose lives were entrusted under their care. My last MAR was about me
becoming the patient undergoing training and how I dealt with being a
patient and a doctor at the same time.
I grew up learning that there are limitations to what I can do
physically, but thanks to my father I also learnt that those I can do, I can
do with everything Ive got and excel if I put my heart to it. This included
my wanting to become a surgeon. Hopefully in a months time, I would
have done what some people thought was impossible and crazy, finish my
residency training still with a WPW. It wasnt a bed of roses, I tired faster
and had to work twice as hard. Having SVTs in the most inappropriate of
times, but nothing worth having is without effort. This I have accepted with
all my heart.
How should physicians in specialty training (resident-physicians)
respond in terms of a decision to quit or not to quit training if they
develop a major medical disorder?
Physicians in specialty training (resident-physicians) are human beings not
immune from major medical disorder. In such a situation, how should they
respond, particularly, to quit or not to quit training?
First of all, once they get the news of the diagnosis that they have a major
106
From the MAR of Sheena, I construct the following scenario:

A compassionate physician encounters a patient whom he deems need
extra-ordinary attention and assistance for one reason or another (such as
extremely depressed, inadequate logistics, and inadequate prior
treatment). The compassionate physician goes the extra mile in
explaining; advising; allaying fear, anxiety, and depression; mitigating
inadequate logistics; accommodating; and in facilitating prompt and
proper management of the patients health concerns. The patient in front
of the physician explicitly shows appreciation. This leads to the
physician believing he has gained the utmost trust, confidence, and
delight of the patient. The physician feels elated for the opportunity to
give extra kindness to a patient in need. He feels elated to help the
patient holistically, compassionately, and professionally. The turn of
events is that the patient does not come back for the offered and agreed
plan of treatment.
This scenario is a reality in the practice of medicine. It had happened to
me when I was in training in the Philippine General Hospital. It is still
happening to me in my private practice setting.
I recall three sub-scenarios in the turn of events that I have experienced

in the past. One is that I completely lose communication with the patient. Second, the patient regrettably inform me he is going to be treated
or has been treated somewhere else and by another physician. Third, the
patient comes back to me for further treatment after being treated by
another physician or after a long hesitation to carry out my offered plan
of treatment.
I have reacted and responded to such turn of events. From my
experience, I offer the following TPORs to the physicians:
The abovementioned scenario is a reality in the practice of

medicine. Be aware of this. Accept it at the same time be prepared
to react and respond properly and professionally.
You may react initially with sadness and anger but never hatred.
This should be followed immediately by understanding and
forgiveness of the patient. The latter constitutes the foundation of
your subsequent professional responses. Try to understand with an
open mind the circumstances that may have led the patient to break
the offered and agreed plan of management. His decision may have
been influenced by the presence of unresolved fear, anxiety and
depression; by advices of relatives and friends which appeared
35
stronger than yours; and other reasons only the patient knows. End
the effort to understand by reminding yourself that patients are
given autonomy or freedom to choose and make decision and that
you as a physician just have to respect whatever decision they
make.
When the patient comes back to you for continued treatment after
the turn of events, be forgiving and accept him under your medical
care.
In spite of the presence of the abovementioned scenario in the
practice of medicine, which naturally brings sadness to the
physicians who experience it, my advice is to continue to be a
compassionate, holistic and professional physician when you
encounter a patient whom you deem need extra-ordinary attention
and assistance for one reason or another (such as extremely
depressed, inadequate logistics, and inadequate prior treatment).
Go the extra mile in explaining; advising; allaying fear, anxiety, and
depression; mitigating inadequate logistics; accommodating; and in
facilitating prompt and proper management of the patients health
concerns. Remember the do good anyway or do it anyway
quotes from Kent Keith (The Paradoxical Commandments) and
from Mother Teresa (Do it Anyway).
People are illogical, unreasonable, and self-centered. Love
them anyway.
Give the world the best you have and you'll get kicked in the
teeth. Give the world the best you have anyway.
Give the world the best you have and you may get hurt. Give
the world your best anyway.
I also would like to offer at least 2 advices to the patients involved in

such a scenario:
Have at least the courtesy of informing the physician who went the
extra mile to assist you that you have a change in the previously
offered and agreed plan of medical management.
You may go back to the physician who went the extra mile to assist
you. There are still physicians who are understanding and
forgiving.

https://ommcsurgerymar2014.wordpress.com/2014/07/21/sssfelicianosmar-14-06-a-lesson-of-forgiveness
36
MAR Title: Valentines Day

Reporter: Hazel Z. Turingan, MD
Year Reported: 2004
NARRATION:
I was diagnosed with a congenital heart disease, technically called a
Wolff Parkinson White Syndrome. Simply put, it has something to do
with the electrical conduction of my heart that determines the rate to
which my heart should beat. Aberrant fibers within my heart overpowers
the normal pacemaker the sinoatrial (SA) node. Thus, I suffered
supraventricular tachycardias (SVTs) from as long as I could remember
and became a frequent visitor to different intensive care units (ICUs), a
place I learned to hate.
These were heart rates going over 270 beats a minute. At this rate, my
heart couldnt adequately pump to deliver enough blood to my body as
well as my brain. Well, we all know in the medical field what that could
do. What triggers the SVT according to experts, could be anything from
getting too tired to as stupid as getting startled. But from experience, it
always happens when I least expected it. Except for attacks I get once or
twice a year, I have lived my life as normally as the girl next door. The
thing that never failed to amaze me was that I usually forget about WPW
and SVT until I get the next attack which would remind me Im not as
normal as I wanted to be. But as my father taught me earlier on, mind
over matter. So I went about pursuing medicine and never thought that
my condition would deter me from achieving my goals.
After getting accepted in residency training, I was told that I needed to
sign a waiver that would give absolution to the hospital to whatever
happens to me since Surgery is strenuous. This was a novelty to me
since I went through school, medicine, clerkship, and internship without
my physical condition becoming an issue of my performance. But I
accepted and signed knowing that I could be a surgery resident and be as
good in my chosen field as any of my colleagues. Things went on
smoothly without a hitch until I reached my third year, when what was a
physical nuisance now became bothersome.
In 2001, after frequent attacks, my work became affected with my
absences. With medications only given to arrest the attacks, I sought
consult once more. I was given a different answer this time. I was
offered to undergo cardiac ablation, an alternative to open heart surgery.
With cardiac catheters inserted in my femorals and jugulars, the team
105
relatives and the physicians. To reach this consensus, however, guidelines

and statistics would be helpful.
Resolutions:
Establish definite guidelines on how to modulate aggressiveness of
treatment for terminally-ill patients and then disseminate these guidelines
to the community.
MAR Title: Routine Post-Operative Instructions on Sexual Activity

After an Operation. A Taboo?
Reporter: Princess Beverlie C. Co, MD
Year Reported: 2014
NARRATION:
A text message was sent to me containing a surprising question that was
never asked to me before. It came from a 17-year-old female whom my
senior and I operated on for empyema of the gallbladder. She already had
her follow-up after being discharged from the hospital so I knew that she
was doing well. The message started with a few questions about certain
foodstuffs that she wanted to know if they were allowed for her. She
asked about spaghetti, burgers and pineapple juice. I had instructed her
before that generally there are no kinds of food prohibited for her and
lessening the intake of high cholesterol foods were recommended. So I
thought that she might have just forgotten or was simply wanting
confirmation of her choices. As I continued reading, the last question
came as a real surprise. It dawned to me that the previous questions were
just small talk and this one was the real question she wanted to ask. Doc,
may tanong pa po ako. Medyo private lang po. Pwede po ba mag-Do?
Ung alam mo na. Para lang alam ko lang din po (Doc, I have another
question. Its quite private. Is it ok to do the deed? You know. So just that
I know) It took me a full 30 minutes to construct my text. I wanted to
keep things light but professional. I replied, Pwede ka naman kumain ng
spaghetti, burger at uminom ng pineapple juice. Pwede ka makipagsex sa
partner mo kung kaya mo na saka hinay-hinay lang. (You can eat spaghetti, burger and drink pineapple juice. You can have sex with your
partner if you feel you can and take it easy.) She replied quickly, thanking
me for the advice.
INSIGHT:
Post-operative instructions are essential for complete recovery and for
patients to be able to take care of themselves at home. It includes
instructions on diet, physical activities, medicines, wound care and follow
-up. When it comes to abdominal surgeries like open cholecystectomy,
we generalize the amount or kind of physical activity our patients may do
for a certain period of time. We often explain that the tolerance of pain
varies from one patient to another and it is one of the factors affecting
mobility and capacity to do or perform certain activities. The pain over
the incision site generally becomes tolerable over a period of 4 weeks or
less but most importantly it is during this time that the wound heals so we
advise them from refraining from strenuous activities such as sports.
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37
I personally have not given advice on sexual activity after an operation

previous to this encounter. I think it is because it is still considered taboo.
Mentioning it even in the most professional way with a straight face stirs
awkwardness and unwanted maliciousness in many patients. Some doctors
do not discuss it unless the patient themselves initiate it. Technically,
doctors are the right persons to ask about sex because we are supposedly
unbiased and are scientifically grounded. However, we must take into
consideration the kind of patient we have. Are they sexually active or plan
to be? Are they open to discussing it with us? Are they of legal age? Are
they prohibited by their beliefs or religion to talk about it?
I have not routinely included it in my discharge instructions mainly

because I think it is implied that sex is a physical activity that involves
physical exertion and exhaustion. Also because none of my patients have
ever asked me before. I was caught off guard when my patient asked me
about it not so much because I am not comfortable discussing it with her
but because of my prejudice for minors engaging in sexual activities and
even more so for unwed minors who have been pregnant. I knew that I was
her doctor, not her sister, not her barkada and not her teacher. I put my
intolerance aside and fulfilled my duties as her physician. As doctors, we
act, talk and carry ourselves in a specific way fitting of an educated
individual with professionalism. This is a basic trait we must have. It is
honed through experience and individualized through influence from ones
background. We must be able to keep our emotions, beliefs and personal
opinion from interfering with our duties as doctors so that we can achieve
our therapeutic goals.
How to give advices on physical activities (inclusive of sex) to patients
after a surgical operation
After a surgical operation, the surgeon-physician should give advices on
the physical activities that the patient can do and on what to avoid or
minimize. A physical activity refers to a bodily movement produced by
the skeletal muscles. The physical activity in daily life can be planned and
unplanned. It may be associated with personal body needs and wants;
household chores; occupation; exercises; sports; sex; etc. The intensity of
the physical activity is dependent on the amount of energy and effort
exerted. It may be categorized into low (such as light walking); moderate
(such as mopping the floor); and high or vigorous (such as playing
basketball).
Aside from advising what physical activities that a patient can do and what
38
MAR Title: Challenges in Hospice Care

Reporter: Reynaldo O. Joson, MD
Year Reported: 2005
NARRATION:
A 90-year-old Filipino woman whom I operated on a year prior for
breast cancer where I did a modified radical mastectomy came back to
the hospital for pallor and bruises. There was no sign of local
recurrence but on chest x-ray, there was an evident 1-cm density. A
hematologic consult was done for the recent symptoms and which
yielded aplastic anemia as the most probable diagnosis. After a
discussion with the relatives, the decision of the latter was no more
aggressive treatment. Only blood transfusion was administered for the
aplastic anemia.and tamoxifen for the probable pulmonary metastasis.
Two weeks before the patient died, she herself refused all forms of
treatment. The relatives signed a do not resuscitativeform. The
patient died without any intravenous lines or any tube attached to her
body.
INSIGHT:
Despite the presence of hospice care and its concept being promoted,
how to deal with terminally-ill patients is a still a challenge to both the
relatives and the physicians. Most relatives and patients and also most
physicians have difficulty determining the extent of aggressiveness and
modulation that should be done in terms of treatment. The pendulum
swings to all-out treatment to achieve a 1% chance of cure rate in one
end to total lack of medications at all in the other end. In between the
pendulum swing, some would give symptomatic medications only;
some would put in some tubes only; etc.
There are no clear-cut guidelines on how to decide to assist the
physicians, patients and relatives. At present, the decision is reached
after a conference among the physicians, patients, and relatives. The
activities usually going on in the conference consist of an interplay of
trust and acceptance of the physicians advices and acceptance of the
patient and relatives of the terminal event. After a physician gives his
advice on prognosis, he awaits the decision of the patient and his
relatives on the aggressiveness of treatment.
The best scenario is consensus of all concerned from patient to
relatives to the attending physicians on what to do, with the patient
given the absolute right to decide and his decision respected by both the
103
to avoid or minimize, the surgeon-physician should also give advice on

when the patient can resume all the health-promoting physical activities
that he usually does before the operation.
The objectives of giving advices on the physical activities after an
operation are, one, to avoid occurrence of adverse events associated with
the operation particularly the incision and two, to allay patients fear and
anxiety with regards to the physical activities.
Advices on physical activities should be given proactively (even before
the patient asks). Such a practice exudes professionalism and
competency of the surgeon-physician and promotes patients delight.
My recommended approach in giving advices on physical activities after
an operation is to start with general guidelines. This is to be followed by
more specific instructions, directly related to the patients medical and
surgical condition and usual physical activities inclusive of occupation,
being done before the operation. The giving of advices ends with
elaboration and answering patients specific concerns and inquiries.
Such an approach will avoid the feeling of awkwardness that the surgeon
-physician may have in asking and discussing physical activity with sensitivity issue like sex. If the patient does not ask the question on sexual
activity for one reason or another, he / she will be able (hopefully) to
deduce the limit from the general guidelines and specific instructions
given. Generically, the general guidelines more or less covers all kinds
of activities including sex in daily living.
On general guidelines for patients on physical activities after an
operation 1. Start with low-intensity activities. Gradually add moderate-intensity
ones. Then, progress to vigorous-intensity ones, that is, if patient usually
does this before the operation and wants these to be continued. (see table
for examples of common different daily life activities and their
categorization as to intensity)
2. Do physical activities guided by the risk for pain in the operative site
and risk for wound dehiscence (disruption). Be on the safe side in
decision-making and be gradual in progression.
Resume all health-promoting physical activities that a patient usually
does before the operation (so-called normal activity) at 4 to 6 weeks after
an operation. This is the usual time of the maturation phase of wound
healing. (see specific instructions for exceptions to this general
recommendation on time of resumption of normal activity)
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39
On more specific instructions on physical activities after an operation The surgeon-physician should give specific instructions in
consideration of the nature and location of operation done, the risk of
pain on the operative site and the risk of disruption or dehiscence of the
incisional wound repair in relations to the three general categories of
physical activities (light, moderate, and vigorous) that may be done by
a patient.
Examples:
If there is an operation for warts on the head and neck, the
patient can usually resume normal activity right after the
procedure.
If there is an operation on one side (say right side) of the
breast in which the whole breast is removed, the patient can be
advised to have low-intensity activity involving the right
upper limb for 2 weeks. During this time, she can have
moderate-intensity activities on the other parts of the body,
namely, head and neck, left upper limb, lower limbs, and
abdomen.
If there is an operation on the abdomen, say removal of the
appendix using an open approach, the patient can be advised
to have low-intensity activity involving the abdomen for 2
weeks. During this time, he can have moderate-intensity
activities on the other parts of the body.
If there is an operation on the abdomen, say removal of the
gallbladder using an open approach, the patient can be advised
to have low-intensity activity involving the abdomen for 2
weeks. If the patient asks specifically whether sexual activity
can be done during this time, the answer can be yes as long as
sexual activity is of low-intensity.
If there is an operation on a groin hernia, the patient can be
advised to have low-intensity activity for 2 weeks. If he wants
to resume his vigorous-intensity activity, like jogging, he can
be advised to have it started after 6 weeks but in gradation
(gradual increase in intensity).
If there is a question on when a patient can resume driving, the
answer will be dependent on the nature and location of the
operation and risk of pain occurring when manipulating the
steering wheel and stepping on the brake pedal. The
occurrence of pain on the operative site while driving carries
the risk of vehicular accident. This should be taken into
consideration when giving advices on when a postoperative
patient can resume driving.
40

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101
What are pros, advantages, and benefits of giving out cellphone numbers
to patients?
Here are some of them:
All patients and their relatives welcome physicians giving out their
cellphone numbers. It is considered as an easy access to the
physicians in times of need. I dont think there will be a patient or a
relative in the Philippines and in the world for that matter, who will
not welcome this.
Giving cellphone numbers to patients promotes rapport. Patients and
relatives see empathy and compassion in physicians giving out their
cellphone numbers. These physicians tend to be liked, which can
contribute to an increasing patient-client base and also patient-client
or customer engagement.
The use of cellphones between physicians and patients facilitates
communication and coordination between the two parties. The
following are key activity areas: a) scheduling of operation,
admission and consultation; b) medical management outside the
hospital and clinic setting; c) referral of other patients to the
physicians; and d) feedback of patients to the physicians.
Below is a table showing a rough categorization of more common daily

life activities based on usual amount of energy or effort exerted. (Note
this is not an absolute categorization. The final categorization will be
dependent on the person performing the physical activity based on
estimate of the amount of energy to exert and actually exerted.)
Low-intensity
Light walking
Brisk walking
Jogging
Running
Sports in
general
Stair climbing
Driving
Lifting objects
/ (slow)
Sex
Bath
From my experience, it is only the disturbance or loss of privacy

created by patients texting or calling the physicians by cellphones after
their stint of duty in the hospital and clinic. The physicians particularly
want to avoid cellphone consultations.
Washing
dishes
Washing
clothes
Desk work
Thus, after weighing the pros and cons, advantages and disadvantages,
and benefit and risks, I personally recommend physicians giving out
cellphone numbers to their patients. Physicians can minimize the
disturbance by instructing and advising the patients on the indications
for communicating through cellphones. To avoid abuses, I have this
policy: Communication with ROJoson through cellphones is
permissible but should be used judiciously. ROJoson reserves the
right to bill for services rendered through cellphones.
Gardening
Teaching in
classrooms
Malling
/ (heavy
weight)
/
What are cons, disadvantages, and risks of giving out cellphone numbers
to patients?
100
High or
Vigorousintensity
/ (lightest
weight)
/
Below are examples of text messages I received from my patients.
Moderateintensity
/
/
/
/
/
/

https://ommcsurgerymar2014.wordpress.com/2014/08/21/pccos-mar14-06-routine-post-operative-instructions-on-sexual-activity-after-anoperation-a-taboo
41
MAR Title: Safety of Hospital Staff

Reporter: Marco Antonio E. Sanico, MD
Year Reported: 2014
NARRATION:
I was at the Emergency Room (ER) one evening when a 62-year-old male
came in accompanied by two National Bureau of Investigation (NBI)
agents. The patient complained of epigastric and right upper quadrant pain
and claimed that it was excruciating. I did my physical examination on him
and had unremarkable findings - his abdomen was non distended, soft, and
non tender. I was then approached by one of the NBI agents. He told me
that the patient was arrested an hour ago for discharging his firearm in
public and was supposed to be brought in for questioning at their precinct.
The patient, however, demanded that he be brought to a hospital first
because of his condition. The agent believed that the patient was
malingering, just so he could avoid detention. As I returned to the patient, I
told him that we would first hold him at the ER to be observed for any
progression of his symptoms and if needed, we could start infusion of fluids
and pain medications. He replied agitated, saying that the ER was so busy
that he would have no chance of resting properly while staying there and
insisted that he be admitted. I reiterated my plan to him and told him that
presently, I had no reason for admitting him, and that I would prefer to have
him at the ER for observation. After around 30 minutes, the patient came
up to our desk, insisting again that he be admitted. This time though he was
very much hostile, telling me that I did not respect him and that I did not
know who he was, showing me his badge indicating that he was an official
of the Bureau of Customs. He then went on to say that I would pay dearly if
I still did not admit him and started pointing his finger at me. I instructed
him to calm down and return to his bed, also telling him that I would see
what I could do regarding his admission. I informed my senior of the case at
hand, the current situation regarding his arrest, and patients demands for
admission. I also included the fact that he was now even more agitated than
before and that there might be a small possibility that we too might get shot
anytime soon. We both then decided to admit the patient, at least for the
mean time, to pacify the patient. Upon admission to the surgery ward, I
returned to the patient and saw that he was now calm and apologetic for the
way he acted at the ER. The following morning, his lawyer arrived and told
me that his patient was now feeling better and wanted to be discharged. I
finished his discharge papers immediately and was glad to see him off that
afternoon. I learned later that day from our staff nurse that the patient wasnt
lying about who he really was, his whole lineage was known for shooting
down people who crossed their paths in Cavite and that he had been
apprehended previously for the same charge.
42
my cellphone numbers publicized in the Internet. I accept the

risks because I realize the benefits outweigh them. For the risks, I try to
find ways to control, such as telling my patients when to call me and not
answering their text messages or calls when indicated.
I recommend the following link for further reading on giving out of
cellphone numbers to patients:
There was a MAR by Dr. Harvey Balucating which was published in
Volume 1 of MAR (2013) entitled: The Advantages of Giving Out Your
Cellphone Number.
I recopied my insights (TPORs) to the MAR of Dr. Balucating here.
Should physicians give their cellphone number to their patients?
Most physicians in the Philippines are reluctant to give their cellphone
numbers to their patients. The primary reason is that they do not want to
be disturbed by their patients after their stint of duty in the hospital and
clinic. Initially, I too, was very reluctant to give me cellphone number to
my patients. I also did not want to be disturbed. However, over the past
6 years, since 2007, I have become more liberal in giving my cellphone
number to my patients. I felt it to be a value-added service to my patients.
(Note: I remember in 2007 after the discussion of the MAR of Dr.
Balucating, although I advised the surgical residents to be selective in
giving out their cellphone numbers and make decision based on
judgement call, I was already encouraging them to be more liberal. I told
them that aside from facilitating scheduling of operations in the
Department of Surgery of Ospital ng Maynila Medical Center [OMMC]
and follow-up of medical management, the giving of cellphone numbers
will establish a patient-client base for the residents. This patient-client
base will help build the practice of the residents after graduation from
OMMC.)
Over the past 2 years, since June 2011, when I established my Facebook,
I publicized my cellphone number. I have patients as friends in my
Facebook.
Just like anything in life, there are pros and cons; advantages and
disadvantages; benefits and risks in giving out cellphone numbers to
patients. The guide to follow is, if the pros, advantages, and benefits
outweigh the cons, disadvantages, and risks, give out the cellphone
numbers.
99
continue to do so. If it will be recognized, then I am grateful. Bedside

works such as daily rounds, wound care and change of dressings, even
small pep talk to the patient and relatives, may seem very menial for us
doctors who do these things every day. But for the patients and relatives, it
is a privilege for them to be noticed and be served. These little things just
like cell phones serve as bridges that connect us to them. These are the
ways that we are being trusted as one of their close friends or one of their
own relatives.
Should physicians give their cellphone number to their patients?

The Medical Anecdotal Report of Dr. Janix de Guzman on the use of
cellphone for communication with patients was written in 2005.
Dr. de Guzman said in his MAR: Cell phones are really the thing of the
present and maybe the future. Yes, at this writing, 2014, practically every
Filipino has a cellphone.
In the practice of medicine, an issue is, should physicians give out their
cellphone numbers to their patients?
My personal stand is that they may, if not should. This has been my stand
expressed as early as 2004 when I was moderating on the MAR
presentation and discussion of the residents in the Department of Surgery
of Ospital ng Maynila Medical Center (OMMC Surgery). The issue would
be taken up whenever there were discussions on explorations of strategies
on how to promote patients delight; how to follow-up patients after
discharge and after an operation in order to know the results of treatment
done as well as to catch and prevent treatment complications early enough;
to facilitate scheduling of operations; and to avoid cancellation of
scheduled operations. I have been encouraging the residents to give out
their cellphone numbers to patients on a selective basis then and I have
practiced what I have been recommending, if not preaching, up to now and
currently, even more extensively.
I allow the option for physicians to give their cellphone numbers
selectively rather than a total NO stand. The selective approach is an
offshoot of balancing the benefits and the risks. The primary benefits are
mentioned above. The primary risk will be interruptions of the physicians
times outside their allotted schedule for the practice of medicine.
Above, I mentioned that currently, I have been giving out my cellphone
numbers to my patients more extensively. As of December 2014, I have
98
INSIGHT:
The safety of our hospital staff and patients is one of the top priorities of
each individual employee here in Ospital ng Maynila Medical Center. Even
with adequate security personnel, we can never ascertain our protection,
especially in the presence of people who are alcoholically intoxicated,
beyond proper reasoning, aggressive and violent, with means and resources
to cause harm. In my case, the patient I attended to was not too happy with
the way I managed him. He kept on insisting that he be admitted and treated
for his medical condition, which to me did not warrant inpatient admission
at that time. However, when a safety issue is present, I had to give the
patients demand for admission a second thought. I weighed in the benefits
and risks and figured that there would apparently be no harm done,
especially physically, if I admitted him for the time being. It would give him
proper time to calm down and result in anyone not being shot at, including
myself. It may seem cowardice when we blatantly give in to demands of
patients, more so when they seem out of context, but to me, the safety of our
hospital staff is more important.
What are the strategies that can be used for patients who openly defy
physicians recommendations and decisions and insisting on their wants
with an accompanying threat, expressed or implied?
In the practice of medicine, physicians will encounter patients with all sorts
of personalities. In terms of reactions to physicians recommendations and
decisions, some would readily respect and accept. Some would not. For
those who would not, there are two subsets, one, passively ignoring the
recommendations and decisions of the physicians and go away. The other
subset, openly defying and insisting on their wants with a threat. The latter
may be a threat of legal suit, public smear, and even physical harm.
All physicians practicing medicine in the Philippines (even abroad) and in
government and private hospitals should be wary of these varied
personalities of patients and their associated challenges. They should be
prepared to manage the challenges, particularly, those patients who openly
defy and insist on their wants and with an accompanying threat, expressed
or implied.
43
My foremost advice is to include assessment of the personality of the

patients during the interview and physical examination phases of the
clinical evaluation. Factor in the personality of the patients when giving
the clinical diagnosis and advising on the paraclinical diagnostic
procedures and treatment with the end-goal of having a collegially arrived
at informed consent and informed refusal. Factor in the personality of the
patients during the discussion before arriving to an informed consent or
informed refusal. During the initial encounter, when one senses the
presence of a potentially defiant patient who may pose as a threat (for legal
suit, public smear, and physical harm), strategize accordingly and in a
timely manner. Avoid a confrontational stance. Avoid being too dogmatic
or inflexible unless a policy of the hospital or statutory or regulatory
requirement has to be enforced. Try to convince the patient to accept your
recommendations and decisions to conform to the hospital policies and
other official requirements. Balance between a threat-cum-harm risk
reduction and principle-policy violation. Consider the safety for self,
hospital staff, and patients in the problem-solving and decision-making. If
there is a need to be confrontational, dogmatic, and to stick to principles
and policies, make sure support from colleagues and hospital
administration is present.
An example of a need to be confrontational and enforcement of hospital
policy is when patients suspected of harboring EBOLA virus insist on
being admitted to a private hospital. For the safety of the hospital patients
and its staff and to control the spread of the EBOLA virus, there is an
administrative order that all suspect patients are to be transferred to
hospitals designated by the Department of Health.
Below are general indications for admission to a hospital. Note the
relativity of the indications. The physician has to make the initial
recommendation based on the general indications. Hospital policies have
to be factored in for the final recommendation and decision.
Indications for admission of patients to a hospital's inpatient beds:
Medical disorders with a severity degree that are dangerous to
manage at home
Medical disorders that need close monitoring by physicians
for diagnostic purpose
Non-surgical disorders that usually need hospital confinement
because of safety and convenience on the part of the patients
44
MAR Title: Cell Phones, Connecting Lives

Reporter: Janix M. de Guzman, MD
Year Reported: 2005
NARRATION:
Last week, I received a text message from an unregistered number. It
read as follows, Good am, doctor. I am the daughter of one of your
patients, Mr. Arguelles. You operated on him a year ago. He died last
April 30, peacefully. I just want you to be informed. Thank you,
doctor, for all you have done.
I remembered him (patient). He came in our institution with a fairly
advanced sarcoma of the foot. He was bothered by this tumor that he
could not walk properly. Beside the pain he was experiencing from
the primary lesion, he was also bothered by the metastatic
lymphadenopathies on the ipsilateral inguinal area. He underwent
wide excision of the primary lesion on the lateral aspect of the foot
and an in-transit lesion in the lower leg and inguinal dissection for the
lymph node metastasis. Though I was not the main surgeon, not even
the first assist, I was part of the team. I did my daily rounds as usual,
including minute bedside works such as post-op wound care and
change of dressings. I considered this role equally vital for his
recovery. He was discharged ambulatory and free from pain.
I never had the chance of meeting him again or any one of his
relatives after his discharge until I received this text message. For a
while, I was taken aback. I had never received an obit in the past
except from a close relative. I regained my composure and replied the
best note I could muster, saying I am sorry and extend my deepest
condolences to the whole family.
INSIGHT:
Cell phones are really the thing of the present and maybe the future. It
evolved from being a luxury gadget afforded by a few in the past then
becoming a necessity for the masses, connecting lives. Normally, I
would not respond to an unregistered number. I was puzzled in a way
or the other how she got hold of my number. But her message was full
of calm, touching, and so, I obliged myself to reply.
It was always one of my philosophies to do a good deed without
waiting for return. As long as I am happy and fulfilled doing it, I will
97
ones achieved strengths and always be ready to admit weaknesses and

mistakes when encountered. This is the humility and meekness traits
desired of them. Lastly, be assertive without being aggressive with the
self-confidence acquired when indicated, instead of being meek all the
times.
http://ommcsurgerymar2012.wordpress.com/2014/12/26/jlffontes-mar-1202-being-humble-shouldnt-mean-losing-self-confidence
96
Wish of the patients and/or relatives primarily for

convenience (needs external caregiver, long travel distance,
etc.) and sense of security
Desire of patients to have health screening programs in an
inpatient setting.

http://ommcsurgerymar2014.wordpress.com/2014/11/03/mesanicos-mar14-09-safety-of-our-hospital-staff
45
MAR Title: Preventing Euthanasia

Reporter: Glenn P. Villanueva, MD
Year Reported: 2014
NARRATION:
How to differentiate and use humility, meekness and self-confidence

as good character traits of a physician-surgeon?
I was the senior-on-duty at the ward when a patient classified under

palliative treatment was endorsed to me for close monitoring. She was a 60
-year-old patient diagnosed with breast cancer stage four with pulmonary
metastasis admitted at the surgical intensive care unit (SICU). The patient
was on mechanical ventilator but was endorsed to me with stable vital
signs. After a few hours, the SICU junior intern informed me that the
patient was hypotensive and there was a sudden change in sensorium. I
then looked for the nearest keen to inform him / her of the situation. There
was her son, on his early twenties, who had been with her throughout her
admission. I explained to him that her mother was deteriorating and would
need further medications and support. The patient had already been
referred to the Family Medicine Department for hospice care prior to this
admission. Thus, he was well aware of the situation.
He then talked to me Doc, tanggap na po namin yung sitwasyon ni
Mommy. Ano po ba yung gagawin naming susunod? Tatanggalin na po
ba yung ventilator at mga swero? Alam nyo na po. (Doctor, we already
accept the situation. What are we going to do next? Are we going to
remove the ventilator and fluids?)
All the while, the son was thinking of doing euthanasia due to the
acceptance that his mother was terminally ill. He even told me that he
already sought consent from his siblings abroad and they agreed on the
plan. I didnt let him know of my surprise on his statements. I told him to
relax and take a deep breath first. I was about to go to the operating room
when this event happened, but I took time to talk to the son to let him
understand the consequences and the meaning of what he was planning to
do.
I gave him a brief definition of euthanasia and the term Do Not
Resuscitate or DNR. I firmly told him that euthanasia could not be done
here in our institution or generally here in the Philippines. I related myself
to the situation and told him that given the same instance, I would never
choose to remove any machine from my patient. I would let my patient die
on a natural way. In the middle of our conversation, the son abruptly
46
All person have character traits, both good and bad. Character traits
are all the aspects of a persons behavior and attitudes that make up
his personality. They are demonstrated by the way they interact with
the world and with people.
Physicians and physician-surgeons also have character traits, both
good and bad. They should realize the traits that they currently have;
discard the bad ones; retain and develop good ones; and know when to
use the good ones.
In the MAR of Dr. John Fonte, he mentioned at least three character
traits, namely, meekness, humility and self-confidence. He attempted
to differentiate them. I will also try to differentiate them here in my
TPOR.
To me, humility means not bragging or over-utilizing ones strengths
and, if occasions call for it, recognizing and apologizing for ones
weaknesses and mistakes. This is a good character trait.
Self-confidence means trust in ones abilities. Enough self-confidence
is a good character trait; frequently or constantly having over-selfconfidence and low- or under-self-confidence are bad traits.
Meekness means being submissive in ones disposition. To some
degree, it may approximate humility which is a good trait. To some
degree too, it may approximate low-self-esteem or low-selfconfidence, which is a bad trait. In the latter situation, the bad trait
can be
converted to a good one by being assertive when called for.
Assertiveness means being self-assured or confident in behavior but
without being aggressive.
In the context of my differentiation of the three traits, I recommend
that all physicians and physician-surgeons focus first on continually
developing enough self-confidence in all competencies expected of
them. Elevate low-self-confidence to adequate self-confidence and
maintain it at that level through continuous learning and practices of
skills. Once adequate self-confidence is achieved, be vigilant against
going overboard, meaning avoid over-self-confidence. Do not brag
95
MAR Title: Being Humble Shouldnt Mean Losing Self-Confidence

Reporter: John Lloyd F. Fonte, MD
Year Reported: 2012
NARRATION:
About two weeks ago, my cousin called and asked me to schedule a
visit for her friend whom she said had a mass on the neck. On
consultation, I immediately noticed the mass. After taking the history
and physical examination, my impression was colloid adenoma (benign
tumor) of the thyroid gland. I then explained to them the
condition and my treatment plan. I was not very confident in doing
thyroidectomy (removal of or part of the thyroid gland) so I offered that
I would ask our head and neck specialist to operate on her. The patient
said that she wanted me instead to operate on her. My cousin seconded
her request and asked me to do the procedure. Though I had some
hesitation, I said yes. It was running on my mind that I should be
humble enough to admit that I cant do the operation just yet. But deep
inside, there was a part of me saying that I had studied and seen enough
cases, and that I should already have self-confidence. I then referred the
patient to the consultant-in-charge and scheduled the
operation the following week.
On the time of the operation, my consultant allowed me to do the case.
Although still a little bit nervous, I was able to operate on my cousins
friend fast and with no intra-operative complication. After the
procedure, I realized that for as long as I prepared myself on the
necessary theoretical knowledge about the case, what I need in
addition is the confidence to put that theoretical knowledge into
surgical skills.
INSIGHT:
Many, me included, sometimes confuse humility with meekness. In
truth, the humble person is very driven. But he is not driven by his own
ego; he is driven by a desire to put into reality all his plans, but only
after a thorough preparations. I realized in this experience that my idea
of humility was not as it should be, and might hamper my growth if not
corrected.
True humility is not a result of an undervaluation of ones capabilities.
Such is a false humility, for it is built on a false foundation. Rather, the
truly humble individual recognizes his limitations, but is keenly aware
of all his strengths and qualities.
94
stopped my explanation to set-up a video conversation through his

computer pad with his siblings abroad. I had no choice but to repeat my
explanation and make them understand. It took me more than half an hour
on the video conversation repeating and recapping my explanation on
euthanasia and DNR. At the end of the conversation, the son agreed to my
plan of doing only DNR and let her mother die the natural way.
INSIGHT:
I will not give a fatal draught to anyone if I am asked, nor will I suggest
any such thing. Hippocratic Oath (Modern Version)
Euthanasia or mercy killing is defined as intentionally ending a life to
relieve pain and suffering. There are different points of views all over the
world but here in the Philippines, euthanasia is not being practiced and it is
against the law.
There are different terms and concepts being used today in the
management of terminally-ill patients. The overall purpose in the
management of a terminally-ill patient is to minimize suffering of the
patient and promote early acceptance from the relatives by giving
emotional support. The popularly used term is hospice care. Our
institution provides this kind of treatment and the Family Medicine
Department is in charge of this. Hospice care is a big help to the primary
physician in dealing with factors outside the actual medications of the
patient. Although we well explain everything to the relatives, sometimes
they still lack a full understanding and give wrong interpretations. The
case in point, I was surprised with the plan of the son when he first came
to me. He had a wrong impression of what he and his siblings were doing.
I shared to him my personal encounter for him to fully understand the
situation since I almost had the same experience of deciding for my father
a few years ago. I told him that I decided to prolong my fathers life even
only from a pulmonary or medical support. That statement made an impact
on him to change his decision and to fully understand the situation. I
wanted to remove from his mind even a bit of thought of removing support
from his mother or probably doing euthanasia.
I saw the son again soon after his mother died. He was very grateful for
the explanation I gave which he said guided him well in his decisionmaking in the final care of his mother.
What are the concepts of euthanasia and its associated issues in the
practice of medicine?
47
Euthanasia has been a very controversial and emotive topic up to now,

abroad and in the Philippines. All physicians practicing medicine should be
aware of the concepts of euthanasia and its associated issues to guide them
in the practice of their profession.
If, after discussion of treatment options, patient and relatives still refuse all
treatment, their decision should be clearly documented. Doctors should also
ensure that the patient and relatives realize they are free to change their
mind and accept treatment if they later wish to do so.
Euthanasia is good death (Etymology: Gk, eu, good; thanatos, death). Its
most popular meaning is mercy killing, which can be applied to human
beings and animals.
There are so many definitions and concepts of euthanasia nowadays. This is

one of the factors that is contributing to the controversy, the other factors
being the bioethical principles and religious concerns.
In the practice of medicine, using the definition from Mosbys Medical
Dictionary, 8th edition, 2009, euthanasia is the deliberate causing of the
death of a person who is suffering from an incurable disease or condition.
From the World Medical Associations Declaration, euthanasia is the act of
deliberately ending the life of a patient, either at his own request or at the
request of close relatives. (Declaration on Euthanasia, The Lancet, June 27,
1987, p. 1505.)
What is informed refusal and what is informed consent? How should

physicians manage these?
Informed refusal is present when a patient decided to decline
a recommended treatment or procedure after all options, risks, benefits and
costs have been thoroughly explained.
Informed consent is present when a patient decided to accept a
recommended treatment or procedure after all options, risks, benefits and
costs have been thoroughly explained.
In both situations, there must be documentation of the thorough
explanations and the refusal or consent, usually signified by a signature.
If one considers the phrase in the two abovementioned definitions, namely,

deliberately causing of death of a person / deliberately ending the life of a
patient, euthanasia is akin to a murder, to a medical murder. A common
example of deliberately causing the death of a patient with an incurable
disease or condition through a painless method is injection of a lethal drug or
injection of lethal dose of a drug, such as muscle relaxant and sedative.
Such an act is also called active euthanasia which is more closely akin to
medical murder as compared to passive euthanasia. Withholding and
withdrawing treatment that is necessary to maintain life is a common
example of passive euthanasia.
In non-emergency situation, a procedure or treatment can only be done

when there is an informed consent. In some emergency situations, an
informed consent may not be explicitly obtained because of the
circumstances.
As of 2014, active euthanasia is illegal in the great majority of countries. It

is legal only in Netherlands, Belgium, and Luxembourg. For passive
euthanasia, such as in the form of withholding and withdrawing treatment,
only a few countries have officially legalized it. It is officially declared legal
in India and Sweden.
Physicians should also respect and accept patients who change their
decision either way, that is, from refusal to consent or from consent to
refusal.
The general legal position all over the world seems to be that while active
euthanasia is illegal unless there is legislation permitting it, passive
euthanasia is legal even without legislation provided certain conditions and
safeguards are maintained. (http://ibnlive.in.com/news/active-euthanasiaversus-passive-euthanasia/145218-3.html) The prevalent practice of ordering Do Not Resuscitate or DNR in the patients charts in hospitals
http://ommcsurgerymar2012.wordpress.com/2012/07/31/ajluceros-mar-1206-respecting-relatives-of-patients-in-the-refusal-for-treatment-2
48
A procedure or treatment should not be done when there is an informed

refusal.
Patients have the rights to informed refusal. Physicians should respect this
right.
93
MAR Title: Respecting Relatives of Patients in the Refusal for

Treatment
Reporter: Alma Jawali Lucero, MD
Year Reported: 2012
NARRATION:
A 57-year-old male with a primary diagnoses of hepatocellular
carcinoma and hydronephrosis, left, secondary to obstructing ureteral
calculi, was admitted. The patient presented with vague abdominal pain,
dysuria and recurrent flank pain. He was referred to a hepatobiliary
consultant and hepatectomy was advised. However, the patients
family did not consent for the procedure.
A referral to a urologist was done and the plan was to do cystoscopy,
retrograde pyelogram and double-J stenting. Two days prior to the
contemplated procedure, the patient was given a risk stratification of
high clinical risk for a low surgical risk procedure. The reason for the
high clinical risk stratification was the consideration of hepatocellular
carcinoma.
worldwide and the advocacy and respect for advance directives

nowadays support the current legal position on passive euthanasia.
In the Philippines, active euthanasia is illegal. Passive euthanasia has
not been officially declared legal or illegal but there is already a
prevalent practice of DNRs and increasing use and respect of advance
directives.
There are other sub-concepts, sub-classifications or sub-categorizations
emanating from the two general types of euthanasia.
Voluntary euthanasia where the patient with a mental capacity
requested for the euthanasia and the request is properly and legally
documented.
Non-voluntary euthanasia where there is no explicit refusal from the
patient for euthanasia and an explicit consent cannot be obtained from
the patient for one reason or another such as a patient in coma; too
young; with impaired mental capacity (such as due to senility; mental
retardation; brain damage).
I received a call from the patients son-in-law who was also a doctor and
a good friend of mine that his family decided to just bring the patient
home. They were frightened when the internist told them of the high
clinical risk. I asked him to come to the hospital with his wife who was
also a doctor to discuss the case of his father-in-law. I reiterated to him
and to his wife carefully the benefits and risks and then asked them if
we would proceed or not with the planned operation. I explained that the
procedure was not that invasive and that the internist would also be
there for intraoperative monitoring of the patient. The internist and
anesthesiologist were with me to explain their parts of management.
After the talk, the family decided to bring the patient home and opted
for palliative management. The patient was discharged with advice they
could come back if ever they would change their decision.
Involuntary euthanasia where euthanasia is performed against the

wishes of the patient; this is medical murder in its highest degree.
INSIGHT:
Doctors should respect the decision of patient and his relatives to refuse
treatment, even if refusal is not considered to be in the best interest of
the patient. This is as long as the consequences and complications
regarding their refusal of treatment have been thoroughly explained to
them.
Thus, euthanasia in medical practice is euthanasia done by the physician

for patients suffering from an incurable disease or condition, either
active or passive, either voluntary or non-voluntary, and should never
be involuntary. Ending the life of a patient suffering from an incurable
disease or condition by a person other than the physician is not
euthanasia in medical practice. It may be suicide done by the patient
himself; assisted by a physician (physician-assisted suicide); or assisted
by another third party other than the physician. Loosely and strictly
speaking, euthanasia may be done by persons other than the physicians,
92
49
The concepts of euthanasia and suicide may overlap. The patient asking
a physician to perform an active euthanasia is akin to committing
suicide, which is defined as killing oneself intentionally. To
differentiate euthanasia from suicide in the context of medical practice,
euthanasia is done by the physician whereas suicide is done by the
patient. Thus, physician-assisted suicide is another related concept of
euthanasia in which the deliberate ending of life of the patient is done
directly by the patient himself, not the physician, although the latter
assisted in one way of another, such as convincing, mentoring, and
prescribing lethal drugs, etc.
such as the patients relatives. The latter can perform active and passive
euthanasia, voluntary or non-voluntary, following the concepts of
euthanasia spelled out for physicians. Just like the physicians, they should
be aware of the implications of their acts.
When is a medical action considered euthanasia? It is euthanasia if there
is a deliberate intention to end the life of patient suffering from an
incurable disease or condition via a medical action that is known to be
instantly lethal if done, whether actively or passively, like withdrawing
and withholding treatment. There is no euthanasia unless the death is
intentionally caused by what was done or not done. No every withholding
and withdrawing medical action as well as aggressive measure is
considered passive euthanasia, especially when the deliberate intention to
end life instantly is lacking. Withholding and withdrawing medical actions
may be done to let the patient die the natural course, not to instantly end
his life. This is not considered euthanasia. Aggressive measures such
giving higher dosage (but not lethal by conventional standards) of drugs
may be done to relieve suffering. If the patient dies resulting from the side
effect of higher dosage, this is not considered euthanasia as there is no
deliberate intention to end life instantly.
In the Medical Anecdotal Report of Dr. Glenn Villanueva, one can see the
varying, if not different, perceptions and interpretations of the physicians
and relatives on the concept of euthanasia. Here are my personal thoughts,
perceptions, opinions, and recommendations on this. Removing the
endotracheal tube and stopping of intravenous fluids can be classified as
passive euthanasia. So is the DNR (Do Not Resuscitate). In these three
actions, there is withdrawing and withholding of treatment that may
prolong the life of the patient, thus, potential passive euthanasia. Note the
emphasis on may. If one knows that that by removing the endotracheal
tube, the patient will surely die instantly, if this done, this is passive
euthanasia. If there is no certainty that the patient will surely die by
removing the endotracheal tube and there is a decision to let the patient die
the natural course without the tube, then there is no passive euthanasia.
The same assumptions are applicable to the stopping of intravenous fluids.
If there is no deliberate intention to end life instantly and there is a
decision to let her die the natural course, there is no passive euthanasia.
The same principles go for the DNR. If there is no deliberate intention to
end life and there is decision to let the patient die the natural course, there
is no passive euthanasia.
framework should be the same. Most important of all, all patients,

regardless of types, should be managed equitably in terms of holism,
professionalism, and compassion.
Thus, to the question, is there or should there be a difference in the
medical management of physician-patients and non-physician-patients,
my overall viewpoint is that there is or should be none (based on the
assumptions and reasons that I have given). If a physician cannot
manage the tag and the emotions associated with a physician-patient to
the point that objective problem-solving and decision-making is being
hampered, then referral to colleagues is indicated.
The best outcome scene will be a physician being able to manage a
physician-patient systematically and objectively and holistically,
professionally and compassionately as he would do for a non-physicianpatient. If there will be an emotion that should not be controlled in the
management of a physician-patient, it will be the feeling of being given
the honor and privilege of managing a colleague in the profession. This
is equivalent to the trust and confidence given by a colleague in the
profession.
http://ommcsurgerymar2013.wordpress.com/2014/12/28/jhdecastrosmar-13-10-managing-a-colleague
Another TPOR on the MAR of Dr. Villanueva is on the removal of

endotracheal tube. The tube can be removed by a physician or by a
relative guided by a physician. This can be done in a situation in which
50
91
management of the physician-patients and non-physician-patients?

My first TPOR is that there should be none in terms of established
problem-solving and decision-making processes and procedures.
Here is my second TPOR.
the physician does not want to do the withdrawal of treatment because of a

mindset and a relative is willing to do it. Note, however, both the
physician and the relative of the patient should know the implications of
the plan. There are more issues that can pick up from the MAR such as is
it better to withhold than to withdraw and how to get the consent. I will
stop here and discuss these in other occasions and opportunities.
The primary difference between the physician-patients and nonphysician-patients in relation to the practicing physicians is the
attachment of a colleague tag to the former. The colleague tag
means the physician and his physician-patients have the same profession,
that is, medical profession. Being physicians, the physician-patients
may be more knowledgeable in the science and art of medicine than the
non-physician-patients. These being so, should the presence of
colleague tag and more knowledge in the science and art of medicine
make a difference in the medical management of the two categories of
patients (again, assuming that the medical management capability and
requirement fall within the specialty practice of the physicians)?
As I said at the very start of my TPOR, euthanasia has been a very

controversial and emotive topic up to now. I also said that all physicians
practicing medicine should be aware of the concepts of euthanasia and its
associated issues to guide them in the practice of their profession,
specifically, in managing situations in which there is a potential issue of
euthanasia. Equipped with the proper type and amount of knowledge, the
physicians should be able to manage potential euthanasia situations in such
a way that there is no legal complications and bothersome consciences for
both physicians and relatives and most important of all, value service to
the patient.
My second TPOR is that there should be none just on the bases of the
presence of a colleague tag and the potential for more knowledge in
the science and art of medicine.
Physicians are supposedly trained to do problem-solving and decisionmaking (PSDM) under all kinds of circumstances and in all types of patients. They are expected to do the PSDM objectively, not affected by
any tag attached to the patients (physician, colleague, relative, etc.).
They are expected to treat all their patients systematically using a structured patient management framework (with clear and rational processes
and procedures) which should be the same for both physician- and nonphysician-patients. They are expected to treat all their patients equitably
in the domain of holism, professionalism, and compassion whether physician- or non-physician-patients.
http://ommcsurgerymar2014.wordpress.com/2014/11/05/gpvillanuevasmar-14-09-preventing-euthanasia
Although in general, physician-patients are more knowledgeable in terms

of the science and art of medicine, there are non-physician-patients who
may be more knowledgeable than physician-patients. Thus, using the
potential for having more knowledge in the science and art of medicine is
not a valid basis to manage physician-patients differently as against
non-physician-patients. This aphorism is also applicable to
non-physician-patients. Non-physician-patients also have variable
amount knowledge in the science and art of medicine. Physicians do not
use the differential potential for more knowledge as a justification to
treat non-physician-patients differently. The patient management
90
51
in the same profession as the physicians they consulted. These physicianpatients are their colleagues in the profession.
Medical Anecdotal Report

MAR Title: The Bridge to a New Stone
Reporter: Lucas Riel Bagares Bersamin, Jr. MD
Year Reported: 2014
NARRATION:
I received a referral from the Pediatric emergency department. The patient
was a 4-year-old male patient who came in with a chief complaint of
abdominal pain. Going through the history, the patient had this pain for
two days and had increased in severity. On further examination and study
of his laboratory work-ups, I noted the patient to have equivocal findings
on his abdomen and deemed him to be suffering from partial intestinal
obstruction. However, I had few doubts unto my diagnosis. I did not want
to feel the burden subjecting the patient to surgery and have complications
that would come with it. I did not want to end up misdiagnosing my patient
due to the difficulty in assessing pediatric patients. So, I informed my
senior resident of the case and showed him my patient. He gave me his
diagnosis of the case and explained to me how he arrived to such. After our
discussion of the diagnosis and management, we subjected our patient to
surgery. I performed an appendectomy procedure and corroborated my
intra-operative findings with what my senior had initially suspected.
During my surgery, he again reminded me of the steps I had to do
meticulously and stressed on these in management to assure adequacy in
treatment. I knew that he had the confidence in me to perform the
procedure with assiduousness but I also knew he was just being himself,
safe and thorough. As I finished the procedure with the patient well on his
way to the recovery room, I felt fortunate to have someone like him to be
guiding me through this delicate procedure and treating this patient. I felt
fortunate to have been under his tutelage and say that I learned a lot from
him. Three years ago, coming with the same situation, I would have told
myself: Ang kulit mo naman sir (Sir, your being importunate). Looking
back at it, I find the comedy from it now and have better understanding of
my senior, on why there is persistence and an overeager attitude in
supervision and instruction. As an intermediate resident, I got to think
about what I would be like when the time comes that I would be the one
guiding my juniors into their cases.
INSIGHT:
In medical school, we are packaged with knowledge enough to bring with
the basics of curing our patients. We hone our skill and knowledge to be
better in our practice. And then, after we graduate, we develop them
52
The main issue is how physicians should manage their physicianpatients. Is there or should there be a difference in the medical
management of physician-patients and non-physician-patients? Is there
or should be a difference in the medical management of relativephysician-patients and non-relative-physician-patients?
Before I proceed further, let me spell out the assumptions and delimit the
scope of discussion of my TPORs.
The first assumption in this TPORs is that the medical management
capability and requirement fall within the specialty practice of the
physicians, meaning, regardless of kinds of patients in terms of
relationship, they have been adequately trained to do the medical
management. I will exclude from this TPORs the situation in which the
physicians are not capable of doing or fulfilling certain requirements of
the medical management. Referral is the outright solution in this
situation.
The second assumption or focus of discussion in this TPORs is that the
medical disorder is a major one in which treatment, conventionally
categorized as a major and even medium intervention, has to be done. I
will exclude from this TPORs the situation in which the medical disorder
requires only a minor treatment, such as prescribing antipyretics and
giving advices.
I will delimit this TPORs to management of non-relative-physicianpatients. For my TPORs on management of relative-physician-patients,
please see the following link that presents my stand on treating relativepatients: (http://ommcsurgerymar2014.wordpress.com/2014/12/18/
mbvelezs-mar-a-heart-breaking-best-option-for-a-relative)
So how should physicians manage physician-patients and who have a
major medical disorder whose treatment is within their specialty
practice?
Here is my first TPOR.
If medical management is divided into 3 parts, namely, diagnosis,
treatment, and advice, (assuming the practicing physicians are capable of
accomplishing these 3 parts in non-physician-patients and non-relative
patients), is there or should there be a difference in the medical
89
scheduled her for the operation. Currently, she was preparing for the
surgery.
INSIGHT:
Managing a colleague can be very tough. Especially in this case when
you personally know the patient and you are working in the same
hospital with her. My dilemma was how to discuss the prognosis with
her since we are considering an aggressive type of tumor because it
occurred in such a young age.
I admired my consultant who handled her for she was able to explain
to her the prognosis and management candidly and accurately to her.
In cases like this, when you will handle a doctor as a patient, the same
objective approach should be given to them. Moreover, we should be
firm and try not to yield or be swayed by their own management. I am
glad that I was able to stood my ground not to forego biopsy and
yielded to her request to remove the tumor right away. Furthermore,
an extra effort should be made to try and make them understand what
needs to be done.
Doctors providing care for other health professionals need to treat
them like other patients, without taking short cuts or making
assumptions about them. Such patients should be offered the same
explanations of what is involved in the investigation and management
of their condition. They may already be well aware of such
information but should be allowed the opportunity to be the patient
and be offered advice and support as any other patients should have.
They may be much better informed than most other patients and their
special knowledge should be recognized, without assumptions being
made about the amount of information and detail they want. They
should be reassured that seeking formal medical care is the right
decision, rather than relying on their own interpretation of their
condition. They should be encouraged to develop a continuing
relationship with their doctor, including routine recall for follow up.
How should physicians manage physician-patients?
All practicing physicians will invariably encounter a situation in which
physicians are their patients. These physicians may be known to them
or not. These physicians may be their relatives or not. What these
physician-patients have in common is that they are physicians who are
88
further. After passing the physician licensure examination, I knew I

wanted to go into surgery residency training in Ospital ng Maynila
Medical Center (OMMC). I always took my training as a privilege and
an honor as I revered the doctors that graduated in this center. I came to
be trained by physicians known for their craft and practice. We would
pay a price in training to be the best and most of the time, sacrifice a
whole lot that would compromise everything else that is left of us. Three
years ago, as a very young member then of this training program, it
seemed a daunting task to absorb all what were passed down unto us by
our consultants and senior residents. It would appear then as a frustration
on my part not to be in the line of understanding with my senior residents.
However, through time, we got a grasp of things and became mature
enough to understand our senior residents. And like a sponge, we tried to
absorb as much knowledge and information to eventually discharge
things we have learned to manage our own patients. And then we would
take in some more. This knowledge passed on to us have been transmitted
with such refinement, like in our first appendectomy; or a little bit jagged,
as in procedures that are usually done in trauma patients. The specific
knowledge we may attain in these cases, handed unto us by our senior
residents, are the things we later carry on, develop, and nourish. As we
transmit the knowledge to our junior residents, we must always be adept
with the right information and attitude towards surgery. It is through this
process that society strives and in our case, the surgical residency. It is
not only the knowledge per se that is transmitted but also what is not
taught in our books and guidelines on how to talk to our patients, explain
difficult procedures, and dealing with other doctors. Other than these
important things in the profession, we also learn about lessons in life and
the like. To learn from a VSD (Voltaire S. de la Cruz) the lessons of
trauma procedures and surgical economics which we may use in
continued education and training. To learn the lessons of maintaining a
high emotional quotient and calmness from a GMG (Glenn M. Gervacio)
that is essential in striking a balance in life and the profession. We learn
the principles in formal cancer surgery, ideal patient care, and service
from an OLO (Onofree L. OConnor) that we may eventually carry on for
our own practice. It is but fitting now that I bid my seniors gratitude in
the tail end of the road in their training. It is also fitting to show
appreciation for the friendship we have. All the lessons gained will
provide us an avenue to a new stone to throw unto my juniors to teach
and make the right lessons ripple through generations of residents in
training.
Why should junior resident-physicians cherish and nourish the
learning they get from their senior resident-physicians?
53
In the training of physicians, after the physician licensure examination, the

certified physicians can pursue further specialty trainings such as General
Surgery; Ophthalmology; Pediatrics; Internal Medicine; ObstetricsGynecology; Orthopedics; etc. The latter can range from 3 to 5 or even
more years of training. During this time, they are usually called residentphysicians. After the specialty training, they can opt to go for more
training, this time subspecialty training. During this time, they are usually
called fellows such as fellow in Cardiology; Neonatology; Head and Neck
Surgery; Hand Surgery; etc.
This TPOR will be on the training of resident-physicians.

As an introduction, as mentioned, the minimum duration of a specialty
training is 3 years. It can be longer, say 5 years or even more, such as 6
years. Pertinent to the topic of my TPOR, the resident-physicians are
broadly classified into junior and senior residents. Senior residents are those
on the upper levels of the training period and junior residents on the lower
levels. The resident-physicians can also be more specifically classified in
terms of year level in the training period such as 1st year, 2nd year,
3rd year, 4th year, and 5th year, that is, if the training period is 5 years.
The focus of this TPOR is on the junior resident-physicians. More
specifically, the question is why they should cherish and nourish the
learning they get from their senior residents.
All residency training programs are designed with the goals that the
residents will cherish and nourish the learning they get from the program.
Cherish means to appreciate and nourish means to keep alive, sustain,
promote, strengthen, and develop further. Appreciation of importance and
usefulness of the training program motivates learning. With medicine being
an inexact science with no absolute period, just comma, in knowledge and
skill acquisition and refinement, nourishment maintains the quality not only
of the training program but also the care of patients by the resident-trainees.
The latter occurs both during and after the training period.
Just as residents usually cherish the learning they get from the consultants
during their training period and nourish them before and after they graduate,
they should also cherish and nourish the learning while still in training.
The junior residents should cherish the learning they get not only from the
consultants but also from their co-residents, particularly from their seniorresidents who in their last years have usually attained an adequate level of
competency as a physician-educator. They should also nourish what they
have learned in their younger years from both the consultants and senior
residents. They should keep alive, sustain, promote, strengthen, and
54
MAR Title: Managing a Colleague

Reporter: Jenny Vi. H. de Castro, MD
Year Reported:2013
NARRATION:
I was approached by a colleague asking if I could examine a palpated
mass on her right breast. She said that she already had a breast
ultrasound and a mammography done; however, it was not with her at
that time. She asked me to be the one to excise her mass in the minor
operating room (OR) at the out patient department. I examined the
mass. It was solid, movable and measured approximately 1.5 cm in its
greatest diameter with smooth borders. I was not able to palpate any
lymph nodes. I then asked her when was the most convenient time for
her to be scheduled for the excision of the mass. Since she was also in
training, she said that she would immediately contact me whenever she
would not be so busy anymore. I agreed.
A month passed, she contacted me again and asked if I could schedule
her already in the minor O.R. She showed me the results of her
ultrasound and mammography. As I palpated the mass, I noticed that it
had drastically increased in size. It now measured approximately 4 cm
in its greatest diameter with corrugated borders. I had not palpated any
lymph nodes like before. I told her that it was best to do a needle biopsy
(a small sample of the lump/mass is removed via aspiration using a
hypodermic needle with or without local anesthetics) of the mass first.
She hesitated for she wanted the mass to be removed straightaway. She
asked if I could forego the biopsy and proceed with the excision right
away. I explained the need for needle biopsy. Fortuitously, she agreed.
I did the needle biopsy and we waited for the result. Three days after, I
received a text from her saying that the initial result was ductal
carcinoma. She said that three different pathology consultants had read
the slides. I was flabbergasted. I did not know what to say. I imagined
being the one in her shoes. I talked to her, choosing carefully the words
to say. I know that she already had the idea of what the surgical
management was. I asked her to choose the consultant who would
handle her case. She admitted that she was so depressed and was so
scared. I told her that we would all be there for her and assist her in
every way that we can.
The next day, I accompanied her to talk to our consultant who
explained the management and prognosis of breast cancer to her. She
listened bravely and agreed to the management. The consultant then
87

http://ommcsurgerymar2013.wordpress.com/2014/12/26/atcelzos-mar13-09towards-patient-safety-in-surgery-my-departments-principle
Powerpoint Templates - 2009 to 2011 (upper one); 2011 onwards
(lower one)
develop further what they learn in younger years. When they reach the
senior years, they are expected to impart to their junior residents what
they have learned and nourished. The impact of the cycle of
nourishment by the residents is the maintenance of the quality of the
training program as well as of that of patient care.
A side note:
The residency training program is essentially a type of an on-the-job
training in a medical specialty wherein patients are involved, never
merely a theoretical (without practicum) training and learning. It is
essentially a collaborative training between and among the residents
(junior and senior) and between and among residents and consultants (the
faculty), never merely a one-man training and learning alone. Thus, the
teachers of the junior residents are the patients; their co-residents
particularly the senior residents; the consultants (the faculty). The junior
residents should cherish and nourish what we learn from the abovementioned teachers as early as the first day of their training.
http://ommcsurgerymar2014.wordpress.com/2014/12/26/lbbersaminsmar-14-10-the-bridge-to-a-new-stone
86
55
MAR Title: Respect the Relatives Decision on Their Dying Patient

Reporter: John Alexis Dingal Canlas, MD
Year Reported: 2013
NARRATION:
It was a rainy evening during my ward duty. We had two critically-ill
patients at our Surgery Intensive Care Unit (SICU). I was approached by
the SICU medical clerk and said that the relatives of one of the SICU
patients decided to go home against medical advice (HAMA). The
patient was a 7-year-old boy who had an intracranial mass admitted at
our institution for an emergency procedure. I immediately went to the
patients room and greeted the patients relatives. After I introduced
myself, I asked the patients relatives to confirm their decision of going
home against medical advice. The patients father said that their whole
family had agreed to sign the HAMA form. He said this with a straight
voice but with sad eyes.
I will soon father a child; my wife is four months pregnant. I felt uneasy
after hearing the HAMA decision of the father of my child-patient. The
father told me that they had already discussed the matter with their
family. Looking at the patient, he had a mechanical ventilator; an
intravenous line on his left hand; and an indwelling urinary catheter. He
had an unstable vital signs. Could I ever bring myself to sign a HAMA
or DNR (Do Not Resuscitate) form if I saw my child unable to breathe
on his own? Unable to open his eyes when hes called? Unable to
respond when his hands are held? Could I give up?
I asked them if they were certain and they said yes without hesitation. I
politely said that I would refer this matter to my senior resident. I looked
for my senior resident and relayed what happened. She told me let them
sign the HAMA form but I should first explain again the condition and
consequences of what would happen to the patient. With a serious and
soft voice but with a crying heart, I explained to the relatives the gravity
of signing the HAMA form and what it entailed. The patients father
then affirmed their previous decision.
I assisted them in going out from the hospital. The patient was
transferred to the ambulance. My hands were trembling while I was
removing the Ambu-bag. I then turned back and immediately went back
to the hospital. Again, the same questions went back to my mind. Could
I ever bring myself to sign a HAMA or DNR form if I saw my child
unable to breathe on his own? Could I give up? I think I could not.
56
at the Department of Surgery at Ospital ng Maynila Medical Center

(OMMC), this principle was reaffirmed. Here I met this phrase, Towards
Patient Safety in Surgery. As I was molded by its training, my core as a
resident was made strong by this guiding principle.
To answer the question for my patient, Yes, I can do the operation here at
our institution. But is it proper? Is it Safe? These are the things we should
consider for our patients. We have to take note that our patients are not
guinea pigs that are just subjected to different experiments. They are
and deserve to be treated humanely. Despite their different status in life we
have the obligation to give them the proper care. We have to give them
what is best and what is safe.
During my training, this is one of the things that make me proud to be part
of OMMC Department of Surgery. In here we give what is best! And we
do what is safe!
How does the Department of Surgery of Ospital ng Maynila Medical
Center remind staff of Patient Safety in Surgery?
Through a Powerpoint template with a tagline (Towards Patient Safety in
Surgery) and a directive (Promote customer delight. Avoid complaints at
all times).
Below are the templates of the Powerpoint being used in the Department of
Surgery of Ospital ng Maynila Medical Center (OMMC Surgery) since
2009 to present.. They contain the taglines of Towards Patient Safety in
Surgery and a directive of Promote customer delight. Avoid complaints
at all times.
Every Tuesday and Thursday, OMMC Surgery has educational
conferences. There are about 80 conference-days in a year. The
Powerpoint template is being used at all times. The tagline and directive
in the Powerpoint template serve as a constant reminder to all staff of the
Department of Surgery.
This is one of the legacies I left behind in the Department of Surgery of
OMMC and also to the patients of Department of the Surgery of
OMMC. The goals of patient safety and customer satisfaction actually
have been set since 2001 when I was appointed Chairman of the
Department. I have reinforced them with a constant reminder through the
Powerpoint starting 2009.
85
MAR Title: Towards Patient Safety in Surgery: My Departments

Principle
Reporter: Ariel T. Celzo, MD
Year Reported: 2013
NARRATION:
It would not be so bad to decline a request and tell them that it could
not be done for the patients sake.
Similar thing happened to me when I received a call from an employee
of one of the administrative offices at our institution. She informed me
that her sister, a 35-year-old-female was admitted at Internal Medicine
ward due to gallstone pancreatitis. I told her that her sister was already
referred to our service and we were managing her for quite some time.
As a courtesy, I even went to her office and discussed with her about
the current condition of her sister. After long minutes of conversation,
she finally asked me if her patient could be operated at our institution. I
simply reiterated the limitation of our hospital and told her the
importance of intra-operative cholangiogram (IOC imaging of the bile
ducts by x-rays), which at that time was not available for our disposal.
Although costly, I even offered a Magnetic Resonance
Cholangiopancreatography (MRCP an imaging technique to visualize
the biliary tract and pancreatic ducts.) so we could have a biliary
clearance prior to operation. I told her that these imaging techniques
were needed to be available for us to do the proper management for her
patient.
I saw a disappointment on her face and went as far as comparing other
patients to her sister. She ranted on why we could not accommodate her
sister even though we were adept on such procedure and had operated
for such a case for years on different patients. I patiently waited for her
to calm down. With the approval of my consultant to my plan, I
reaffirmed that the condition of her patient was different and such
ancillary procedures were needed for the safety of the patient and not
for any other reason. At the end of conversation, she thanked me for
answering her questions and decided to transfer the patient to other I
nstitution.
INSIGHT:
First do no harm. This is the guiding principle that was instilled on
me ever since I became a doctor. As I entered into residency training
84
INSIGHT:
Death is inevitable and we will all encounter this as they say. We are
more exposed to it than others because we are in the medical field. We
are often the bearers of not so good and worse, really bad news.
We may encounter circumstances that we may be emotionally attached.
As physicians we always need to be guided by our objectives in order to
be at our best and perform the necessary procedures that will save lives.
We also need to give all the medical options available in these special
cases.
In this situation, I did not agree with the decision of the relatives but I had
to respect their request. Having this question to ponder upon, I examined
everything that had transpired accordingly. Should I have prevented them
from going home after giving them a full account what the patient was
going and would go through?
With this experience, I learned how to detach my emotions but still be a
caring physician. I tried to be more objective over these matters and
concerns. I had learned a lot over the previous medical anecdotal reports
of my seniors and co-residents and came up with a more ethical and
professional approach. I became guided and true to these facts of life.
Why and how should physicians control or manage their mindsets and
emotions when dealing with patients?
A mindset is a particular way of thinking; a persons attitude or set of
opinions about something (Merriam-Webster Dictionary).
An emotion is a strong feeling (Merriam-Webster Dictionary).
Every person has a mindset and emotions, physicians included.

The practice of medicine involves problem-solving and decision-making
(PS-DM) during the entire period of physician-patient
interaction. Resolution of a health concern involves PS-DM by both the
physician and the patient. The physician assists the patient in PS-DM
with the patient and his relative having the final say, particularly on the
DM.
Both the physician and the patient should be as objective and rational as
57
possible in accomplishing the PS-DM processes, from formulation of

diagnosis, to selection of diagnostic aids, to selection of treatment,
monitoring, evaluating methods, to giving and responding to advices and
recommendations. There are well-established principles and processes
in PS-DM in the management of a patient (see ROJosons Management
of a Patient Process http://rojosonmedicaleducation.wordpress.com/
category/management-of-a-patient-process). There are well-established
ethical principles that can be used in PS-DM. There are myriad hard
data and information in the medical literature that can be used in
PS-DM.
Being objective and rational in PS-DM carries a higher chance for a

correct decision and correspondingly, a higher chance for better outcome
in the management of a patient.
http://ommcsurgerymar2014.wordpress.com/2014/12/11/pjcgagnos-mar-1410the-hurdles-of-transferring-a-patient-to-another-hospital
Transfers are effected through qualified personnel, proper transportation

and equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer.
Agreement to accept the physician in transfer should be obtained from a
physician or responsible individual at the receiving hospital in advance
of transfer.
Appropriate medical summary and other pertinent records should accompany the patient to the receiving facility.
Mindsets and emotions of the physician and patient (and his relative)
should be controlled and managed accordingly so as not to affect the
objectivity and rationality of the PS-DM. The first person who should
control and is in a better position to control mindsets and emotions is the
physician as he is supposed to be professionally trained for this kind of
challenge. The physician should then assist the patient and his relative
in controlling their mindsets and emotions primarily through giving
indicated hard advices and providing social support as necessary. At the
end of everything, after attempting to be as objective and rational as
possible in PS-DM and controlling mindsets and emotions that may
affect objectivity and rationality by both parties, whatever final decision
is made by the patient and his relative, the physician must respect
it. (Note: a formal informed consent or informed refusal must be present
and documented.)
http://ommcsurgerymar2013.wordpress.com/2014/12/25/jdcanlas-mar13-07respect-the-relatives-decision-on-their-dying-patient
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83

What should physicians know about Transfer of Patients to Another
Hospital Types, Reasons, and Policies?
MAR Title: Challenges Due to Closure of the Operating Rooms

Reporter: Marienelle Recto Maulion, MD
Year Reported: 2014
Definition of Transfer to Another Hospital
NARRATION:
A patient is initially seen and managed by a physician in one hospital,

either at the emergency department or the inpatient department. The
patient needs to be managed in an inpatient basis in a hospital. The
transfer is to another hospital.
It was a peaceful day for me while manning the Surgery emergency

room. The news that our operating rooms were closed for a while for
disinfection might have already reached other hospitals. I had only few
patients coming in. After a while, I received a text message from my
patient saying that she was already cleared from Internal Medicine and
wanted to be scheduled immediately. I replied that I could not schedule
her yet due to the closure of the operating room and was uncertain when
the operating days would resume. Then she called, Doc, baka po mapaso
ang mga laboratory ko at mag ulit na naman. Operahan nyo na po
ako. (Doctor, my laboratory results may expire and may need to be
repeated again. Please operate on me.) I told her again that she could not
be operated on yet because the operating room was closed and I asked
her to be patient. I also expressed that I would schedule her immediately
once the doors would be open for operation. A week later, she again
called, but unfortunately, operating rooms were still closed. To address
her concern on her clearance being expired, I asked her to come to the
out-patient department (OPD) so I could relay to the Internal Medicine
Department our situation at hand and might be able to extend the
expiration. I saw her at the OPD with a worried face. I told her to relax a
bit and everything would be alright. I brought her to the Internal
Medicine Department while I conversed with my fellow resident. My
colleague from Internal Medicine reassured me that if the patient would
be admitted and her clearance had expired, I would only come to her and
she would update the clearance. That being said, my patients face
changed from being worrisome to smiling. We thanked my fellow
resident and left the OPD. I tapped my patients shoulder and said that
everything would be alright. I promised that I would contact her as soon
as we could admit patients for operation. She thanked me and said, Doc,
pasensya na po sa paulit ulit kong text sa inyo, lilipat na sana po ako ng
ospital, pero dahil po okay na po ang lahat, naniniwala ako hindi nyo ako
pababayaan. (Doctor, I am sorry for my repeated text messages. I was
about to transfer to another hospital, but because everything is alright
now. I believe that you will not abandon me.)
Types of Transfer Based on Initiators

Transfers to another hospital can be initiated by the attending physician
and/or the hospital in the initial hospital or by the patient and/or
relatives / guardians / third-party payors. In either types, there must be
an informed consent of the patient and optimal health and well being of
the patient should be the principal goal of patient transfer.
Reasons for Transfer to Another Hospital
There are a lot of possible reasons why patients need or want to be
transferred to another hospital. These reasons can be lumped into 5:
1.
2.
3.
4.
5.
Limited service and facility in the initial hospital

Patient / relative / guardian / third party payor not
satisfied with the service and facility of the hospital
Limited funds for the hospital expenses
Dictate of a relative / guardian for whatever reasons
Dictate of a third party payor for whatever reasons
For whatever reasons, there must be an informed consent of the patient

and optimal health and well being of the patient should be the principal
goal of patient transfer.
Policies and Procedures in the Transfer of Patients to Another
Hospital
The optimal health and well being of the patient should be the
principal goal of patient transfer.
The transferring physician should inform the patient or responsible
party of the risks and benefits of transfer and document these.
Before transfer, patients consent should be obtained and
documented.
82
INSIGHT:
The closure of the operating room for several days has been a challenge.
It is both a blessing and a curse. It is a blessing because no elective and
59
emergency operations were allowed. Hence, benign duty days. It is a curse

because it pushes our census below the minimum and as surgeons, our
skills ceased to be enhanced and honed. It is also unfortunate for the
patients who are expecting to have their operation be scheduled and for
those who come to the doors of the emergency room, hoping that we will
be able to accommodate them. Most of the surgical patients who came in
the emergency room are very insisting and do not want to accept the fact
that we cannot accommodate them. Some of the elective patients are also
agitated due to the closure of the operating rooms and maybe thinking they
may not be operated on as they have hoped for. To overcome the
challenges, I requested that the triage desk place a copy of a memorandum
of the closure of the operating room, so surgical patients and their relatives
will see it immediately. I will also confirm the closure and will address
immediate concerns of the patient before transfer. Even if we are not
operating, we can read our surgical books that will enhance our knowledge
in operating. For my patients for elective operations, personally reassuring
them will prevent losing them to another hospital. Also it will allay their
fears and prevent misunderstandings to happen.
What are the implications of a temporary cessation of services in a

hospital and how should hospital administrators manage them,
particularly, in mitigating the negative effects?
Temporary cessation of some services will invariably occur during the
lifespan of a hospital. The causes may be renovation for expansion and
improvement, disinfection, negative effects of a disaster, breakdown of
equipment, etc. This is a challenge that all hospital administrators and
workforce face. It is considered as a crisis primarily and an opportunity
secondarily.
Temporary cessation of some hospital services is considered a crisis
because it is a time of intense difficulty in deciding what to do to mitigate
the negative effects. The negative effects usually consist of business and
other opportunity losses and inconveniences for all stakeholders (owners,
clients, and workforce).
INSIGHT:
To be admitted in a hospital is very stressful not only to the patient but
also to the relatives. More often than not, these lay people dont have
any idea of their relatives disease and what will happen in the course of
treatment. It is our job and responsibility as physicians to explain and
let them understand every step of management. By doing so, we avoid
any misunderstanding or miscommunication. This will in-turn develop
good rapport and good patient-physician relationship.
Transferring a patient to another hospital is a possibility that a patient
may encounter once admitted in a hospital. There are a lot of reasons a
patient may need to be transferred to another hospital. In the case I
narrated above, the patient had no clear-cut indication to be transferred
except for the request of the employer. In my judgment, it is the
relatives decision that we should recognize.
There are many processes that a patient, relative, attending physician,
and the hospital where the patient initially went have to hurdle in
transferring patients. See below.
Based on policies on transferring patients, the following guidelines
should be followed:
The optimal health and well being of the patient should be the
principal goal of patient transfer.
The transferring physician should inform the patient or responsible
party of the risks and benefits of transfer and document these.
Before transfer, patients consent should be obtained and documented whenever possible.
Transfers are effected through qualified personnel and transportation and equipment, as required, including the use of necessary and
medically appropriate life support measures during the transfer.
Agreement to accept the physician in transfer should be obtained
from a physician or responsible individual at the receiving hospital
in advance of transfer.
Appropriate medical summary and other pertinent records should
accompany the patient to the receiving facility.
The main tangible negative results of business opportunity losses for

private hospitals include drop in revenues and number of patient-clients
with the latter going or transferring to other hospitals. The main tangible
result of business opportunity losses for government hospitals consists of a
Reference: Policy on Appropriate Interhospital Patient Transfer.

American College of Emergency Physician. June 1997.
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81
MAR Title: The Hurdles of Transferring a Patient to Another Hospital

Reporter: Patrick Jovan Concepcion Gagno, MD
Year Reported:2014
NARRATION:
One of my junior interns referred a patient to me. She said that a relative
of one of our admitted patients wanted to talk to me. I immediately went
to the patients room. I met a woman in her early thirties, sitting beside
our patient. The latter was a 32-year-old male diagnosed with acute
subdural hematoma (an accumulation of blood between the arachnoid and
the dura) secondary to a vehicular accident. The patient had a Glasgow
Coma Scale of 15 and was managed medically.He was admitted as a
Non-Manilan pay-patient.
I introduced myself and asked what her concern was all about.
The relative voiced out that her brothers employer, who sponsored the
patients admission, was persuading them to transfer to another public
hospital. She said the employer wanted to talk to me on the phone. I got
to talk to the employer and asked what were the concerns behind the
contemplated transfer. I soon found out that, since the patient was
admitted as a pay-patient, the employer was concerned of the hospital bills
and other fees that they couldbe incurred. I suggested to the employer to
ask the social serviceof the hospital for assistance. However, she was
insistent on the transfer as shesaid she had talked to a doctor in the other
hospital already. I tried to get the name of the doctor so I could properly
endorse the patient and facilitate a smooth transfer but the employer could
not give me a name.
I then tried to talk to the patients relative and explained that transferring
to another hospital would be easy as long as there would be a receiving
neurosurgeon in the other institution. Without a neurosurgeon, they would
have to hurdle again the same processes of being admitted in an
Emergency Room. Besides, the patients comfort would also be
compromised. Transferring the patient might also cause some delay or
interruption in the treatment. I advised the relative to talk to her brothers
employer regarding the situation.
The next morning, when I made my rounds, I got to talk to the relative
again. She said she had settled the situation with her brothers employer.
They had decided not to transfer the patient anymore since they observed
that proper treatment and attention werebeing given to their patient in our
institution. (Postscript: Eventually, patient recovered and was discharged
well.)
80
drop in number of patient-clients utilizing their services. The nonbusiness opportunity losses include drop in the opportunities for
learning and research of the hospitals and their workforces,
particularly, those with external accreditation requirements to fulfill
and maintain.
The main tangible negative results of inconveniences associated with
temporary cessation of services for both private and government
hospitals include anxieties and complaints of the patient-clients and
the difficulty of the workforce managing such anxieties and
complaints.
Temporary cessation of some hospital services is or should be
considered as an opportunity also in the midst of crisis. For both the
hospitals and workforce, the temporary cessation of hospital services
should be an opportunity for re-energizing and catching up for
purposes of advancement and growth. The main tangible positive
effects of opportunity for re-energizing and catching up include or
should include better facility, better services, and better workforce.
As mentioned above, temporary cessation of some services will
invariably occur during the lifespan of a hospital. Just like disasters,
particularly natural ones, which will invariably occur, there must be a
prevention, mitigation, preparedness, response, and recovery program
for temporary cessation of hospital services. The risk (temporary
cessation of services) reduction program should be in place as early as
in the starting phase of hospital construction and vigilantly monitored
and updated during the entire life of the hospital. The risk reduction
program should be part of the action plans in the initial strategic planning of the hospital and in subsequent ones. Prevention and mitigation
of temporary cessation of hospital services from all possible causes
such as renovation for expansion and improvement, disinfection,
negative effects of a disaster, breakdown of equipment, should be
spelled out as a continuous target. If unavoidably, temporary cessation
of some hospital services has to be declared, at least its occurrence
will not be as frequent as in a situation in which there is no proactive
program or plan at all for prevention and mitigation. Furthermore, the
negative effects will be lesser in magnitude.
Temporary cessation of some hospital services may occur abruptly or
unexpectedly such as sudden breakdown of hospital equipment and
destruction by earthquake. In such situations, there must be response
and contingency plans to mitigate the negative effects, particularly on
the business and other opportunity losses and inconveniences of
61
stakeholders.
Temporary cessation of some hospital services may also occur as a result
of an intention and decision from the hospital administration such as in
situations in which there will be renovations for improvement and
expansion. In such situations, there must be response and contingency
plans to mitigate the negative effects of the crisis and to maximize the
positive effects of the opportunity associated with the cessation of
services.
The hospitals and its workforce must have structured and comprehensive
response and contingency plans to mitigate at least the following negative
effects:
So, when respected, physicians should continue to act professionally

in carrying out their duties and more so, when they have to respond
and intervene to a disruptive behavior by another party. In the latter
situation, physicians should remain calm and never yell back, use
intimating and foul language, demonstrate rude behavior, etc.
http://ommcsurgerymar2014.wordpress.com/2014/12/11/aaalvezsmar-14-10disrespect-from-a-civil-servant
Drop in revenues
Drop in number of patient-clients
Anxieties and complaints of patient-clients
Drop in opportunities for learning and research of workforce
The hospitals and its workforce must have structured and comprehensive
response and contingency plans to maximize the following positive
effects that can be derived from the crisis (particularly, re-energizing and
catching-up):
Training of workforce in managing anxieties and complaints of patient-clients

Better facility
Better services
Better workforce
On top of the prevention, mitigation, preparedness, and response plans,

there must also be a recovery plan. The latter should include a goal that
will statistically reverse as soon as possible the negative effects
associated with the temporary cessation of services, namely, drop in
revenues, number of patient-clients, number of complaints, and
opportunity for learning and research of workforce. The response and
contingency plans in maximizing the positive results, namely, training in
managing anxieties and complaints of patient-clients, better facility,
better services, and better workforce, can and should be used to facilitate
the recovery plan.
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79
that this incident will not go unnoticed.

INSIGHT:
Overall, to answer the question: how should hospital administrators

manage temporary cessation of hospital services, the following are
general strategies:
We often encounter individuals disrespecting our profession. However,

it is rare that another civil servant or professional will express his
disrespect towards us hospital personnel. Every public official and
employee shall observe professionalism, just, and sincerity as standards
of personal conduct in dealing with anyone we come across in our tour
of duty.
We, as public officials and employees, should remember to perform

and discharge our duties with the highest degree of professionalism,
just and sincerity. However, sometimes due to stress or pressure, we
tend to forgot these things which results to disagreements among
professionals.
In this case, we had difficulty in dealing with the man in uniform. His
misconception about our profession and superiority complex might be
the cause to disrespect and threaten us. However, as a public officer, it
is not an excuse for his attitude towards us. This incident warrants
attention to our administrators and hospital staff to stop this kind of
treatment to the frontliners of our hospital.
Leadership demonstrate aspiration, inspiration, motivation,

commitment, support, and role modeling in the risk reduction and
response plans
Managership demonstrate technical competence in formulating,
implementing and evaluating risk reduction and response plans
which must at least be structured, comprehensive and effective
Communication communicate clearly and effectively to both
internal and external stakeholders to allay anxieties, prevent
complaints, and motivate and support workforce, particularly on the
opportunities for advancement and growth
Education educate staff on how to manage anxieties and
complaints of patient-clients and provide structured educational
programs during the time of cessation of services with the goals of
better facilities, services, and workforce in the recovery phase

http://ommcsurgerymar2014.wordpress.com/2014/12/24/mrmaulionsmar-14-10-challenges-due-to-closure-of-the-operating-rooms

What should physicians do when they are disrespected?
Physicians can be disrespected by any human beings they interact in
this world patients, government employees, physician-colleagues,
students, etc. and anytime at that.
So, how should physicians behave when they are disrespected?
The general answer is to continue to act professionally. Remember,
your reputation as a professional comes first.
According to Merriam-Websters Dictionary, professionalism is having
or showing the skill, good judgment, and polite behavior that is
expected from a person who is trained to do a job well. Being
professional, generally means speaking to others respectfully and
politely and behaving in accordance with the law and social acceptance.
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63
MAR Title: Managing the Operations of My Patient in a Limited Budget

Reporter: Eugenette B. Saluta, MD
Year Reported: 2014
NARRATION:
MAR Title: Disrespect From a Civil Servant

Reporter: Allain Abad Alvez, MD
Year Reported:2014
NARRATION:
It was almost a month ago when I first met my patient. She was a 50-yearold female who was involved in an industrial accident. She was a retired
operator of a machine for weaving fish nets and was just called to return to
work that day because one of the machines in the factory had stopped
working and she was the only one with experience to fix it. Unfortunately,
her hand was caught in the machine causing for it to be mangled under the
jaws of the machine. When her hand was freed, a large chunk of her forearm with part of her hand was missing and her hand dangled in an odd
direction.
When I first saw her in the emergency room, I had a feeling that her case
would be complicated. As I thoroughly cleaned out the machine oil from
her wound, I explained to her that her case would entail an operation on
her bones and on her skin too since the defect was too large to be closed by
suturing alone. I was first met by silence and in the back of my mind I was
already thinking of writing a Transfer Letter, since she appeared to be not
consenting to the proposed procedures. Fortunately, her immediate supervisor, who I earlier sent out to gather materials for medications and
dressings, returned and agreed to take care of all her expenses in the
hospital. I thought then that it was a done deal.
I was at the Emergency Room at 2 oclock in the morning. I was

checking out some patients. Suddenly, a policeman brought in a drunk
woman for medicolegal examination due to alarming scandal. We later
found out that the drunk woman was an alleged victim of violence
against women. I told the policeman that they should bring the woman
to the Woman and Child Protection Desk. The policeman did not take
it lightly and insisted that it was just a simple medicolegal case. We,
with my senior resident, asserted the woman be brought to the proper
authorities.
I then admitted the patient and had her referred to the respective
consultants. Few days into her admission, while cleaning her wound, she
relayed to me that her employer had already given her a limit in her
expenses since as they explained to her, she was already no longer
regularly employed in the company and as such would not receive any
more benefits. I noted the uneasiness in the tone of her voice. She was
casually passing it off to me like small talk but I knew she was afraid of
what would happen to her. I felt sorry for my patient because she seems to
be a hard-working woman who was only working to make ends meet for
her family. At the same time, I panicked knowing that we had limited
budget for her two-stage procedure. I tried to assure her that I would try
my best to help her in procuring her materials for the operation and she
would be able to walk out of the hospital with the best management we
could provide.
An hour passed, the drunk woman was brought in again by the same
policeman for vandalism. I was seeing our admission at that time to be
ready for the morning endorsement. I suddenly saw and heard the
policeman saying to a medical intern while pointing a finger to her,
Anong 30 hours na duty? E nakikita ko lang naman kayong natutulog
dito. Alam ko na yang trabaho nyo. (30 hours? I always see you
sleeping here. I know your job here.) I was shocked to hear the
policeman say those words. I went to them and mediate to avoid further disagreement. I asked the medical intern what happened. The
intern was only telling the policeman to avoid leaving brought-in
patients. I supported her point. However, the policeman became irate
and began ranting towards the medical intern. The policeman was
saying with his voice raised that they wer only few on duty and the
doctors and nurses of the hospital were only sleeping. He even
threatened us to take care of ourselves outside the hospital promises. I
immediately called our security to bring out the policeman since he
was being scandalous. I told him, Sir, alam ko dapat tayong mga nasa
gobyerno ay may respeto sa mga trabaho natin. Alam ko ang hirap ng
trabaho niyo pero wala po tayong karapatan para bastusin ng mga
nagtratrabaho dito sa ospital. (Sir, I know that we, as government
employees, should have respect to our jobs. I understand the difficulty
of your work but you have no right to disrespect our hospital
personnel.) The policeman was then brought out of the Emergency
Room by the hospital security.
From then on, I started to consciously make her management as budget

friendly as possible. I gathered the left-over materials from my other
A few minutes passed. The policeman came back. He apologized for

his behavior. I also extended my apologies to him. However, I told him
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Identify the nature of the anxiety and fear that the patient and his
relatives may have on the surgical operation and their associated
factors / causes (which can include mindset, perceptions, past
unpleasant direct and indirect experiences, etc.). The information
obtained from this identification procedure should guide the
surgeons in doing specific measures to allay the anxiety and fear
such as converting the negative mindset and perception to positive
ones and in adjusting the communication to be given such as giving
more extensive and intensive explanations and avoiding words and
phrases that may aggravate the situation.
Communicate clearly with the patient and his relatives. Make sure
communication is completely understood. Use diagrams, illustrations and any form of visual aids liberally. Use paper and pen
liberally to facilitate explanation and understanding.
Use non-worrisome or non-threatening words and phrases in the
explanation.
Continually emphasize the benefits of the surgical operations in the
communication.
For the risks, use probability rate, rather than possibility rate, in
giving quantifying information or statistics. The possibility rate is
always 100% but the probability rate is never 100% and is usually
much much lower.
Mitigate the aggravating effect of the cost (or expenses) of the
surgical operation on the patients anxiety and fear of a surgical
operation.
Use whatever creative and innovative tactic to provide emotional
support. A surgeons act of compassion felt by the patient provides
the strongest emotional support.
If needed, provide social support particularly from patients who
have gone through the surgical operations.
Use whatever creative and innovative tactic to gain the trust and
confidence of the patient as this ultimately is the strongest weapon in
allaying anxiety and fear of the surgical operation.
From my experience, using the abovementioned general strategies,

contingent strategy, tactic, and operational procedures will result in a
high probability (as high as 90%) that an informed consent can be
obtained from the patient. The result will never be 100% successful.
This is a reality. There will always be a small percentage of patients who
will end up signing an informed refusal. The surgeon just has to content
with this and be consoled he has tried his best.
patients and used them for her daily wound care. When her first
operation was finished, I gathered all the extra anesthetics and materials
for her second operation. Little by little, I was able to gather the needed
materials for her second operation such that I only instructed her to
procure few of the regulated anesthetics. I was genuinely happy for my
patient when on the third day after the second operation, I revealed to
her a well-taken skin graft. She was smiling that finally her wound was
closed.
She was my first month-long staying patient in the ward, and it felt
truly a reward when she walked out of the hospital doors with a full arm
and satisfied with our management.
INSIGHT:
As physicians working in a government hospital almost half of the
patients we encounter are indigent or those who are living below the
poverty line. They are often the ones who have been suffering the
longest from their conditions only coming to the doctors office when
they could no longer tolerate the pain. When we give them the
medications and laboratory requests for their conditions, they are also
most likely the ones to show up months after or worse be the proverbial
Lost to Follow-up.
As a doctor training in our set-up, I find them both a blessing and a
curse. A curse because they are the patients, who mess with what you
have learned from medical school the proper management of a disease
condition. A blessing because they teach you to evaluate what
laboratory requests, medicines, and procedures are most beneficial for
the patient. They also teach you to be resourceful on how we could
carry on our management in the most budget-friendly way as possible.
In my case with my patient, I tried to lessen her daily expenses by
gathering the left-over sterile gauzes from other patients and using them
for her wound dressing. It is also worth mentioning the help I got from
the negative pressure dressing (which also makes use by the way of an
ingenious makeshift device) taught by my consultant. This entails a one
-time application of the dressing, which could be replaced for even as
long as after 7 days.
My encounter with my patient has been a long struggle but at the end it
felt like an achievement of sorts. I was able to properly distribute the
meager funds of my patient but at the same time provide the best management I, with our hospital setting, could provide for her condition.

http://ommcsurgerymar2014.wordpress.com/2014/12/12/oplizasos-mar14-10-thou-shall-not-fear-surgery
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ROJOSONS INSIGHT (TPORs):

How should physicians manage patients with limited budget?
From the MAR of Dr. Saluta, I pick the theme of how to manage
patients with limited budget for my insight. I will use the word
budget to mean money for medical expenses.
There are three categories of patients when it comes to budget. One,
patients with no budget at all, meaning, they have no money at all for
the medical expenses. In this category are the extremely indigent patients. Two, patients with limited budget, meaning there is money
available but there is a limit relative to the amount of the medical
expenses to be or that have been incurred. In this category are usually
the patients in the low- and middle-economic groups. Three, unlimited
budget, meaning there is money available to cover whatever amount of
medical expenses to be or that have been incurred. In this category are
usually the patients in the upper- and high-economic groups.
I will use anxiety and fear interchangeably to mean apprehension,

worry, nervousness or any unpleasant feeling on the recommended
surgical operation which may prevent the patient from subjecting
himself to the operation.
To start with, all human beings with sound mind will have anxiety
and fear for any surgical operation. Human beings include
physicians and surgeons. The anxiety and fear just vary in degree or
intensity depending on the mindset and its associated personality of
the human patients.
From personal experience, I can group human patients into three
categories in terms of degree of control of anxiety and fear for a
surgical operation. Category 1: Patients with good control of
anxiety and fear of surgical operation. Category 2: Patients with
moderate control of anxiety and fear of surgical operation. Category
3: Patients with poor control of anxiety and fear of surgical
operation.
Although my insights will be focusing on those with limited budget, it

is possible that the strategies and processes that I will recommend may
be applicable to patients in first and third categories, particularly, the
first.
For all patients who are to undergo a surgical operation, with the
assumption that all of them have anxiety and fear in varying degrees,
the surgeons must exert efforts to allay anxiety and fear in all
patients.
My recommended general strategies consist of the following:

Proper explanation of the surgical operation to be done putting
more emphasis on the benefits than on the potential risks
Provision of emotional and social support
Building of patients trust and confidence on the surgeon
All physicians must practice the principles of value-based medical

and health care services to their patients. Value-based medical
and health care services is simply providing medical and health
care services in such a way that the cost of the management is kept
to the lowest minimum possible or most reasonable expense
possible while continuing to maintain and improve quality and safe
outcomes. The value in the term value-based means that whatever and however one delivers the medical and health care services,
the patients must perceive and appreciate their value. Excellent
health outcomes with minimal or reasonable cost is what patients
value.
Management of all patients starts with a clinical diagnosis, meaning
a statement of the nature of the health problem. This is derived
from the interview and physical examination of the patient only,
without diagnostic tests yet (which entail costs). Clinical diagnosis
is used as the take-off point and basis for all problem-solving and
decision-making in the management of the patient. An erroneous
and improper clinical diagnosis has significant risks for
66
My recommended contingent strategy consists of exerting extra

efforts to those patients in Categories 2 and 3.
My recommended tactic consists of a holistic, professional and
compassionate communication with the patient.
My recommended operational or actionable procedures consists of
the following:
Assess the mindset and the associated personality of the patient

and his relatives. The information obtained from this assessment should guide the surgeons in implementing and adjusting
the general and contingent strategies mentioned above.
75
came back with the official histopathology report of the specimen that I
took out. It was really a lipoma.
INSIGHT:
We get different reactions from our patients who consult with us with
their health problems. It is vital on our part to adjust to these different
personalities when we treat them. We must be prepared with the
knowledge and skills to be able to explain to them what they have and
give them the proper management they deserve.
A minor surgery or even a simple medical procedure such as blood
extraction can cause inconvenience, fear or anxiety, particularly to
those patients who will be subjected to an operation for the first time.
This can become a challenge for the physician or surgeon who will
perform the operation - how to manage the fear or anxiety so that the
patient will not run away from an operation that is needed and so that
the operation will run smoothly and easily for both the patient and the
surgeon. The goal is to dispel fear and anxiety so that the patient will
not feel uneasy and will cooperate during the procedure. Proper
communication with the patient to gain trust and confidence can be
critical.
Here are some of my suggestions:
Surgeons/physicians should give a complete explanation of the
procedure to be done, its benefits, possible complications, and
costs.
In cases of uncertain diagnosis, they should give a probable diagnosis, not a possible diagnosis.
They must be equipped with knowledge of the case and skills on
how to do the operation.
They must have a good communications skill.
They must obtain a signed informed consent.

What should surgeons do to manage patients who are anxious and
afraid of a surgical operation?
My TPORs will be limited to this scenario: a surgical operation is
needed for treatment of a surgical condition in an adult patient with
sound mind and the patient is anxious and afraid of the surgical
operation. What should the surgeon do to manage the patient and his
anxiety and fear so that the needed operation will push through.
74
unnecessary medical expenses resulting from unnecessary

paraclinical diagnostic and treatment procedures recommended and
done and unnecessary drugs prescribed. Thus, a strategy is for
physicians to come with a clinical diagnosis that is as accurate and
specific as possible at the initial encounter and subsequent followups.
After the clinical diagnosis, all physicians must have a systematic
process* in deciding whether a paraclinical diagnostic procedure is
needed or not. Not all patients will need a diagnostic test after the
clinical diagnosis. In the situation in which the clinical diagnosis is
already certain as determined by the physician-clinician after doing
interview and physical examination, no diagnostic test is needed.
Doing a diagnostic test in situations in which it is not needed anymore is making the patient spent unnecessarily and the side effect is
draining the limited budget.
If there is an indication for a paraclinical diagnostic procedure after
the clinical diagnosis, again all physicians must have a systematic
process* in the selection. They should make a table that compares
the benefit, risk, cost, and availability data of the different options for
paraclinical diagnostic procedures. They should assist the patient in
deciding on the acceptably effective, affordable and available
procedure. They should assist the patient in deciding on the option
with minimum possible or most reasonable expenses yet maintaining
quality and safe outcomes (value-based health care).
For the treatment procedure, again all physicians must have a
systematic process* in the selection. They should make a table that
compares the benefit, risk, cost, and availability data of the different
options for treatment procedures. They should assist the patient in
deciding on the acceptably effective, affordable and available
procedure. They should assist the patient in deciding on the option
with minimum possible or most reasonable expenses yet maintaining
quality and safe outcomes (value-based health care).
If after accomplishing all the strategies and procedures mentioned
above, the amount of the estimated medical expenses is still way
above the patients budget, all physicians should discuss with the
patient on how to solve the problem of lack of money. The requirements that must be fulfilled before the physicians go the extra mile to
help in this aspect are that the patient is honest with his declared
limited budget and there are no relatives or friends who can help him.
How and to what extent to help the patient with the problem of lack
of money for the needed medical expenses will depend on a
judgment call as influenced by a physicians knowledge of prognosis
of the disease and treatment; degree of compassion; and resourcefulness. The options are to personally help out or to seek external
67
assistance. The physicians can help out by giving their service pro
bono, some amount of their own money or their available medical
materials. The external assistance can be from their colleagues in
the health institution; from an office or program in their health
institution established to provide financial and material assistance;
or from people or organizations outside their health institution.
Postscript:
A physician practicing the abovementioned strategies and procedures in
all patients with limited budget for their medical expenses is a holistic,
professional and compassionate physician.
Recommended Further Reading and Reference:
ROJosons Patient Management Process
https://sites.google.com/site/patientmanagementprocess/home
http://ommcsurgerymar2014.wordpress.com/2014/07/21/ebsalutas-mar14-06-managing-the-operations-of-my-patient-in-a-limited-budget
MAR Title: Thou Shall Not Fear Surgery

Reporter: Owen Parma Lizaso, MD
Year Reported: 2014
NARRATION:
It was about the third week of October when I was on a pre-duty status
doing minor surgery. Indeed, a very busy day for it was the re-opening
of the minor operating room. There were about 20 patients needed to be
operated on. I just finished my first operation, got a very brief breather
while waiting for the next patient. After a while, Sir Randolph (the
nurse-on-duty) approached me and told me that the next patient was
ready. He was a 43-year-old male who had a mass (about 2x2 cm) on
his back, located near his right scapular region. Based on data from the
history and physical examination, my consideration was that the mass
was a lipoma (a benign tumor that arises from subcutaneous adipose
tissues).
Before I started the operation, I explained to the patient my diagnosis,
my plan and operative techniques. As I was about to start the procedure,
I observed that the patient started to complain of discomfort in his right
shoulder and became uneasy. I stopped for a while and asked him why
he was feeling uneasy. He told me that he was worried about the mass
that he had and afraid that it could be a malignant one. He also told me
that he had fear of complications such as bleeding.
Naku doktor, matagal ko na po itong inalagaan. Minsan po tuwing
sumasakit, napapansin ko na lumalaki sya (Im sorry, Doctor, Ive
been carrying this mass for a while now and Ive noticed that it
increases in size during episodes of pain.)
Inaalala ko po yung mga nagsabi sa kin na meron daw pong masamang
bukol at yung hindi masamang bukol. Kasi pag ganito katagal raw po,
malamang masamang bukol ito. (I was worrying about the folks saying
that, it can be a malignant mass for I had it for such a long time).
Iniisip ko rin po na baka po duguin tayo, baka po mahirapan
kayo. (Im anxious of the complication that I might bleed.)
I waited for a few minutes for him to calm down. I told him my
diagnosis and explained to him about benign and malignant soft tissue
tumors. Then, I proceeded with the operation. Fortunately it went well.
I told the patient to bring the specimen to the histopathology section for
examination. Before sending him home, I instructed the patient on
proper wound care and prescribed him home medications. I told him
that my initial finding pointed to a benign mass and that if he was
feeling uneasy, he could always come back anytime. Weeks after, he
68
73
difference in the medical management of the two categories of

patients? Restating, should the presence of physicians attachment to
a patient make a difference in the medical management of the two
categories of patients (again, assuming that the medical management
capability and requirement fall within the surgical specialty practice of
the physician-surgeon)?
MAR Title: A Heart-Breaking, Best Option for a Relative

Reporter: Mark Balceda Velez, MD
Year Reported: 2014
NARRATION:
Physicians are supposedly trained to do problem-solving and decisionmaking (PSDM) under all kinds of circumstances (emergency and non
-emergency; stressful; physically-laden; emotionally-laden situations)
and they are expected to do the PSDM objectively. With this training,
they should be able to handle the attachment, which is essentially an
emotionally-laden situation, in the PSDM. This is the second reason in
support of my second TPOR.
It was one tiring day after a 24-hour hospital duty when my cousin
called to tell me that one of our aunts was having a darkened and
mummified 4th digit of her right foot. She then asked me if our aunt
could be seen and admitted in our institution for proper management. I
immediately said yes. Upon my aunts arrival to the hospital, I,
together with my senior residents, noted dry gangrene of the 4 th digit of
her right foot. I then started proper management and eventually
admitted her to the ward. The following day, my mother and other
relatives visited her in the hospital. It was a very difficult moment for
me thinking of how to discuss her condition to all of them. I then asked
for the help of my senior residents and in a very detailed manner, we
disclosed everything, from the diagnosis up to the planned management, which was a Ray Amputation (amputation through the
metatarsal) of the 4th and 5th digit or a possible Below the Knee
Amputation (BKA). I felt the struggle from their eyes on how to
accept what happened to our aunt as well what was planned for her.
Physicians are supposedly trained to be compassionate to all their

patients. Compassion is an emotion that a physician feels in response
to the suffering of a patient that motivates a desire for the former to
help. Compassion and attachment both involve emotion. Compassion
is factored in the PSDM. Why not do the With this training, they
should be able to handle the attachment, which is essentially an
emotionally-laden situation, in the PSDM. This is the second reason in
support of my second TPOR.
The next day, I referred my aunt to our Thoracic and Cardio-Vascular

Surgery (TCVS) Specialist and she explained to her that the most
distal possible amputation that had to be done would be a BKA. When
the arterial duplex scan result came in, it showed complete obstruction
of the mid- to distal posterior tibial artery. Our TCVS Consultant then
explained to me that Above the Knee Amputation (AKA) should be
done, but since it was very heart-breaking for us, she allowed us then
to do a BKA but with close monitoring of the wound.
Should there be a differential physicians compassion for different

patients? More specifically, should there be a differential physicians
compassion in favor of relative-patients simply because of an
attachment?
My senior resident and I explained again to my aunt what was best for
her condition. She accepted the plan of amputation, though very heartpounding for her. We then immediately prepared her for surgery. My
two immediate seniors were with me during the operation. As I was
about to cut the two bones of her leg, I felt a bit of agony deep inside
my heart. I knew that my aunt was feeling the same. Thinking of what
would best benefit her condition, I then proceeded and together with
my seniors completed the BKA. Close monitoring of her condition was
done after the operation. She was eventually discharged. My aunt and
my family, despite the amputation that had to be done, felt happy that
my aunt received the best care by me assisted by professional
supervision from my senior residents and consultants.
My second TPOR is that there should be none just on the basis of the
presence of a physicians attachment to a patient.
Aside from the presence of differential physicians attachment in the 2

categories of patients and within each category, there are three other
reasons why I think relative-patients should be not treated differently.
Non-relative-patients viewpoint and wish Treat us like your

relative patients.
http://ommcsurgerymar2014.wordpress.com/2014/12/17/mbvelezsmar-14-09a-heart-breaking-best-option-for-a-relative
72
69
INSIGHT:
We physicians have sworn to an oath of providing the best quality of
care for our patients. However, there will be times wherein the best
management is difficult to accept for them, especially when an
important part of their body will be removed. What makes it even
more difficult for us physicians is when our own relatives become
our patients. It becomes a tougher challenge for us to battle with the
trust they are giving us, the well-established relationship to take care
of, and the year-studied scientific medical field we are into, all mixed
-up together. Disclosing a poor condition of our relatives to them
definitely makes it nearly unacceptable for them, and also for us, who
understands their ailment better. Having a colleague with us in
explaining difficult medical facts to them is a big help for us, in
delivering a non-hesitant and complete discussion, and for them as
well, in accepting and understanding further non-negotiable heartbreaking information. In line with this, we can also easily gain their
trust knowing that their own relative is present to stand as their doctor
and genuine care-provider, who will surely think of them to be safely
treated. Nevertheless, being the ones who recognize what the
problem and the solution are, we should still think and carry out what
is really best for them.
the surgical specialty practice of the physician-surgeons. This is the

first assumption here or delimitation in this TPORs. I will exclude
from this TPORs the situation in which the physician-surgeons are not
capable of doing or fulfilling certain requirements of the medical
management. Referral is the outright solution in this situation.
The second assumption or focus of discussion in this TPORs is that
the medical disorder is a major one in which surgical treatment
conventionally categorized as major and even medium has to be done.
I will exclude from this TPORs the situation in which the medical
disorder requires only a minor surgical treatment.
Here is my first TPOR.
If medical management is divided into 3 parts, namely, diagnosis,
treatment, and advice, (assuming the practicing physician-surgeons
are capable of accomplishing these 3 parts in non-relative-patients), is
there or should there be a difference in the medical management of
the two categories of patients?
My first TPOR is that there should be none in terms of established
problem-solving and decision-making processes and procedures.
Here is my second TPOR.

How should surgeons manage patients who are their relatives and
who have a major medical disorder whose treatment is within their
surgical specialty practice?
All practicing physicians will invariably encounter a situation in
which relatives are their patients.
The main issue is how they should manage their relative-patients. Is
there or should there be a difference in the medical management of
relative-patients and non-relative-patients?
Before I proceed further, let me delimit the scope of discussion of my
TPORs.
Non-relative-patients and relative-patients are all human patients
whose medical management capability and requirement fall within
70
The traditional difference between the relative-patients and

non-relative-patients in relation to the practicing physician-surgeons
is the degree of the so-called attachment. The word attachment here
will be defined as the deep and enduring emotional bond that connects
the physician to the patient, not the other way around. The
physicians attachment is usually stronger or deeper for relativepatients than for non-relative-patients because of greater interactions
in terms of time and space. One has to take note that the degree of
attachment is not uniform within the relative-patient category. There
will be situations in which the physicians attachment will be stronger
or deeper for relative-patient No. 1 than for relative-patient No. 2.
One has to take note too that even for non-relative-patients,
physicians attachment may be developed particularly across time.
Thus, even in the non-relative-patient category, there will be
differential physicians attachment.
In the presence of differential physicians attachment in the 2 categories of patients (also within each category), should there be a
71

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Medical Anecdotal Reports - Volume 2

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for the Development of

Medical Anecdotal Reports Volume 2

Table of MARs by Issues and Topics Discussed

Preface of Volume 2 of MARs (2014)

Preface of Volume 1 of MARs (2013)

Medical Anecdotal Reports (see Tables of MARs)

Medical Anecdotal Reporting as a TeachingLearning Activity in a Clinical Department in the

List of surgical residents of OMMC Surgery who

Feedback on the MAR Project by Surgical

Introduction of MAR Volume 1 (2013)

Epiloque of MAR Volume 1 (2013)

About the Author

Medical Anecdotal Reports Volume 2

Seeing Hope and

The Bridge to a New

Medical Anecdotal Reports Volume 2

Long Life Span of

Medical Anecdotal Reports Volume 2

Table of MARs by Issues and Topics Discussed

Program Director, Education for Health Development in the Philippines

Issues and Topics Discussed

Project Director, Medical Anecdotal Reports, Ospital ng Maynila Medical

What are the things that physicians can learn from

Author- Scientific Papers > 100; Scientific Books/Primers/Course Packs

The Medical Anecdotal Report as a feedback and

How should junior resident-physicians prepare

What should physicians do to patients whom they have

Author Websites [https://sites.google.com/site/rojosonwebsites] = 207

Details of ROJosons Biodata:

Medical Anecdotal Reports Volume 2

Table of MARs by Issues and Topics Discussed

About the Author

Issues and Topics Discussed

How should physicians manage patients with limited

What is informed refusal and what is informed

How to differentiate and use humility, meekness and

Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg

Please give me feedback particularly on the following:

Preface of Volume 2 of the MARs (2014)

The Residents of the Department of Surgery of OMMC

Thank you very much for the support.

Preface of Volume 1 of the MARs (2013)

Epilogue of MAR Volume 1 (2013)

In April 2004, I started a project which I named Medical Anecdotal Reports

As mentioned in the Preface, I started actively developing this book in June

I included two of my personally written MARs to make a total of 25 in this

Since after presenting a formative evaluation paper on the MAR project in

This book has an online version

the 4th Asia-Pacific Conference on Problem-based Learning in Health

Finally, in June 2013, 7 months prior to my compulsory retirement from

1. As of June 2013, my estimate is that I have about 1,400 MARs (April

2. I will be publishing by volumes with 15 to 20 MARs per volume.

First volume should be out by November 2013. Subsequent volumes

I will be using the Internet to complement the book. Websites will be

I hope that with the abovementioned design, I will be approximating the

Introduction of MAR Volume 1 (2013)

Medical Anecdotal Reporting as a Teaching-Learning Activity in a

The Residents of the Department of Surgery of OMMC

Thank you very much for the support.

Medical Anecdotal Reporting as a Teaching-Learning Activity in a

from 2004 to 2014

This book has an online version (http://

Surgeons of course should have excellent decision-making skills and