from: A PIECE OF MY MIND

by Rey Vivo, MD (UPCM 2002)
Published in JAMA, April 16, 2008—Vol 299, No. 15

The veil of clouds parted reluctantly as we made our final descent. Through some breaks in the overcast, the metropolis lights appeared like any other city’s, the landscape hardly distinguishable from where we had departed only 14 hours earlier. As the faint light of
dawn began to filter through the palm trees piercing the skyline and travel‐weary passengers started to chatter excitedly in an utterly recognizable language, it became increasingly clear to me that I have arrived at my destination.
Nearly four years since completing my residency in Steeler city and some months of work as a new faculty member in Red Raider territory, I returned to my home country for the first time as a full‐fledged internist and accidental tourist. My decision to travel was made less
by choice than of necessity—a need to revisit with family and a more personal need to deepen my appreciation for where I was and where I am. Back when I was a medical student at the University of the Philippines, I could not imagine forgetting the pathos that inundated the daily grind amid the profusion of patients and scarcity of resources. While training in the
United States didn’t quite make me forget, it acclimatized me to a milieu of sufficiency where each bed is always occupied by one patient—never two; CT scans and MRIs are only an elevator ride away—not a distant commute; and glucose strips are never cut
lengthwise into 6 razor‐thin pieces so that 5 other patients can have their sugar checked. These glaring disparities spawned random epiphanies during my return trip, which proved to me that to look back is indeed to look within.
After the warm hugs and hellos and a couple days of relaxation, I obliged some relatives who were thrilled to be seen by a physician from the United States. My diabetic aunt was my first unofficial consult. Unofficial because it took place in their open patio instead of an office, no billing was involved, and my right hand was holding not a stethoscope but a
plantain fritter. Such are my casual medical encounters with family: frugal on confidentiality but generous on patient comfort. Her history was straightforward:
progressive blurring of vision, frequently unchecked blood pressure, occasionally missed meds, and totally neglected glucose readings. I broke into my well rehearsed
monologue on diabetes education and instinctively scribbled some blood tests on a small
sheet of paper that I handed to her.
My aunt’s return visit the next day put the skids on my unbridled diagnostic workup. She had gone to four different laboratories and not one could run the test that was now staring back at me in my own handwriting: “glycated hemoglobin.” I felt ashamed
for putting my aunt through the needless runaround but more so for being insensitive to our local limitations in medical care. Have I unlearned the cardinal value of resourcefulness that was indoctrinated in medical school? Have I lost the art of getting more for less? When we were still applying as interns, my classmates and I thought that a good way
of selling ourselves was to accentuate our “clinical eye” sharpened by many years of pinning a diagnosis for our indigent patients with the fewest and cheapest tests possible. Now here I was, back from practicing in the cradle of cutting‐edge science overlooking the
uncomplicated and inexpensive glucose strip. In an effort equal parts damage control and self
admonishment, I advised my aunt instead to check her glucose and blood pressure regularly for the next three days and to get simple laboratory tests.
Since residency training, I have met some patients who could barely match their medicine to their medical condition. But I have not been more concerned about this lack of patient education until I met more people during my vacation‐turned‐free clinic. From my aunt
who was unaware of the value of glucose monitoring to a neighbor who honestly thought that she had acquired heart failure from eating sour fruits, every anecdote of medical misconception transformed my initial amusement into alarm. Granted, I was staying in a small town an hour outside Manila (my folks left the city for their hometown after their retirement), but this
was hardly the countryside. It was rather an urban microcosm replete with all of the perils of city living: road congestion, pollution, and fast food. Yet looks were deceiving, and the proof lay in the quality of education and health consciousness that seemed to
have evaded this town’s makeover.
Truth is, the problem is complex on so many levels. The local educational system, in general, is sharply divided: good, pricey, and privately owned schools are concentrated in the bigger cities while free, public schools remain the wellspring of substandard
education in smaller towns. In this age, some individuals still embrace mystical and naturalistic
health beliefs. For instance, the indigenous principle of balancing “hot” and “cold” (ie, avoiding rapid shifts from warm to cool water or weather) is blamed for a wide array of illnesses. Perhaps a more contemporary challenge is the burgeoning impact of cardiovascular
and related chronic diseases in the Philippines. That heart disease has equaled infectious illness as a leading killer is notquite unexpected for a people who spent “300 years in the convent and 100 years in Hollywood”—an oft‐quoted reference to our remote Spanish colonial history and our more recent and unceasing American influence. Quick as we have been
in adopting a Western culture, the adaptation to the demands of chronic disease has been sluggish. I have found that a number of patients, like my aunt, perceive diabetes as if it was an infection that goes away in days instead of a condition that needs a daily and
disciplined approach. Oftener than not, she and many others wake up without a thought to glucose checks, LDL levels, and the looming danger of a myocardial infarction. (In sharp contrast, my hypertensive mother religiously monitors and medicates—a consciousness
no doubt driven by her city education and medical insurance background.) I wonder, what will it take to educate Filipinos and many others in developing countries on the surging threats of cardiovascular and related diseases? When my aunt presented her test results—her numbers were expectedly off the charts—I explained the rationale for each drug that I recommended and told her some worst‐case outcomes of nonadherence in the hope of engaging her better
with her care. I honestly felt that my effort was futile— I had so far failed in pushing my own father for a repeat colonoscopy no matter my discourses about the prospects of his previous polyp—so I was extra pleased to get an e‐mail that my aunt had at least rechecked her blood pressure since I left.
Toward the end of my vacation, I came upon an online report on the declining public appeal of traditionally prestigious careers like medicine and law. Evidently, I thought to myself, they must have failed to survey Filipinos who regard physicians as every mother’s dream for her child to become—or marry. I was wrong.
I took my folks to a resort island an hour’s flight south of the capital where I met the owner. She had worked in Switzerland as a nurse for 17 years before deciding to return home. She told us about her 3 sons, the oldest of whom was about to start college, so I asked her
what course her son planned to take. “He wanted to become a doctor,” she replied.
“Great,” I responded, proudly.“But I discouraged him and told him he was just going
to grow old,” she continued unapologetically, “so I urged him to take up nursing instead.”
Growing up, I knew that agriculture was our country’s primary industry and rice our top export. Fast forward 20‐something years and I am wrong yet again. Judging by the number of nursing schools that have mushroomed across our islands and the dominant foreign language that resonates in our nursing stations in Texas (nope, it’s not Espan˜ ol), I am convinced
beyond doubt that nurses are now our leading export.
And it’s easy to understand why: they get attractive immigration and financial bundles that easily allow them to take their families with them. Perhaps a most interesting subplot is that physicians too are joining this migration en masse—as nurses. Inside the “fasttrack”
classrooms for nursing aspirants, the most common players seem to be older physicians who by
being far removed from their basic science lessons think themselves as long shots for nailing the USMLEs.
Then there is a close friend who realized after graduation that she wasn’t keen on embracing a
physician’s obligations but wanted to stay in health care, and the much publicized medical board topnotcher who was largely chided by the local media for jumping onto the bandwagon of migrant nursing aspirants. Their reasons are diverse but the persuasions kindred: they all want a “better” life for themselves and their families. Surely, my colleagues’
plight jolted me to not take for granted the very thing I should be grateful for, the profession I have been fortunate to practice, in the manner I have chosen to do
it.
Before I knew it, I was sitting on my return flight eastward across the Pacific. Soon we began our final descent and there were no trees in sight, let alone any clouds in my head. All I had was an unobstructed view of the vast plains of West Texas and a refreshingly
uncluttered point of view. As the morning light filtered through the window, it dawned on me that the strange purpose of a getaway is to usher the brain to rest that the mind may reflect with renewed lucidity. Away from work, I had a fresher appreciation of where I was,
where I am, and the journey inbetween. Away from my home country yet again, I realized
that my short trip allowed me not only to rediscover my roots but also to rediscover myself.