Dear Doctor.

Even before medical school, I have always been enthusiastic of becoming a physician for the Filipinos. When I finally became one in 2013, I have since been very vocal to my friends and colleagues how a wonderful opportunity it is to serve the country.

I was never afraid and have fully enjoyed hospital duties, until now. With the rapidly increasing incidence and deaths of patients with COVID-19, chaotic experiences at grocery stores because of people hoarding essentials for home quarantine, doctor friends actually getting quarantined, admitted, and DYING, plus the shortage of PPEs (personal protective equipment), one cannot help but think “T**g i*a, what am I doing here?

But in the midst of all my doubts, insecurities, and fear, I received this message from one of my previous interns:

Hi Sir! Pina-uwi po kami ng residents because of the APMC memo. But we volunteered to stay po to help out in the non-frontline areas. Hindi din daw siya maccredit ng APMC as training hours, but it’s okay. We’re here for the patients. Stay safe po!

After reading this, my mind froze. Tears started falling. And I found myself asking, “How did we even get here? Why are we feeling afraid? Why are we doubting ourselves?

I took out a pen and paper, started reflecting, and realized that perhaps maybe we have forgotten.

So Dear Doctor, if you feel the same way, allow me to share these three reflection points as we face the very toxic days ahead of us.

Go back to the time when you wanted to be a doctor. Why did you want to be one?

We all have our own reasons but I believe that generally we went into medicine because we wanted to serve. Despite the rigors and difficulties of medical school and training, we still choose to persevere. Remember the times when you told yourself “Ayoko na. Pagod na pagod na ako.”? Yet you didn’t give up. You pushed through the times when you think were the most difficult moments of your life, and now you are here -still standing strong. Still a doctor. Still continuing to serve.

Why did you choose to stay in the country?

Some of us might have thought of training abroad, or even start a new life in more advanced countries -and that is totally okay because you continue to improve medicine in your own ways nonetheless and make us all proud.

But for most of us who chose to stay here, why? Whatever our reasons are, I think for the most part we choose to stay because we love this country. Despite all of its inadequacies, we find joy in living here and in finding ways to make the Philippines a better place for everyone.

The world is in a public health emergency. Your country needs you now more than ever. Are you backing up? Or are you joining the fight?

You already know the answer to this. Do you remember that time when you were already home but you couldn’t sleep well because you had a toxic patient admitted at the hospital? Do you remember that patient crying out to you “Doc, tulungan nyo po kami.” Now, the WHOLE COUNTRY is crying out to us for help. For sure, every physician, nurse, or paramedical staff all know how to respond.

So Dear Doctor, even if most establishments are closed, everyone is advised to stay home, and yet here we are on skeletal duty, DO NOT BE AFRAID. We’re all in this together. 10-15 years of medical training has prepared us for this moment. 

We have been through a lot of tough and harsh times before; we will sail through. Remember: To serve your country is always an act of privilege, and not a sacrifice. 

Sipag. Tiyaga. Pananampalataya. We got this.

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*Pic by a good friend, Prim Paypon.

Shout out to all UP-PGH interns who volunteered to stay and continue to serve. Jose Rizal was indeed right when he said “Ang Kabataan ang pag-asa ng bayan!”

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To all consultants, residents, nurses, paramedical professionals, and my co-fellows, #OneGenMed starts tomorrow. No distinction of subspecialties. Everyone’s an internist -residents, fellows, and consultants. One division. One Gen Med. It is truly an honor to be serving the country with you guys!

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Lastly, knocking your kind hearts for donations. Remember, these PPEs are what keeps your healthcare workers functioning and even alive. We need all the help we can get. Our sincerest gratitude to all.

 

From the UP-PGH. Department of Medicine:

In line with the increasing number of COVID cases and the potential hazards to our healthcare workers who serve as frontliners in the assessment and delivery of care, we are calling for donations to be able to procure Personal Protective Equipments (PPEs) for those who will be taking care of these patients . The PPEs will serve as their protection to decrease the chance of them getting the COVID virus.

We believe that during this time of uncertainty, we should all unite with a common goal of serving our patients by also protecting our healthcare workers.

Please direct your contributions to the followIng accounts. Thank you very much and may God be with all of us.

SAGIP BUHAY MEDICAL FOUNDATION, INC.
Account Numbers (Metrobank UN Avenue Branch):
Peso #044-304466181-1 (SA)
Dollar #044-204401415-1 (SA)
Metrobank Swift Code: MBTCPHMM

Once deposited, email transaction slip to sagipbuhay2015@yahoo.com

Please earmark it for COVID IM task force.

Healthy Eats by Kat: Chicken Wrap

The science is clear: If you want to live long, exercise more, have enough sleep, do not smoke, limit alcohol intake, and eat the right kind of food.

 

This year, Kat made a personal promise to eat as healthy as possible. This makes me the lucky beneficiary. It’s hard to “eat healthy” when you’re living a busy life in the Metro -not only are they costly at restaurants, the 5 minute line and order pick-up in fast-food chains are the easier and more practical choice. Or are they really?

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A happy wife leads = healthy life

 

From eating at fast-food restos which became a poor habit last year, Kat now prepares our food at home -fresh, delicious, and most of all packed with good and essential nutrients.

 

I’ll try my best to share every Saturday our favourite picks for the week and hopefully inspire and convince you that consistently eating healthy is fun and enjoyable, and most of all -it doesn’t have to be expensive.

 

This week’s pick is Kat’s Chicken Wrap.

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Kat’s Chicken Wrap

 

 

The ingredients:

  1. Romaine lettuce
  2. Organic red quinoa
  3. Chopped tomatoes
  4. Cheddar cheese
  5. Hummus
  6. Chicken breast marinated in garlic and pepper

 

The finished product:

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Kat’s Chicken Wrap prior to rolling

 

The verdict: easy to make, delicious, and light yet nutrient-packed.

Have a great weekend, everyone. And remember, eat healthy! =)

PS. I won’t be mentioning any brands in my site so if you want to know the specifics of the products and the micros, Kat would be happy to discuss with you. Feel free to email her at katrinatingmd@gmail.com =)

 

Make it count.

“Your life is God’s most precious gift to you and to the people around you. Make it count.”

These were the words Ate Elma told me today as she had her one of her last few follow-ups with me. She is a Stage 4 breast cancer patient who has been receiving treatment at our institution (UP-PGH Cancer Institute) for a decade now. I’m already the fifth batch of cancer doctor who has treated her and she is very much aware that in a couple of months, half of the team will graduate (hopefully) and she will be having a new physician.

 

It has only been two weeks since our clinic resumed after the holidays, but these two weeks seemed like forever. Patient visits were longer than usual and full of mixed emotions -some were joyful tears, while some were sad goodbyes.

 

After quite a handful of deaths I have encountered during my training, I never thought that saying “goodbye” and “thank you” to the patients whom I have taken cared of and shared both good and difficult times with would be so emotionally taxing. I can still vividly remember moments when “complete treatment responses” were celebrated, and times when “cancer recurrences” were mourned.

 

This makes us, physicians, indebted to all the patients whom we have had the fortunate privilege of serving, and in the process learn and  become what we are today and what we will be in the future.

 

Today Ate Elma reminded me that everything in life is a gift. Everyone we meet is gift.

Our life is God’s gift. Let’s make it count.

 

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Penabled by my colleague and amazing friend, Lance (bottledbrain), since 2019. But these pens given by my patients are my favorite. Thank you. ❤

 

 

Our God is a Perfect God -Conversations over Lemongrass, Herbs and Passion Fruit Soda

A couple of weeks ago, Lance (who blogs at www.bottledbrain.com) and I were privileged to receive a grant from ESMO (European Society of Medical Oncology) to attend an advanced course in prostate cancer. Lance is my fellowship batchmate whom I’ve probably had the most conversations with -not only because we both live in Ortigas and take the train ride daily together, but we also have the same waking hours (up by 4am, asleep by 9pm). So yes – when everyone else is still in bed, there’s a high chance you’ll see us both sipping our coffee at some nearby café.

 

During this trip, we were blessed with free time to visit Muji Café at Plaza Singapura where we tried the lemongrass, herbs, and passion fruit soda. It was sophisticatedly good, and was able to quench our physical thirst and desire to try out the place.

 

Lance and I talk about almost everything -from petty things like the couple fighting behind our table, to life when we were kids, how we both managed to survive medical school and residency, me sharing to him how it feels to be an only-child, him sharing to me how it feels like to have a younger and older brother and their amazing stories with his beloved tatay and nanay, to stories about times when we had triumphs and defeats.

 

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At MUJI Cafe: Lance enjoying his lemongrass, herbs, and passion fruit soda and me trying out the red shiso.

 

We realized that despite all of the challenges and difficulties we are currently facing with our personal and professional lives, we are still blessed beyond what we deserve. And we both agreed with the fact that “Our God is a Perfect God.” -He does not fail. He does not fail to provide for our needs. He does not fail to protect us from harm. He does not fail to make sure that we are headed to somewhere good.

 

Psalm 18:30 says “As for God, His way is perfect: The Lord’s word is flawless; He shields all who take refuge in Him.”

 

Our God is a Perfect God. I pray that you take comfort in this truth, in the same way that Lance and I do.

 

God bless you.+

 

HARRISON’S Principles of Internal Medicine 20th Edition

 

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Hi there!

Below is the link to a pdf copy of the new Harrison’s Principles of Internal Medicine 20th Edition book. I got this copy from my former Chief Fellow (Dr. Vergara) in the hospital where I am currently doing my Fellowship Training in Medical Oncology (UP-PGH).

I am sharing it with you, for the sake of the hundreds of patients we see in the hospitals everyday. May this book and God guide us always in all our decisions and actions in providing our patients the best medical care possible.

Enjoy, and God be with you always!

Download on this link: Harrison’s Principles of Internal Medicine 20th Edition

 

10 Things We Were Reminded at the ESMO Head and Neck Preceptorship

Last weekend (April 13-14, 2019), I was very fortunate to have had the opportunity of participating at the European Society of Medical Oncology (ESMO) Head and Neck Cancer Preceptorship Programme held at Kowloon, Hong Kong.

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Program Packet and ID

This program was chaired by the leading experts in the field -Dr. Anthony Chan from Hong Kong and Dr. Jean-Pascal Machiels from Belgium; which included the following speakers: Dr. Melvin Chua (Singapore), Dr. Brigette Ma (Hong Kong), Dr. Sandra Nuyts (Belgium), Dr. Christian Simon (Belgium), Dr. Joseph Wee (Singapore), And Dr. John Woo (Hong Kong).

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Program Schedule

 

Here are the top 10 reminders I got from the program:

  1. The best approach in treating head and neck cancer involves a multidisciplinary team.

With the rapidly changing advances in the management of head and neck cancers, it is always best for the patient to be offered treatment options discussed by a multidisciplinary team which includes but is not limited to: Head and Neck Surgery, Medical Oncology, Radiation Oncology, Dentistry, Speech Pathology, Rehab, Dietary, and the Nursing Team.

 

  1. Human Papilloma Virus (HPV) tumoral status is a validated positive prognostic factor for oropharyngeal cancers. However, the treatment of HPV-positive oropharyngeal cancer should still be based on the TNM staging.

Although it has been validated that early stage HPV-related tumors have a 5-year overall survival (OS) of 90%, the new staging system incorporating HPV or p16 positivity is only used for prognostication as of this time. There are currently ongoing trials aimed at treatment deintensification for this subset of patients, but treatment decisions should be based according to the TNM staging as of the moment.

ORO HPV +Oro HPV-

 

  1. Intensity-Modulated Radiation Therapy (IMRT) is preferred when doing radiation treatment for head and neck cancers.

IMRT uses advanced technology to focus the high radiation doses on the targets and avoid irradiation of non-involved tissues. Several randomized controlled trials (RCTs) have shown that IMRT (compared to conventional RT)  causes less chronic side effects such as dysphagia and xerostomia which have been proven in some studies to improve the patients’ quality of life.

 

  1. I will consider using neoadjuvant chemotherapy in carefully selected patients who need “debulking.”

Induction chemotherapy followed by radiation therapy (compared with definitive concurrent chemo-RT) for patients with hypopharyngeal and laryngeal cancers is associated with better long term survival but a lower organ preservation rate.

For head and neck cancers other than these subsites, we were reminded to use neoadjuvant chemotherapy with extreme caution (preferably in the setting of a clinical trial) as this treatment approach is considered investigational. However, it may be applied in specific cases where locally advanced tumors pose complications related to RT or in patients who need “debulking” due to local complications.

 

  1. I will consider using Epstein-Barr Virus (EBV) DNA testing in patients with Nasopharyngeal Cancer (NPCA).

In high-incidence regions such as Asia, the undifferentiated type of NPCA is prevalent and highly associated with EBV. The close association of EBV with cancer is presently being exploited to develop diagnostic tools based on detection of EBV material in tissue (EBER) or in blood (EBV DNA or antibodies). Currently, the most important application of EBV DNA in blood is to detect residual disease after treatment and recurrent disease on surveillance.

 

  1. I will use Gemcitabine – Cisplatin in treating metastatic NPCA.

A phase 3 RCT by the Sun Yat-Sen University group showed that Gemcitabine plus cisplatin (versus cisplatin with 5-Fluorouracil) prolongs progression-free survival (7 vs 5.6 months) in patients with recurrent or metastatic nasopharyngeal carcinoma. The results establish gemcitabine plus cisplatin as the standard first-line treatment option for this population.

 

  1. I will use Cetuximab with cisplatin-fluorouracil chemotherapy in non-nasopharyngeal head and neck cancer patients with recurrent, unresectable, or metastatic disease with no surgery or RT option.

The addition of Cetuximab to cisplatin-FU is the standard first line treatment, as it resulted in a 2.7 month increase in median survival and a 2.3 month prolongation of progression-free survival (PFS), thus its designation as a Category 1 recommendation by NCCN in these particular subset of patients.

When using Cetuximab, it is important to remember the following associated grade 3/4 side effects: skin toxicity, hypomagnesemia, and infusion-related reactions.

 

  1. I will not use Cetuximab as first line in NPCA patients.

Present data shows that cetuximab does not improve outcomes when added to concurrent chemoradiation with high-dose cisplatin nor does it have any advantage when replacing cisplatin in combination with radiation therapy.

 

  1. I will consider using immunotherapy as second line treatment for patients with head and neck cancers with recurrent, unresectable, or metastatic disease with no surgery or RT option.

Nivolumab and pembrolizumab are Category 1 and 2B recommendations as subsequent line treatment for Non-NPCA patients with disease progression on or after platinum therapy and previously treated NPCA patients respectively.

 

10. Improving the patients’ quality of life is an essential aspect of treating head and neck cancers.

Treatment of head and neck cancers involves both acute and chronic side effects (eg. xerostomia, mucositis, dermatitis, pain, dysphagia, loss of taste, osteoradionecrosis) and it is important that these are addressed.

In managing patients with metastatic head and neck cancer patients, it is important to remember that combination chemotherapy is associated with higher response rates than single-agent therapy, but has not produced better survival outcomes compared with monotherapy.

 

My bonus but probably the most essential reminder for clinicians taking care of cancer patients: “Always take time to nourish the soul.”

After the conference was concluded, I was very fortunate to personally thank Dr. Anthony Chan, one of the chairs of the program and definitely a leading expert of head and neck oncology. As we exchanged our goodbyes and well wishes, he randomly mentioned that he was “crossing the street to attend church service” and that “it’s very important to always take time to nourish the soul by prayers.”

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Dr. Sabando (St. Luke’s Medical Center) Dr. Lim (University of Santo Tomas), Dr. Balolong-Garcia (St. Luke’s Medical Center), with Dr. Jean-Pascal Machiels, Dr. Anthony Chan, myself, and Dr. Brigette Ma.

Happy Easter, everyone!

 

*The statements here are the personal views of the author.

Two Monks and the Bees by Sir Joey

Yesterday during one of our conferences at the UP-PGH Section of Medical Oncology, our chairman Dr. Jorge Ignacio reminded us to never get tired of serving the Filipino people especially the poor, the sick, and the dying.

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UP-PGH Section of Medical Oncology Consultants and Fellows 2019

No matter what the circumstance is and despite of all the unique pressures and challenges we encounter in taking care of the poorest of the poor cancer patients in the Philippines, it is essential that KINDNESS and HUMILITY should still prevail.

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Our chairman, Dr. Jorge Ignacio

Sir Joey concludes by retelling his story about the two monks and the bees.

“Two monks were walking down the road on the way to their temple. Every time they see the bees struggle, one of the monks would always help the bees. After that monk helped the bees, this was their conversation:

Monk 1: I’m sorry if I’m walking a little slower. The bee stings hurt.

Monk 2: Can I ask a question? Why do you still help the bees every time you see them, when all they do is sting you in return?

Monk 1: It is the nature of the bees to sting. It is our nature to help.”

 

Have a Blessed weekend, everyone. =)