bonding time

When Maxine came here, there was certainly enough of a reason for me to get going and see Toronto. Believe it or not, I have been here for about ten months when she came and all that I have been to were the outlet malls of Mississauga and of course, the Eaton Center. Me, a shopaholic? Not so, I am a professed window-shopper though. Being the mother that I am, my mind does a quick mental conversion of how anything would cost in Philippine pesos...that is usually enough to turn me off any purchase.
Anyway, back to our mother-daughter adventures.

Of course, we had to go to the bookstore and wherelse but at the "World's Biggest Bookstore" which is just two blocks from where we lived. I will not forget how her eyes lit up at the sight of rows upon rows of books. I have no doubt that she could have pitched a tent there and spent the night. Even more so though at the Disney Store...I think we went there a dozen times!! If she could only haul all the stuff she wanted to buy there, I think she would have!

On one Saturday, I purchased a TTC all day family pass. We got off at every possible subway station to discover what was there. That was fun and certainly, I got to learn more about the geography. We wound the day up at the Harbour Front Center. What a lovely view. It was a clear crisp day.

A visit to the Toronto Zoo is a delight for any child. Not a great idea though for any mother who is post call. I had a vision of animals in cages and I could sit loungingly in the benches. I didn't know what I was in for. Turned out it was a kilometric hike! More like 3 or 4 kilometers as the animal exhibits were spread out, mimicking their habitat. It was in the last week of April and on that day, it felt like the first real day of spring. The sun was out and for the first time, I was sweating. Gleefully, Maxine would grab hold of my hand, lead me to the next animal in the path, strike a pose, coax me to take a picture then dart off to the next. Just to slow her down, I made her read the captions posted by the animal exhibits. She read them but quickly though. That was a gruelling 5 hours in the Zoo. I know my feet would remember.

The Science Center was equally awe inspiring. Thankfully, it was indoors. Walking was part of the deal but at least it was in airconditioned comfort. We would dart in and out from exhibit to exhibit. It surely is a treat for the imagination. From being a bob-sledder to being a gymnast on the balance beam. Making our won stop motion animated movies to learning about the environment and the world. Maxine particularly enjoyed the "hair raising" electricity show.

What Toronto trip will be complete without a visit to the CN Tower? It was a lovely sunny day went we went. All the way up to the skypod. The view was certainly clear from the top. Certainly, a favorite with Maxine. We went twice. A mother can only indulge her daughter on too few occasions.

But the all time favorite would be Niagara Falls. It was beautiful and grand. The Maid of the Mist ride was certainly not just misty. It was wet-wet-wet. But who cares? To get so near to one of nature's wonders...a little water did not hurt at all. Maxine and I were hand in hand along the promenade, and then sat among the tulips...it was priceless.

Perhaps Wonderland the next time?

the circle of life

Now that I have discovered blogging, I am on a race against my own forgetfulness.

I feel that with blogging, I am establishing a link to my history so that my children, my family can peer back at who I am.

I had started to blog as a form of therapy I guess. Now, I just want to input all that I experience. Among the most memorable thus far while here in Toronto is my daughter's visit.

I thank my parents for bringing her over. I embraced the time they were all here. I enjoyed making the big meals to share with everyone. Sinigang, nilaga, tinola, chicken asparagus, mixed vegetables in peanut sauce...I was certainly quite the gourmet...much to my parents' surprise. Somehow, they have always thought I was totally clueless in the kitchen having been raised with our own personal cook.

How life's wheels turn.

I remember my mother serving me food as a child...making sure I ate well. Now, she is 78. It was my turn to make sure she was properly eating.

"Ma, gusto nyo ba ng strawberries? Igawa ko kayo ng may gatas? Oatmeal? Busog na ba kayo?"

Back then, my father would hold me tightly by the hand as we crossed the street. Now, I have him by the elbow. "Dad, dito tayo dadaan at ingatan nyo ang hakbang may pababa."

I became the one relied upon. It felt good that I was caring for my parents...though in simple ways, I know that they are bound to remember.

They have long gone. But still we have made a re-connection.

Already, my father was saying to me on the phone, "Bel, nami-miss ko ang lugar mo. Maganda dyan."

That was enough said. In his own way, I knew that he was missing me too.

stepping out

It may seem that all I do is go to work, home and then online.

Not quite.

I share my apartment with Pat. Now, Pat is a vivacious creature. Not quite a year into living here, she has gained quite a circle of friends -- among nurses and RT's she works with. As I had also started my rotation in the unit she was working at, I got sucked into that vortex. What a happy twister that is. Certainly, an outlet for all my misery and profound bouts of sadness. How thankful I am.

Now, the first time we ventured out with our Canadian friends, we went to this club, Easy at the Fifth. What a scene. Hardly any chairs around, the place was meant for dancing. A mass of bodies grinding and gyrating to the beat of the music. It was loud. No conversation here. All that was needed was movement...any which way was fine. It was totally anonymous. I could do anything. I felt care free. I can just imagine those liner commercials...hehehehe.... I certainly had my share of moves.

It has been quite a time since I had gone out to place like this. I have graduated to the sit down and listen to a live band crowd since my mid to late 20's.

I am glad I went. It was therapy without the hefty cost.

fractions at 530am

My cellphone rang out to life. Half asleep, I fumbled for my phone somewhere beneath the covers of my bed. It was half past five in the morning. One text message received. It was from my daughter. "Good am mama. I need your help." Oh, my. Why? My mind and heart raced as I struggled in dialing the all too familiar numbers to call home. What was wrong? Why is she needing help? Where is her freaking father? After a few attempts, I finally get a ringing sound. Maxine answered.
"Maxine, what is wrong baby?"
"Oh, mama, you are awake."
"What is the matter? why do you need help?"
"Mama, I need help to do my fractions. Papa is not here yet and it is almost dinner time. Will you help me?"
At home, there is a rule that homework must be finished before dinner time. It seems that my husband will be coming home late and she is stuck on her fractions.
An overwhelming rush of relief came over me. I found myself laughing.
"That's it? Well, of course, baby. I will help you."
"Go to the internet. We will do it online."
This is perhaps one of my most "mother moments". Solving math problems involving fractions. She would hold up a piece of paper with the problem and flash it to me via webcam. I will write down the answer at the same time explaining how I came up with such.
Who said I couldn't be half way around the world and help with math?
I truly am a global mom.

a physician in the 21st century - EBM style

Speech to UP-PGH graduating class of medical residents and fellows
February 11, 2007
by Dr. Antonio Dans
I would like to thank the graduating class of residents and fellows for inviting me to speak to you today. I speak to you so often and I am surprised you haven't had enough. The difficulty for me was looking for something to say, that you had not heard before. So for tonight, I chose to give a message, not from myself, but from my generation. I did a survey!
The research Q was this: What do former residents and fellows of PGH know now, that they wish they knew when they graduated?
Methodology: This was a survey sent by SMS.
Inclusion Criteria: 1) former student, resident or fellow 2) graduated shortly before or after me and 3) must be listed in my cell phone.
Results: There were 72 text messages were sent out, and 68 responses were received - a surprisingly high 94% response rate. Of these however, only 56 were analyzable - a dismal 78%. "Sana nag nursing na lang ako" for example, does not refer to something I wish I knew. Or "Sana di ko na binoto si GMA" - falsely implying he only graduated at the time GMA ran. Or, the most common impertinent answer, "Hus dis pls", as if it mattered who was asking.
Of the analyzable responses, there were 5 main categories. Let me get rid of the miscellaneous ones first. From Dr. Hilda Alava - "I wish I knew you had to buy stocks to practice in some hospitals." Now be aware. From Leny Fernandez - I wish I knew how to charge patients. (Yup, important)
I wish I knew who my real friends were - from Dr. Boying dela Paz. (Look beside you now and think hard). From Shelley dela Vega: I wish I knew that I should wear sun block. (Someday she might explain this to me)
From Dr. Edward Wang just a few minutes ago - I'm sorry Tony; I haven't learned anything since fellowship. And a similar reply from Raymond Alonzo - "Nothing. I already knew everything even then". Other than these, responses fell into 4 general categories, which I would like to share with you. General category # 1. We wish we knew then, that we knew so little.
Beta-blockers are bad for CHF, Vitamin C improves immunity, and all enlarged tonsils should be removed. Not many years ago, these were non-debatable bits of "knowledge". Today, they are nothing more than somber testimony to the fallibility of the human mind. Here's a sobering thought, which most of us have discovered by now - "Half of what we learn in medical school is wrong. We just don't know which half" (from Dr. Dave Sackett, one of the pioneers of Clinical Epidemiology).
If ONLY we knew this, then we wouldn't have bothered to memorize many of the things we were asked to. We wouldn't have focused on accumulating knowledge per se, but on developing skills to keep up with information. How to track, how to appraise, how to apply the medical literature, which, after all, represents the collective experience of the medical profession.
If ONLY we knew this, then we would have paid less attention to knowledge per se, cultivating instead, our creativity. Einstein said, "Imagination is more important than knowledge". No he didn't text me. But I agree with him. With knowledge alone you become outdated like an old book. With creativity, you can actually discover new knowledge, and rewrite the books yourself! True, you need knowledge to understand problems, but remember, you need creativity to solve it.
For sure, the medical curriculum, and indeed our residency training program, must think of ways to de-emphasize absolute knowledge. We must spend as much time cultivating self-learning, creativity, and problem-solving skills. This is easier said than done. It requires not just a change in content, but also a change in teaching style. The "all-knowing consultant" of the past, must abandon the impossible image of omniscience. Instead we must role model humility, intellectual curiosity, information- seeking behavior, creativity and problem-solving skills. If we agree on this, admitting, "I'm not sure what to do, let's look it up" - would have far better pedagogical value than an authoritarian approach: "there is only one way to mange this case".
The 2nd general category - We wish we knew then, that there were many things more important than hard work.
So, knowledge isn't important, and now, hard work isn't important. This tells you a lot about my generation. Think about it though. Hard work is great - but it makes life sound like a prison sentence: 75 years of hard work! Surely, even doctors are human. Faced with the prospect of hard labor, many will burn out. Others will avert this by migrating to greener pastures, or even shifting careers. One reason for this is that perhaps, our model has been wrong all along. Instead of modeling hard work, shouldn't we be modeling zest? There's big difference. Hard workers do things because they have to. People with zest do things because they love to do it. Students easily sense this. When arranging for preceptorials, they see the difference between "OSCE nanaman, kakatapos lang natin a!" as opposed to "Uy enjoy ako dun a, lets do it again next year!"
If we had known this before, many of us would have nurtured our zest. We would have protected time for activities that revive our energy. Unfortunately, our training places a premium on pure hard work - staying in the hospital long after office hours, coming in early before shifts, giving up weekends and holidays, working through meal times. To live up to such expectations, we have given up things that maintain our zest - time with our family and our friends, and time on leisure activities that revive us physically, spiritually, and emotionally. Except for the strongest, this leaves most of us tired, and drained - and ready to leave for good.
We must rethink expectations made of residents and fellows. In recent years, many training programs in medicine have paid closer attention to institutionalize measures to prevent compassion fatigue. This will take some introspection and planning from the point of view of the department. Meanwhile, there are things you can do. Diagnose yourself. If you don't wake up in the morning excited and raring to go, at least now and then, then something is wrong. Rest. Organize your schedule. Pray. Do something new. You have to revive your zest.
General category # 3. We wish we knew then, that the practice of medicine was more an art than a science. Dr. Greg Rogelio of SLMC texted me: "I wish I knew that medicine was more than a science. A lot of it is art and personal touch. Graduates of government training, like myself, aren't made to realize that." I agree with Greg. We were required to read tons of material, but we were taught nothing about how to relate with people. Have we helped you relate well with your patients and with your peers, with people of different social classes and levels of education? How much do your patients like you? Do they look forward to visiting you again? We're so used to evaluating patients that we forget we are being evaluated too. And between the two, their evaluation of you is more important than the one you make of them. There is this saying - patients don't care what you know, unless they know that you care! How much you read - that determines success in medical training. How well you relate to people - that determines success in your medical career.
If we knew that then, we would have done more than just listen to what our consultants say. We would have paid more attention to how they say things. Perhaps we should program communication skills into residency training, and increase its importance in the instruments we use to evaluate you. We have workshops on all sorts of things, but I haven't heard of any on patient communication and bedside manners.
And finally, general category # 4. We wish we knew then, that there was a lot of room for change. We wanted to be accepted by our profession so much, that we didn't see that so many things needed change. Eugene Ramos texted me: I should have had more confidence to follow my own lead. People who I thought knew more turned out to be no better than me. And from Miriam Timonera in Iligan: Ang dami palang bisyo ng doctor. Many more made subtle criticisms of the medical profession, that we did not realize when we graduated. Recognizing the need for change is important, but it isn't always easy. Our educational system breeds conformity. We try to turn all of our students into realists. "Don't try to change how we do things - it has been tried and tested for many years!" Sound familiar? I wonder, how hard have we tried to nurture your other half - the idealist? The one that wants to rebel against society, change the status quo, and fight for a better world? We honor conformists in school because they have discipline and they don't rock the boat - but after school, it's the rebel we honor - the people who saw what is, and tried to change it into what ought to be - people like Mahatma Gandhi, Martin Luther King and Ninoy Aquino.
I am proud of my generation of doctors from PGH. And I am proud of being part of the faculty. While we have no national heroes or martyrs, many of us have rebelled against the status quo in some small way, and have been able to implement some improvements in how we teach, how we practice, and how we do research.
Summary and conclusion: There are 4 things people from my generation want to convey, at least those who were in my cell phone. In one way these 4 messages represent deficiencies in how our generation learned medicine. In another way, understanding these 4 messages may help you prepare for the real world.
1) Knowledge isn't important 2) Hard work is overrated 3) Medicine isn't just a science 4) Do not conform to society. Further studies: It would be interesting to do a cohort study after this survey. My hypothesis is that these characteristics will predict success in your medical career. The hard workers will probably burn out, and those with zest will run circles around them. The knowledgeable ones will probably land decent jobs earlier, because of their excellent grades, but the creative ones will soon fly past them in the rank and file. The conformists will stagnate in the past; the idealists will create the future. Encyclopedic ones will have silent careers, but those who relate and communicate well - they will be heard by their patients and peers.
I am no longer sure how to end this talk. My speech teacher told me once, if you don't have one message when you speak, then you have none. Now that's a hard one, given the cacophony of responses I received. I did marvel at one thing though - how quickly people answered, and how passionate their answers were. Looking back, I think THAT is the singular message from my generation to yours - nurture passion for your work. Not fashion with an F. I know many of you think that is the formula for success. Passion with a P. Passion drives all 4 categories of messages. Passion for what you do will fuel your curiosity and creativity, so that knowledge does not stagnate. Passion will add zest to your life, so that what you do does not seem like work at all. Passion will add meaning to how you deal with patients and peers - because passion is contagious, and many times more effective than words. Finally passion will lead you to a cause, and will drive the rebel in you to change things. Now for me, THAT's worth remembering.
I have truly learned so much preparing for this talk. To the graduating class of 2007, you are amply prepared and we are all TRULY proud of you. Now go out and change the world... because you can. Whatever you do. Do it with passion.
Congratulations, thank you, and good night!

the internet and DS

Silly as it may seem, I don't know who invented the internet. But whoever you are, I thank you from the bottom of my heart.
Through the internet, I maintain strong ties with my family. Day in and day out, we go online. I marvel at the webcam. Though mine isn't at all that hi tech (in that I see their images as if on a stop motion sequence) I am still grateful.

My, how the kids have grown!

It is endearing to see Nikki looking up to Maxine. She is in sort of a copy cat phase. Whatever her ate (big sister) does, she follows. They both love to dance. And once they get started, just like the energizer bunny, they can just go on and on and on ...and then collapse in a heap of laughter.

However, Nikki isn't all just a follower, she is particularly assertive and bossy...her first word? "Ayoko!" (No!) ..like any typical two year old. Jun would say, "Mama, yung dalawang babae mo...sumasakit na ulo ko." (Mama, your two girls are giving me a headache.)...but of course said in the most endearing way as any loving father would. Nikki and Lomi would argue over what to watch. She just loves the purple dinosaur and Lomi has just had about enough of him. But being the true kuya (older brother), Lomi would give in to Nikki, if only to stop her piercing screams which she employs masterfully to get her way.

To me, it is quite surreal that Maxine was here with me in April and then now, I see her through a box in the screen once more. "Mama, Papa said there are new rules in using the DS?" When Maxine was here, before she left, I bought a Nintendo DS for her. It seems that the toy has been permanently glued to her hands and eyes since then much to Jun's dismay.

Rule no. 1 - thou shall use the DS once a day while it still vacation time in Manila and thou shall cease its use when the keeper (Papa) says so
Rule no. 2- thou shall surrender the DS to the keeper after its use
Rule no. 3- in the season of academic year, thou shall use the DS only on Fridays and Saturdays for a period of two hours and only after when matters of home assigned school work has been completely attended to

There, it has been forever etched into this blog.

leaving home

When I decided to work here in Toronto, my mind knew fully well that it was going to be for three years. My mind thought, I can do it. My soul thought, this must be what God had planned for me and so this fellowship has been offered to me. To which my mind acquiesced then that the offer was too good to pass up. But my heart was unsure...terrified even with the thought that I would be leaving all of my loved ones. My biggest worry was to leave my three children. I am very lucky to have Jun who has stepped up to the challenge of being father and mother.

My 9 year old boy Lomi, who is autistic, would certainly miss me. About three months before I left, we had a calendar on the wall, counting down the number of days left before my departure. It was a visual reminder for him that mama would be leaving. He would say, "Mama Donna ride airplane, go to Canada. Sleep in Canada." It was particularly heartwrenching on the day before I left as I was finishing in packing my suitcases. Lomi was dumping his own stuff in my bags insisting that he was going as well. "Lomi will ride airplane. Go to Canada with Mama Donna. Sleep in Canada."

Maxine is my beautiful little girl. She had just turned 8 two weeks before I left on June 24, 2006. She had me to herself on the day of her birthday. "Mama, do you really have to go?" I told her, yes...but if she wanted me to stay, she only has to say so and I will not go. I remember Maxine, pulling up to her full height and touching my face. "Well, you have been preparing for this a long time now mama. If you must go to do what you want to do..I understand." My heart felt like it was in a viselike grip. Maxine then gave me a drawing she had made. "Keep this mama ha." The paper was folded crosswise in half. On one half was a drawing of me and on the other half, of her. On the middle of the paper, she drew the sun and the moon. "Just remember mama, we will be looking at the same sun and the same moon." The tears were just flowing by then. I am amazed at Maxine....at her strength and with the support she renders. I am proud of her.

My youngest, Nikki, was 14 months old when I left. Truth to tell, I did not cease breastfeeding to the day I left. I thought, she will always remember me...my smell, being in my arms...that familiar feeling wherein she would find comfort and be soothe with my presence. I left knowing that she will probably not know me at all when I come back again. When Lomi and Maxine were in their formative years as toddlers, I had always been there for them. First time to use the spoon and fork well. First time to use the potty. First time to know the alphabet, 1-2-3. All the first times. I would never experience those with Nikki. My heart just kept on sinking with the realization. I am thankful that Jun made sure though that Nikki will always be reminded. My pictures were posted along walls where it would be at her eye level. "Nikki, who is that?" --- "Mama!"

A year has since passed. I still forge on here in Toronto. And I find myself asking, "Why?"