On Shoulders of Giants: A Message from an Elder Fellow to New Diplomates
Authors: Llamanzares Teodoro P. 
Published: April 2019

Magandang Gabi po sa inyong lahat lalo na sa mga bagong specialista (o Diplomate) ng ating samahang PBO-HNS na pinararangalan natin ngayon; Ganuon din sa kanilang mga kabiyak, at mga magulang, mga marangal nating panauhin at syempre sa mga dati kong kasama sa PSO at PBO-HNS. Itong samahang ito ang hindi tumitigil na paunlarin ang mga patakaran ng Society at para ang ENT Diplomate ay maging tunay na specialist at hindi “ispecialista daw.”

For the single ones among you, let’s give your parents special citation for having sacrificed not only once during your medical student days but twice-during your residency days. Their encouragement and material aid are phenomenal. Likewise to those married, your spouses either had a more challenging housewife’s role or became “house bands” during your busy training days.

So in this talk of mine which you may consider “unsolicited advice,” I will mention some idealistic-- even bordering on the philosophical -- reminders of some of our pillars in the specialty and my own experience as a budding practitioner. Also my personal pitfalls and how to possibly solve them. After all, when we reach our sunset years, we can discuss such topics ad infinitum.

            Success in your practice is more or less guaranteed. After all, our specialty is still relatively young and in demand and our membership is still wanting in proportion to the needs of a 100-million population. I still have to see an ENT practitioner unhappy in his chosen field. The only factor that may be unfavourable is your questionable attitude towards your patient, your colleagues in the profession and the hospital administrators in the institution where you belong. In an article by the multi-awarded neurotologist Dr. Michael Glasscock entitled “The Lost Art of Medicine,”1 he enumerated the basic principles of the time-honored physician-patient relationship which are:

“The Science of Medicine” which you have just endured by passing the board so I will not elaborate on it.

“The Art of Medicine” which is multifaceted approach to patient care that takes into consideration the patient’s emotional as well as his physical well-being.

I remember a patient, my own cousin, who fainted in front of me when he learned from the histopath that he had cancer. I miscalculated his intelligence against his anxiety, which brings me to the next topic;

“The Art of Full Disclosure” a most important aspect of good patient care is keeping the patient fully informed. A well-informed patient is an understanding patient who may think twice or more before suing you after a surgical complication, because you have explained that possibility to him. A DVD or disc on the surgical procedure, showing its advantages, indications, and possible complications can be a good source of informed consent. An anatomic picture in your laptop can explain the pathophysiology and help prevent problems in the lifestyle of -- let’s say-- a chronically allergic patient.

“The Art of Listening” studies have shown that during the initial interview an average doctor interrupts the patient’s story within 17-20 seconds. This frustrates the patient. True, the patient can be a poor historian so you can prompt him-- but not to the point of leading the story. Remember 40 to even 60% of his story can be the source of the diagnosis.

“The Art of Compassion” Postoperatively make rounds twice a day and even more if the case is a difficult one. This lets the patient and family know that you are on top of the situation and are concerned about their well-being. A secure physician will suggest a second opinion before the patient and/or family ask for one.1 And again will not even consider a malpractice suit if a complication happens. Those are the emotionally-charged problems you may encounter. So it’s not only the 3A’s of malpractice, namely Ability, Availability, Acceptability that can ensure success. Maybe add 2 more – Accessibility and Affordability for obvious reasons, when inefficiency is very palpable, such as in this unfortunate place known as Metro Manila with its horrendous traffic and other problems. There is a clamour for the next president to create a “department of common sense.” As to affordability, you may be the best ENT doctor but if your PF is preposterous, that will be a definite turn-off for the patient.

Here are few reminders for a starter:

Recruit a “smiling staff” from the secretary in the reception room, your clinic nurse and/or clinic assistant. Nothing can be a better welcome scene for a sick, depressed patient than a smiling, assuring face.

Be always on time as posted. Working patients have to rush back to work and get disappointed with errant doctors, and seek one who is available.

A few red flags in practice:

Beware of a secretary who may be a cheat, charging your pro bono patients without your knowledge and pocketing the money.

A colleague who captures “walk-in” patients by socializing with personnel from the admitting section, OPD-ER nurses and residents. No wonder inspite of “on call” scheduling you never received any patient from these departments. These events really happen.

One of the fastest ways for a quick fix to accumulate patients is to join HMO’s. Financial returns may not be as great as private patients but in the long run an HMO-satisfied patient is eventually your recruiter of his relatives and friends. Some downsides on joining HMO’s:

Controlling your work-ups such as by refusing necessary, thorough, but expensive requests.

Delayed payments.

Defining what is pre-existing illness.

In this day and age of social media, here are some do’s and don’ts: Never refuse an invitation to TV forums. During my time the two popular ones were: “Kapwa Ko, Mahal Ko” and “Damayan.” I was invited a few times to guest in these fora. As a result, my telephone lines became busy answering calls about my schedule. I felt like a superstar.

            The availability of information about your practice at a click of a mouse will allow you to reduce your marketing budgets. You can even create your own website or thru the services of facebook, twitter, etc. As long as your statements in your ads are not false, misleading and deceptive you can’t go wrong.

            Some examples of false statements:

Statements of ability to do subspecialty procedures where in fact he did it with a “ghost surgeon.”

Has had fellowship in a well-known medical center abroad but actually spent just a few days of observation.

Example of deceptive claims: - paid testimonials by prominent patients about his greatness.

Still some other tricks of the trade:

Practice in the provinces where you grew up. People there are very familiar with you, a returning professional, who will appreciate your humanitarian services. You will be the pride of your family. A very rewarding feeling indeed.

Accept speaking engagements from other medical groups, and socio-civic clubs. Again, they become your sources of referral.

The PhilHealth is a noble undertaking by the government for those who have less in life should have more in law. It is a law and we are all bound to abide by it. Let us not abuse it as is happening with one of the other specialties.

            I understand there is also an ongoing controversy between LGU’s and provincial hospitals about PhilHealth Returns. Thinking of academic medicine and research? You don’t have to be in a classroom or in the laboratory. Remember even the ancient Oath of Hippocrates mentioned this art of sharing knowledge and experience with others, when it states: “I will impart this knowledge of the art to my own sons and those of my teachers and to other disciples…”2 Teaching can also be self-serving since it forces one to study more and updated.  Masama naman na mas marunong pa sayo ang estudyante mo.

            In closing, let me remind you about the past. While you are in a solitary moment savouring the thought of your enormous professional success, please remember the toils, the sacrifices, the idealism of the “heroic nine” who founded our specialty society, and the Board and the subsequent leaders who nourished it. Don’t forget your Department Chairmen, Training Officers and Consultant staff who shared their time and expertise with you. They are part and parcel of your success. So there goes the remark of a French philosopher, Bernard De Charter: “We are like dwarfs seated on giants shoulders. If we can see far, it’s not because we are tall but because we are seated on giant’s shoulders.”3

            And most of these giants are with us tonight and they are all very proud of you. Good evening and thank you for the pleasure of sharing these ideas with you today.