Let’s talk about fentanyl…

The other week, I wrote about how wrong the president was when he said that fentanyl is “just a painkiller”.

From that blog post, we learned that it’s not just a painkiller. Because it is part of a group of drugs called opioids, this class of drug interacts with opioid receptors in the brain and elicit a wide range of responses in the body – from a feeling of relief from pain to relaxation, pleasure and contentment.

We talked about it’s licit (approved and proper) use for medicinal purposes. It’s approved indication include: managing acute and chronic pain particularly that due to cancer, nerve damage, back injury, major trauma and surgery. The caveat here is to use this only when all other lesser potent and addicting analgesics (narcotic or non-narcotic) fail.

It’s illicit (illegal) use is multiple and dangerous. Drug addicts get hold of the patch and extract the fentanyl from the patch and inject it. More commonly, however, is “diverting” method.

Diversion occurs when a medication that is prescribed by a medical professional, is not used appropriately, or is given or sold to a third party. (Alcohol and Drug Foundation, Australia)

Prescribed fentanyl can be “diverted” when:

  • individuals obtain medication inappropriately through their profession (e.g. doctors prescribe for themselves or among their peers)
  • individuals use their own prescribed medication recreationally for a non-medically intended purpose (e.g., to get euphoric effects or use it for sleep problems and not as a pain reliever)
  • individuals use medication prescribed to another person

There is NO safe level of drug use and what may be good for the goose, may not be good for the gander.  This means that its effect varies within and among different persons using the drug.

The most common side effects or “experiences” are:

  • nausea, vomiting
  • constipation and/or diarrhea
  • reduced appetite
  • wind, indigestion, cramps
  • drowsiness, confusion
  • weakness or fatigue
  • dizziness
  • euphoria
  • headache
  • incoherent or slurred or impaired speech and thought process
  • impaired balance
  • slow pulse (bradycardia) and hypotension (lowering of blood pressure)
  • rash (especially inflammation, itching, swelling at the patch site for those on the transdermal preparation

Since we know what fentanyl does and what its side effects are, let’s talk about withdrawing from this drug.

Withdrawing after using it for a long time is very challenging.  That’s because the body has gotten used to having opiates work at the receptor sites and withdrawing will mean that the body has to get used to functioning without it.  That’s what addiction is.  Whether you are a nicotine, alcohol, caffeine or drug dependent, the physiological function and response of your body has been altered to adapt to these.  Your body craves and longs for it.  Anything that changes your physiological function by craving for a substance that has made your body adapt to the pharmacologic effects of the regulated products.

The problem with fentanyl is that the withdrawal symptoms start as early as 8-12 hours after the last dose.  Withdrawal symptoms include:

  • goose bumps
  • bouts of chills alternating with bouts of flushing and excessive sweating
  • irritability
  • insomnia
  • loss of appetite
  • yawning and sneezing
  • watery eyes and runny nose
  • vomiting and nausea
  • diarrhea
  • increased heart rate and blood pressure
  • pains in the bones and muscle
  • general weakness
  • depression alternating with bouts of anger and confusion

Fentanyl is NOT JUST a pain killer.  It’s use and abuse are dangerous if not used properly (I heard that someone doesn’t really like following his doctors and takes an extra pop of the drug if he feels like it).

I am writing this to educate people that quitting after being on addicting agents is challenging and difficult to do.  That the side effects are sometimes difficult to differentiate from the actual disease (example is pain in bones and muscle during withdrawal versus using the drug for treatment of pain).  That when we are addicted to a substance, we will always rationalise why and how it is used.

You are wrong!

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When news like this circulates, it is mandatory that the medical community should react.

Whatever the president insists, he is totally wrong on this matter.

Fentanyl is a potent synthetic opioid.

It is 100 times more potent than morphine as an analgesic. (Yes, Mr. President.  It is a painkiller.  A very very very strong pain killer.)

Its pharmacologic effects are – analgesia, sedation, nausea, vomiting, itching and respiratory depression. Compared to other opioids, fentanyl causes more muscle rigidity.

It’s approved medical uses (licit) are:

  • management of cancer pain in patients already receiving opioid medication for their underlying persistent pain  (for the sublingual tablet formulations)
  • management of chronic pain in patients who require continuous opioid analgesia (for the transdermal preparation)
  • analgesia and anaesthesia in surgery (as citrate for injections given intravenously, intramuscularly, spinally or epidurally)

It is abused (illicit) for the following effects:

  • euphoria
  • substitute for heroin in opioid dependent individuals

Whether it is used licitly or illicitly, fentanyl use is addicting. Drugs that cause dependence are classified as habit forming and categorised as dangerous drugs. Under the DEA (drug enforcement agency of the United States), Fentanyl is controlled under Schedule II of the Controlled Substances Act.

A drug under Schedule II of the Controlled Substances Act means that:

  • The drug has a high potential for abuse.
  • The drug has a currently accepted medical use in treatment in the US or a currently accepted medical use with severe restrictions.
  • Abuse of the drug may lead to severe psychological or physical dependence.

In the Philippines, the Dangerous Drug Board and Philippines Drug Enforcement Agency have rules on prescribing narcotics and regulated substances.  The schedule in the Philippines is similar to the United States. Fentanyl is classified under Level II (previously called Schedule II). While it carries the same classifying definition as the US DEA, in addition:

  • Only doctors with S2 licences can prescribe them.  (Not all doctors have a S2 license.)
  • There is a separate yellow prescription form (that can only be purchased through the selected hospitals by S2 licensed physicians) that needs to be accomplished.  Fentanyl falls under that category.

Fentanyl is a controlled substance. In any part of the world. And yes. Even in China and Russia.

It is not JUST a pain killer.

It is addicting. It is regulated. Controlled substances are classified as with medical evidence or without. Either ways, it has abuse potentials. Only schedule or level II drugs are “legally” allowed to be prescribed. But it does not mean that just because it is prescribed it is not addicting.

I really don’t care if you’re using this for the various pains you claim to have. I’m really not concerned whether you’re really sick or not, or how sick you are. I just don’t like the fact that you go around having to rationalize what medicines you use to the point of changing the science of medicine, pharmacology and regulatory science.

Just because you are president, you do not get to change the fact that fentanyl is an opiate.


We’re all going to die

…but what you do before that happens is what matters most.

I am writing this for a friend whose mother was diagnosed to have cancer. The family wanted her to undergo surgery, chemotherapy and radiotherapy. After two cups of tea and a cup of tears, she asked my opinion.

I told her I had none.

I was sad. And wouldn’t want the same kind of situation where one would have to decide on matters where the heart and the mind collide.

As healers we want what is best for our patients. We offer the best treatment options, health care and assurance. Medicine, after all, is not a perfect science. We work with odds, weighing benefits over risk. We work against odds, with scarce resources and that will to survive.

I told my friend if she had asked her mother, what her wishes are. After all, her mother is educated and should be informed at the options available to her. Unlike many Filipinos, their family does not need to hurdle the financial obstacle. Cancer therapy today has made strides in not only minimizing side effects, but in improving survival rate as well. Cutting edge technology in medical science has altered the landscape on how we address diseases today.

She told me that her brothers and sisters wanted the best care and that the doctors had explained to them the outcome. In spite of the poor prognosis, her mother would probably have 6-12 months more. Or longer. The outcomes were unpredictable and based on various variables. She would have to contend with some side effects with treatment. Without treatment, the outcome was grim. But the children wanted their mother to receive the best treatment. And to be given that chance to battle her disease.

It would be another day before I saw the family. It was a somber meeting. Because I was the pediatrician of all her kids, her mother wanted to hear my opinion.

I told her I wasn’t sure of what to say except echo what the doctors already confirmed. Held her hand and asked her, what would you like to happen?

She smiled back and told me, she was ready.

The quality of life would be intolerable. She was tired. And she had seen other members of the family go through cancer treatment. She told me that she would just be procrastinating the inevitable. There would be time. To make amends. To enjoy life as life should be. To be able to finally fulfill her bucket list. To go with dignity and peace. Then she asked me, “if you were in my shoes, would you still pursue the treatment options”?

I smiled. Held her hands. Then hugged her. And she knew my answer.

That was a year ago. Without any treatment she lived another year. Battling pain and living life. They buried her a week ago. A celebration of life, love, and the choice to live …and die with dignity.

You see, we’re all going to die. But what you do before that, matters most.

A cup of hope

The other week when I was making rounds with my residents, we were discussing a patient who was the victim of a vehicular accident.

Prognosis was poor. Complications post surgery were multiple. Financial resources were scarce. What do patients or their relatives expect from their doctors? When faced with this dilemma, how do we arrive at a holistic approach at addressing this matter?

In medical school, we are taught the essentials of diagnosis and treatment. While bioethics is part of the theoretical considerations taught to us, placing this into practice is often forgotten. Until we are faced in real life with the dilemma in patient care.

As healers, we need to remember that it’s not only providing treatment to patients that are important. I tell my residents:

1. The patients expenses should always be taken into consideration. After all, it is not your money. And you have no right to spend it any way you want. Make sure that you approach the work-up based on the working diagnosis. Do a good history taking. Be sensitive to the needs of the patient and their family.

2. As medical students or those in training, don’t treat patients as training materials. Empathy, sympathy and genuine concern are the cornerstones of the good doctor. Remember: we are not god. Learn to touch their hearts more than their hands.

3. Sit down with them and discuss their illness. Everyone – whether they pay or are charity patients – deserve equal care and attention. Before prescribing, make sure that the patients need the medicine. If natural treatment is available (bed rest, water, fresh air, change in lifestyle), don’t prescribe medicines that are not superior to these.

4. Break it to them gently. Especially for those where the bad news will need comprehension and a bit more time to process, make sure you use terms that are understandable. Pause in between explanations and ask them if they understood and if they have additional questions.

5. Reassure them that you are with them in their road to recovery. Constantly update them on day-to-day changes. If you need to add tests, tell them why. Don’t be trigger happy requesting for unnecessary tests. Think before requesting. It’s not your money to spend. Imagine yourself as the patient. Always. How would you want your doctor to approach your illness?

6. During end of life issues, gather the family and explain in a language and words that they will understand. Provide them with clear options on both BENEFITS and RISKS on outcome. Place yourselves in their shoes and ask yourself, how will I want to hear the bad news?

7. And in our daily prayers, don’t forget the people we care for. Pray with them and for them. Adding a layer of faith by asking for spiritual guidance and enlightenment during these difficult times lighten the burden, and buys a cup of hope.

I get the point when patients or their relatives are taken aback when an unlikely diagnosis is heard. After all, no one is ready to look at death straight in the eyes.

Medicine after all provides every day with the possibility of a miracle.

Hippocrates said that

Wherever the art of medicine is loved, there is also a love of humanity.

Incidentally, the patient from the vehicular accident passed away. The family who was poor from the get go now has a mounting debt to settle. The party responsible for the “reckless imprudence” stopped providing funds to the victim.

We need to learn to let go…

because even at the throngs of death, there is dignity…

No approved therapeutic claim

For the record, let me start with a disclaimer.

I am not against complementary alternative medicine (CAM).  They may have their roles in various health and illness.  But just because they are “natural” or “alternative” does not give them the territory of absolutely safety. While there may be a role for many CAMs, the need to prove that the benefits outweigh the risks is important. And coming out with well controlled studies are essential to demonstrate that it can actually cure and is treatment to a disease. Otherwise, their claims will always be supplementary at best.

The Food and Drug Administration evaluates medicines based on quality, efficacy and safety standards.  If they meet these criteria, then they are given marketing authorisation.

On the clinical aspect, a drug (or supplement or complementary medicine) to be useful must at best fulfill the following: suitability (need), efficacy, safety, and affordability. For those that are off patent, interchangeability standards are required.

Let’s use dry cough as an example.

Most herbal medicines apply their products as food during the registration process. The reason for this may be multiple in nature.

Doing robust clinical trials are costly. It’s important that they follow Good Clinical Practice and approved by an accredited Ethics Review Board or Institutional Review Board to ensure that no harm is unwarrantedly done in the proposed studies or that the benefit of conducting the trial outweighs other risks. They should, at the very least be able to demonstrate beyond reasonable doubt (statistically significant difference) that between the experimental agent and placebo and/or standard accepted therapy, the experimental agent works.

Even something as minor as dry cough, to claim that it works better than water or     drugs in the symptomatic relief can cost an arm and a leg to execute properly.

Most herbal manufacturers don’t have that kind of money OR refuse to part with that amount of money.  Because pharmacognostically, the herbal agent may have mucolytic property, they can claim that the preparation may exhibit the same therapeutic properties as conventional drugs. All they will need to do is to (a) claim it is food and/or (b) use an endorser or testimonials to market the product. As to whether it is ethical to use these avenues for registering a product for a specific claim – the rule of thumb they follow is – THE ROAD TO NO APPROVED THERAPEUTIC CLAIMS.

It is not a medicine.  It is not for the treatment of a disease.  It simply helps.  It is natural.  It is an adjunct or supplement.

The second reason is proprietary ownership. CAM is a multibillion billion dollar business.  Grand View Research Inc. reported on April 2017 that the CAM industry would be worth around $196.87 BILLION USD by 2025.  That’s about 6 years down the road for us.  CAM finds its path into chronic diseases – hypertension, diabetes, kidney problems, liver ailments, cancer, etc.  The push here is driven by the increasing cost of conventional medicines and the marketing drive to overall wellness using vitamins, supplements, minerals and naturopathy.  But since the ingredients used in many CAM products are plant and nature derived, the proprietary rights to sources that are natural from the get go make it easy to replicate many of these success stories on botanicals. In short, nature has no patent.

Natural agents will need to, however, demonstrate its purity and safety.  The consistency in the manufacture of these products from batch to batch, their stability, interactions between ingredients that can cause potentiating or harmful effects when mixed with other herbal products are some considerations when evaluating these products.

After all, not all roses will be the same, even if they come from the same root or stem. Even the leaves of one bush of rose will vary among themselves.

It is easy to see, how skeptical the CAM industry is in sharing their “trade secrets”.  After all, even with vitamin C alone, the sources are vast and evidently wide if you were looking at a basket of fruits alone.

Third is the business aspect of CAM.  With rules and ethical norms guiding the principles of marketing in the pharmaceutical industry becoming more important, the business of CAM is unregulated to this degree.  Food, after all, is something that one can easily concoct and sell, even on an underground basis.  Drugs require that all products are under the radar of every National Regulatory Authority.  But CAM usually escapes both the mind of the consumer and the distributor through their no approved therapeutic claim pitch.  Actors and actresses, media men, personalities and every Tom, Dick, and Harry are easily paid to claim that taking herbal agents have made them look more radiant, younger, become smarter, or even have a better boner during sex.

In addition, unlike drugs which are given 20% senior citizen and PWD discounts (and less 12% Value Added Tax), supplements are not covered with this entitlement.

Then there’s the extravagant extended claim that it’s a do it all “medicine”. By golly, it will attempt to address allergies even if it’s nothing but a purported immunomodulator. Allergic disorders are NOT an immunologic problem per se. And there are more of this kind of marketing. Grow taller, be brighter, achieve more are dreams we all chase.

Do they really work?

The problem with CAM is that they’re also easily adulterated.  Under the guise of a supplement, many products have been noted to have active ingredients of conventional drugs but are sold as supplements and natural products and claim to work “as good as the conventional drug and are safer because they are ‘natural’.”

There was news back in September 2016 where a local supplement for erectile dysfunction was noted to be adulterated with tadalafil, a conventional drug that is used for treating this disorder.  Some Chinese ointments and creams contain a mixture of steroids and other antibacterial or anti fungals and claim that it is a do it all topical agent for the treatment for skin problems. They find their way into the shelves of dubious unlicensed outlets but are sold through pyramidal schemes or online. Hence the need for even herbal products being regulated to some degree.

The gullible consumer is often convinced of the efficacy of a product from testimonials of friends and family. Their marketing push will always be “natural” is safe.

I often get the question from patients on which multivitamin preparation is best or what cough remedy is suitable for their child.  I answer always – food for the former, and water for the latter. Nothing comes more natural than that!

While some (if not many) of these herbal products actually benefit the patients who use it for a specific disease, the consumer is warned about the purity of the products that make a claim, especially those whose claims are superfluous.  In addition, it is always good to discuss treatment strategies with your doctor when you are taking CAM.  The physician should likewise read up on the field of CAM so that he/she can guide his/her patients toward total body wellness.

To first do no harm is not the purview of only one specialty.  It is, everyone’s business to make sure that it is not abused for financial remuneration alone.

Because profiting from something that doesn’t work – whether conventional or CAM – is harm on patients who buy a bottle or a pill of hope.

No approved therapeutic claim #PetPeeveStories

I have nothing against complementary alternative medicine. Let that be my disclaimer before you go on to reading this post. After all, there is a scientific basis for herbal products. I understand the general public that wants to use “herbal supplements” and other forms of complementary alternative treatment modalities (acupuncture, Ayurvedic Medicine, massage, etc) for either prevention or treatment of an underlying disease.

For the understanding of the reader, CAM or complementary and alternative medicine is the general term for health and wellness therapies not part of conventional Western Medicine. Complementary refers to treatment used alongside conventional medicine. Alternative refers to treatment in place of conventional therapy.

The focus of CAM is the person as a whole – emotional, physical, spiritual, and mental health. Natural products, also known as naturopathy, include herbs and dietary supplements.

With increasing use of CAM worldwide, the term Integrative Medicine has been preferred to describe the best of conventional care with the best of alternative medicines.

Sadly, while not a lot of patients understand what CAM is, the lack of knowledge and information by many doctors limits the integration into best clinical practice of CAM with conventional medicine. It is important in this equation that BOTH parties understand each other when using CAM as part of, or as a substitute for, conventional medicine.

The peeve in this issue is the misunderstanding of either parties about CAM.

Complementary therapies used alongside may help in the management of certain diseases. For example, marijuana in patients undergoing chemotherapy has beneficial properties on the nausea and vomiting side effects of chemotherapeutic agents. Instead of having to administer an anti-emetic agent, minimising more drugs which can result in drug to drug interaction may benefit select patients.

Like many other things in life, what may be good for the goose may not necessarily be applicable for the gander. Which means, that just because it works for someone, it is applicable to all.

Many alternative therapies lack controlled clinical trials. Clinical trials is the road taken by conventional medicines in order to support the claim of efficacy over placebo or other standard therapy. It is thereby encouraged that when looking for the evidence of efficacy and safety, clinical trials over testimonials are the rule rather than the exception.

Physicians are encouraged to learn about the benefits and risks of CAM, the science behind their development, and their uses and contraindications as well as potential drug interactions with conventional medicine so that when discussing it with patients who inquire about this issue, they can discuss on a cerebral level, its potential use and misuse with the patient.

Two important points should be cited here:

1. Physicians should not base their recommendation of CAM on financial gains by selling a product in their clinics, without appropriate information on the supplement.

2. Some doctors refuse to use it because they say the patient will not benefit from its complementary, alternative or integrative use not because there is truly no “approved therapeutic claim”, but because the doctor does not know what the product and the question is.

As physicians, the prime objective is to do no harm to patients. This includes assisting them in the various levels of care of their illness. Patients rely highly on recommendations of doctors. When the doctor shuns away information (valid or not) brought to his/her attention by patients who pick up a variety of information on the Internet, it is their responsibility to keep updated and assist the patient in arriving at a consensus in the management of the patient’s illness.

No one deserves anything less.

A friendly advice to patients, don’t believe everything on the Internet. It takes very little effort to sell something that can bring you harm. Discuss CAM with your physician or someone knowledgable in this first.

The five senses #PetPeeveStories

There are five senses – sight, sound, smell, touch, and taste. Not everyone though may have all these senses intact either because of an underlying medical condition or selective loss of faculties.

For example, newborns are unable to see the human face well. At birth the normal term infant has a vision of 20/200 to 20/400. That’s why the best distance for gazing into your bundle of joy is around 8-12 inches away. Because they are nearsighted, anything further than that is a blur.

Unless you’re a newborn or literally blind, please use your eyes to look for things and not your mouth.

I’m sure you’re familiar with this conversation:

Boy: Mom where is my pen? (Talking while he’s busy on the iPad)

Mom: On your table

Boy: Which table mom? (Still busy on the iPad)

Mom: If your pen can walk to you, it would. Use your eyes and not your mouth. You’ll never find it using your mouth!

The sense of smell is the most sensitive. Anosmia is the loss (total or partial) of the sense of smell. It can be temporary or permanent. The most common cause is nasal congestion from allergies, a cold or infection. But nasal polyps, cancerous growths, head injuries or neurological problems are diseases that can cause anosmia.

You notice how people have bad hygiene and they still can’t tell they smell awful? Unless you’re into pungent odour or have anosmia, be mindful that the greater majority have a healthy sense of smell.

Those who get off with stinky smell (and I mean literally in an erotic way) should know that it is a manifestation of benign masochism.

Halitosis (bad breath) is my ultimate pet peeve. I cannot, for the very heart of me, stand having to breath or eat at the same time talk to someone who’s breath smells bad. Really bad.

How do you tell someone that he/she has body odour or bad breath without necessarily offending him/her?

Tough question? These tips may help:

1. Drop some hints (I think my breath smells terrible. I’ll have some water. Or offer some breath aids – here have a gum. If he turns it down, say, I insist!)

2. Be direct (Filipinos aren’t good at this. We’re usually onion skinned and think it will offend people.). In general, the closer you are to the person, the more direct you should be. Don’t broadcast it all over the dining table. You can whisper it to him/her or discuss the issue in private. Even people with odorous problems have feelings.

3. Say it anonymously (like leaving a kind note or email or ask someone else to do it for you).

For the good of the environment, people with hygiene problems must be told they have. After all, we’re breathing the same air and are entitled to a “healthy” environment as well.

When you’re hard of hearing it can only mean that you’re probably deaf (partially or totally) or just don’t want to listen. Big difference there. Appreciating sounds is appreciating life.

When the sense of sound is obstructed at an early age (say the child had meningitis at birth which affected the sense of hearing because of complications), their neurodevelopmental milestones particularly adaptive and language skills are the most impaired. Then there is, of course, having renal diseases. Toxins that damage the kidneys affect blood vessels and the inner ear. That is why people who have chronic renal problems have audiologic problems as well. The elderly is another group who are hard of hearing.

Aging and loss of hearing is a phenomenon called presbycusis (or age-related hearing loss).

Hearing disorders are not uncommon. Rustling leaves are heard at 20 db. Bird calls and library whispers are at 40 db. Normal speech is 60 db. A lawn mower sound is around 90 db. A concert is about 120 db. Painful damage to the ear occurs at 140 db. As a general rule, sounds above 85 db are harmful. Imagine someone with a headset and those of us in a crowded noisy train can hear your music. You must be deaf!

And those people who pretend to not hear?

I don’t even understand why there are people who have a headset at work. No offense meant here but you don’t stick two plugs into your ear and say “excuse me” and point to the earplugs when someone at work calls your attention or asks you a question.

Tactile sensations are due to the nerve supplies in our body. Somatosensory senses are scattered all over the body on our skin. With this intact, we can feel cold, heat, pain and pressure.

The pathways for processing touch are separate. Because of this, the physical sensation of pain can be separated from its emotional impact. And the pleasurable aspect of touch can be removed from the actual sensation. Losing the sense of touch is called anaphia. In daily parlance, we call it numbness.

Figuratively (or even literally) there are those who are thick skinned. They are numbed and callous to other people’s feelings. To say they have no feelings is an insult to someone who suffers from anaphia because of a true medical condition. But they exist. And the sense of touch (physically and emotionally) is sorely lacking because of apathy and personal issues.

Gustatory sense is the most delicious sense in our body. It makes us appreciate the wonders of cooking and the different foods of the world. Without the sense of taste, there will be no school for Culinary Arts, no job for chefs and bakers, no work for waiters, no business for restaurants. There are five senses to taste: salty, sweet, sour, bitter and umami. Dysgeusia is a condition where a foul, rancid, salty or metallic taste persists in the mouth. Ageusia is the inability to detect any tastes at all.

The sense of taste can be affected by factors such as age, disease, or medications you’re taking.

When people say that what you do is immoral or wrong and “leaves a bad taste in the mouth”, they’re literally and figuratively an idiom that refers to an act or deed that leaves an unpleasant memory.

Someone who lies through and through about something he professes to do but does not practice what he preaches will always “leave a bad taste in the mouth”.

“The doctor is out” #PetPeeveStories


It’s never appropriate to give away your personal mobile number to patients. Unless the number you give is an office phone, or you have a personal secretary whom patients can get in touch with, then yes, it’s never appropriate to give away your personal phone numbers.

Patients will ALWAYS want to know how to get in touch with the doctor. I get that. Many, usually ask for your mobile number – just in case – they need to get in touch with you when they or their kids get sick.

Ever since I started my practice, asking for my personal number has been my number one pet peeve. “No you may not have it. On my card is the number of my clinic where you can contact me during office hours.”

During the earlier days when the pager was still in vogue, I didn’t mind that my pager number was emblazoned on my calling card. After all, it was one anonymous number and the patient had to get through another anonymous person who would filter the information that would be sent to me. It’s like having a private secretary that you needed to go through before I got the “emergency” message. My pager would vibrate. The message would appear. And I could call from my landline or phone (there were no Smartphones then), wherever I was. Or I would just save it for later if it wasn’t urgent.

But technology would change the landscape of clinical practice. Gone were the days when you were the CEO of your own private practice. Smartphones and tablets changed the way you dealt with patients. There are medical professionals who have “professionalised” their medical services providing online “consultations and opinions”.  Some take it a level higher by being able to “Viber” or  FaceTime with patients as well! And here’s where it gets really tricky and icky.

I have no quarrel with technology. Just where and how it’s used.

1. Personal space and professionalism is important

Doctors have a personal life. When the patient has an emergency, I am not 911. Take them to the nearest hospital. They should know what to do there. For the younger ones who’re trying to give away their personal numbers so that they can create a following (or a patient base) – DON’T! You’re making yourself open to liabilities and law suits by acquiescing to the patients desires. Keep a professional distance.  If they can pay to go to the hairdresser and queue to watch a movie, I think they can pay for a professional medical/surgical consultation. NEVER EVER GIVE A DIAGNOSIS TO A PATIENT YOU HAVE NOT PHYSICALLY EXAMINED OR SEEN.

I will tackle a general pet peeve on mobile phone use etiquette another day. Remember, you don’t have a right to call anytime you like. Because there is a text messaging service, kindly text first if the party you are calling can take your call. If they don’t reply in the next 5-10 minutes, it means they’re busy. Don’t call just because they don’t respond. If it needs attention, resend the message after 5-10 minutes. We may be seeing other patients or watching a movie or having fun with our family or cooking dinner or sleeping. We have a life, too.

The rule of thumb is – if it’s urgent or an emergency, take the patient to the hospital.

2. The email has landed… together with shit

So the Smartphones have made it “business is open” 24/7 for everyone.  It’s like a “pager” all over your precious space.  It’s all over my business card anyway, so I allowed it to be part of how to “contact” me.  And with “data” being cheaper than SMS services, it was fine, until the day I received a lot of shit in my email. I meant, literally, SHIT.  Pictures of their baby’s SHIT! SHIT! SHIT! and more SHIT!

Some moms thought that sending me those gross looking shit enveloped by a diaper would make me clinch the diagnosis.  It’s like an online revalida! I had questions to ask – did he have a fever, were there precipitating situations that made your boy poop green turd, is there any form of pain, are there rashes, what was his last meal? Of course, I wanted to ask if there was a stethoscope lying around in the house and could she listen to his tummy and tell me if the boy had hyperactive or normoactive or hypoactive bowel sounds.  Feel his tummy and tell me, is the liver big, can you feel the spleen, is there a mass, is there direct or indirect tenderness? Oh by chance do you guys have an ultrasound machine lying around in your house as well? Coz if you do, can you get to do an abdominal ultrasound while you’re at it?

The email just threw my whole textbook of physical examination and history taking out the window! All because the mother was worried about the turd!

The rule of thumb is – if it’s urgent or an emergency, take the patient to the hospital.

The second rule of thumb is – for God’s sake, take him to the nearest doctor in your area. I won’t mind!

You don’t have to flash all that turd or take naked pictures of the body and send it by email for me to give you a “provisionary” diagnosis. And hopefully get a prescription.  Some of these people will even exchange emails with you when you tell them that they need to bring the child to the clinic.  The favourite excuse? CODING!!!!!

I’m like, come on, if you feel that the kid is really sick and you need to go to see a doctor, I don’t think the traffic officer will try to stop you.  If he does – SHOW HIM THE F*CKING TURD YOU SENT ME BY EMAIL AND THROW IT IN HIS FACE!

3. Time is precious

A few years after I started my practice, I tried implementing a “by appointment” system.  That meant that patients who wanted to be seen without having to wait could do so by setting up an appointment (instead of the first come, first serve basis).   That’s because patients were complaining that the queue was too long. There was no cut-off.  They had other appointments to go to. And so on and so forth.

Did it work? NO!

Sadly, I think I was either ahead of my time or that this kind of system is unfit for Filipino patients.  Why did I say it did not work? It’s like this – they liked to make appointments, BUT 99% DID NOT BOTHER TO CALL IF THEY WANTED TO CANCEL!!! It’s soooo Filipino.  It’s like sending out an invite with the letters RSVP in bold.  You think they’d even bother calling to say they’re not coming? NO!!

The rule of thumb is – make sure that you respect each other’s time (both doctors and patients). 

I hate it as well that when a colleague says that his clinic hours are 10AM-12NN, he arrives tadaahhhh – 1PM!  We need to be conscious of other people’s time. Professionalism dictates that we observe the time of our patients as well.  After all, they have a life as well.  We all need to be somewhere, somehow, doing something that is important to us. If you’re running late, let the secretary know so that the secretary can inform the patients the time of your arrival. Let’s all respect each other’s time and space.

Of course, that means there’s the patient who’s also running late. Very very late. So when I say that clinic hours are 10am-12nn, it means that the last patient must come before 12nn because I need to leave at 12nn. But no!! Some of them pile up at 12nn so that they think they’re the last patient and won’t have to queue. (A separate blog on queuing is on the menu.) And the patients get irritated that they’re not the last to be seen. Five of them arrive at exactly 12nn. And there are still 2 more on the way. Each hoping to be the “last” patient for the morning. And that my friends is why the doctor is late for his next clinic at 2pm at another hospital.

4. Dear Google 

The internet has made everyone a keyboard warrior.  We’re only a few taps away from asking what the diagnosis of Burkitt’s Lymphoma or Kawasaki Disease is.  Press search and your friendly reference Google will help you find 1,000,000 hits in less than 1 second.  What do you do with all these references? Without appropriate training on how to critically appraise the published literature, the typical patient will scan through the easiest to understand (read – written in layman’s terms) or get discombobulated with the complex terms.  The next day, they’re at your clinic, all anxious and worried that their lives or of their children are about to end. On one hand is a whole envelope of print outs from what was downloaded last night! And they have a million questions…

They are, after all, within their right to ask.  That’s why there is a consultation.  How you face Google as their defence attorney is another matter altogether.

The rule of thumb is – Google is not a doctor.  Wikipedia is not a good reference material (READ: ATTENTION MEDICAL STUDENTS).

Which goes to the point of keeping up with the changing paradigms in the practice of your specialty or subspecialty. It’s called CONTINUING MEDICAL EDUCATION. Medicine is not an exact science.  There are hits and misses.  Mostly hits.  But we need to make sure that we are updated in our practice.  Because the patient sure is! And it would be shameful that when you’re caught with your pants down where the patient knows more than you, they’re probably not going to go back to you or recommend you.  It would be doubly shameful that you try to get around the fact that you didn’t know the reply to the great question your patient posted, by LYING through your teeth.

Remember, we’re all entitled to second, third, and even more opinions of our clinical condition.

The second rule of thumb is – Brush up on your practice. Take your Continuing Medical Education seriously.  Patients deserve nothing less when it comes to treating them.

Technology may assist us at organizing our office files and databases and create better efficiency in the hospitals and clinics. It is NEVER, however, the best way to assess the health of your patient. And not seeing the patient and fully examining, yet providing a prescription treatment through text messages or emails that later results in an adverse reaction is a recipe for disaster and a law suit.

State-of-the-art gadgets, equipments and medical devices are useless if what is between those ears are empty.

A gentle reminder. If your doctor gives you his/her personal mobile number – don’t abuse it. It doesn’t mean you’re besties already and that you need to send a text even at an ungodly hour or when he/she is out of the country (yes – we pay the roaming charges not you), if and when you need to. Proper decorum dictates that you treat each other in a professional manner or find someone who’s willing to live up with your expectations.

Being considerate is highly appreciated.

p.s. Don’t use the messenger on FB or other social media apps to get in touch with your doctor. It’s rude.