Saturday, August 09, 2008

lessons from canossa.

(As part of our rotation in Family Medicine, we immersed ourselves for a week at the Canossa Family Health Facility in Tondo. This piece was submitted as part of the post-rotation requirements, bearing solid testimony to the amount and depth of insight the experience taught me.)

My very first malingering patient was also my very first patient on my very first day at the Canossa Health and Social Center. With all the energy and excitement expected of a first-time ICC, I enthusiastically leapt to her chief complaint of numbness at the fingertips, deciding that a test for sensation is necessitated. The usual instructions were given: Close your eyes and tell me if you feel anything. A nod, and then a cheeky smile, after which she proceeded to cover both eyes with an arm pretending to comply with the procedure. But from where I was seated I could spot an unmistakable twinkle of mischief covertly peeking out of the corner of her eye. Right there and then I knew Canossa was about to teach me my very first lesson: patience.

There are going to be many more such lessons.

The first time the name “Canossa” was mentioned during the orientation was also the first time I heard of such a place, never mind that I live only about 15-20 minutes away from the area. It was described as a haven of health in the midst of the urban squalor that is Tondo, a sanctuary of wellness for the residents living in the area. I envisioned it as such, and hoped much that in the days to come, I would be able to make a least a small difference in the lives of the patients I will meet along the way.

Kindly picture me then: the incredulous newly self-proclaimed champion of poor people’s health, smug and overly satisfied for having been able to prescribe Cotrimoxazole for a female pediatric patient with recurrent UTI. Thanks to my ever-dependable MIMS, I even went a step further and got the recommended dose and treatment duration verbatim, not missing one presumably vital phrase from the book. Imagine my disbelief and chagrin when, upon seeing my prescription, the attending doctor exclaimed, “Compute! Compute! Never forget the patient’s weight!”

Second lesson: humility. It was all that’s needed to burst my prematurely swollen rubber-bubble-of-a-head and make me realize that there are a lot more bitter melons to devour before I properly earned the right to strut my stuff.

In a resource-poor setting like Canossa, for instance, it is never enough to dabble in the highfalutin rhetorics of medical lore. One must know the diagnosis and the treatment, yes; but far more challenging is the task of having to utilize the social determinants of health – in particular finances and environment – in streamlining the proposed therapeutic regimen to the needs and capabilities of the patient. That goes with prioritizing which laboratory tests to order, or which drugs to prescribe, one small step at a time.

Once I found myself dealing with an elderly female, a recent TB graduate, who came in consulting for arthritis and hypertension. She was hooked on Accupril® (Imidapril) but her BP remained obnoxiously high and non-responsive. A mix of theory, research and common sense told me to suggest shifting to Accuzide® (Imidapril + Hydrochlorothiazide) which seemed an appropriate enough drug for Stage II hypertension, and I reluctantly scribbled the therapeutic plan on a sheet of paper. Lo and behold – when the patient emerged from the (true) doctor’s office, prescription in hand, nothing changed – down to my last sentence of treatment duration!

I must say incidents like these provide the rare silver lining on the gray cloud of any aspiring medical student, and I am immensely thankful to Canossa for raising my confidence to greater, nobler heights. Little, puny medical students like us might consider themselves inept for the job, but for the lines of patients awaiting their turn at Canossa, it didn’t matter. You were the doctor. You were THEIR doctor. Or at least, they see you as one.

My third lesson: faith.

It is faith that has steadfastly remained at the helm of everything else, all through these years. Faith in oneself, plus faith in the belief that a modest health center rooted right smack in shantytown will stubbornly defy the years and persist. Such faith, I believe, goes more than just the fact that Canossa is nun-run. Every morning and afternoon, before activities kick off to their usual flurry, a hymn of worship is offered to the heavens, accompanied afterwards by a short reflection on the day’s Gospel, a fitting act of thanksgiving to the One who has constantly and faithfully heaped blessings of good health, longevity, and success.

Because in itself, Canossa is a success story of success stories packing in more success stories. The volunteers in the “Lingap Lusog” program who administer the DOTS regimen to TB patients were once TB patients themselves, having undergone the same pains of abiding by the arduous six-month DOTS commandment of having to report for daily shots without fail, but which served as the ultimate pot of gold beyond a bleak and potentially endless rainbow.

The entirety of the experience could only prove too humbling for someone who has only begun to learn wearing the sophisticated shoes of the clinics. Our inexperience readily gave way to the subtle expertise of the midwives who could detect fetal position, lie, and stance in the blink of an eye where it could’ve taken us minutes to even just manage a decent educated guess. And nothing compares to the vast opportunities waiting in store for one outside the four walls of the classroom: The indefinable joy of listening to the faint whiff-like beating of a fetal heart inside its mother’s womb. The unspoken wonder of witnessing the gift that is neonatal screening being gently performed on a frail, crying bundle of life. The self-induced catharsis of listening to a patient interject family woes in between symptoms of a yet undiagnosed condition.

All the while trying to be as professional as possible.

As we left Canossa on our last day, the words of Ate Nila somehow came ringing back to haunt my troubled thoughts. “Many doctors have promised to come back but they never did,” she commented, shaking her head. There was a hint of sadness in her voice. “The few who did return, like Dr. Josie, are our heroes. They are true heroes.”

Which prompted me to ponder: Does Canossa really need a hero, after all?

Perhaps it doesn’t.

Those heroes already exist in its midst, empowered and strengthened by a community that’s determined to win the raging battle against disease, at any cost. I’m definitely proud to say I had been one of those heroes – if only for a while, through giving back to my fellow countrymen the best I have, the best I can, and the best I am.