Why Good Enough Is Never Good Enough

“Nakaka-disappoint nga Sir, eh. Kaka-declare pa lang na suspended ang klase bukas dahil sa ulan, tinatanong na agad ako kung puwede bang half day sila. Nung (medical) clerk ako, kahit gaano pa kataas ‘yung baha at kahit gaano kalakas ‘yung ulan, pumapasok kami.”

“You have to realize, not everybody sees the world the same way you do.”

“Pero kapag doktor ka naman Sir, wala ka nang nalalamang holiday at suspension. Kailan pa nila matututunan ‘yun?”

I was assisting my consultant in the operating room when we had this conversation. It had been almost a year since I was designated resident-in-charge of the rotating interns in Neurosurgery; an unexpected break during the operation provided an opportunity to vent my frustration. I had been receiving negative feedback from the section’s consultants of late.

The clinical rotation in Neurosurgery lasts only a week. The interns would go on 24-hour duty in the ER once or twice during the rotation; the rest of the week, they only needed to report during office hours, 7 am to 5 pm during weekdays and 7 am to 12 noon on weekends.The only major requirement is to examine one patient and to present the case to the consultant-of-week in a two-hour discussion. In the dichotomy of clinical rotations, this would definitely fall under the benign category.

But almost invariably, the consultants would complain to me that the rotating medical interns performed way below expectations. Often, I could not say anything in defense of the students.

Despite ample warning, many of the interns would show up for their preceptorials with a crammed Powerpoint presentation. Only one or two (from a group of four or five) would actually take time to get a detailed clinical history and perform a comprehensive neurologic examination. Fundoscopy, mental status assessment, and gait testing are often forgotten. Once, a consultant walked out during the discussion when the interns presented a case of spinal cord compression without doing a detailed sensory and motor examination. Presentations are copied and pasted verbatim from the Internet or from basic neurology textbooks. And only the assigned member would actually review the cranial CT and MRI plates.

What’s more bothersome are some interns who neglect their basic responsibilities: reporting for duty at 8 am, not reporting at all during weekends, failing to complete clinical abstracts and discharge summaries despite repeated requests from nurses and patients’ watchers, going to the operating room to play with their handheld devices or chat with co-interns rather than to actually observe surgeries, and lack of genuine effort to monitor critical patients conscientiously. Of course this is not true for everyone. But in the hospital which exposes medical students to the most number of neurosurgical cases in the country, outstanding interns who impress consultants and residents have become the exception rather than the norm.

“Baka naman kasi masyadong mataas ang standards mo,” one of my co-residents remarked.

I understand that not everyone will become a neurosurgeon after medical school, but students should at least strive to learn core concepts in neurology and neurosurgery, so that when they practice as general physicians, they would know how to manage emergent cases and refer as necessary. I daresay nobody would disagree that there’s a problem when interns do not know how to do a complete cranial nerve examination or give an accurate Glasgow Coma Score.

Perhaps part of the blame lies in the current medical curriculum, such that seven days in the section is too little time to review what one should have learned in the last four years. Do the interns expect didactic lectures at this stage of their medical education? Do they realize that after medical school, it is self-directed learning that will serve as one’s constant source of new information?

Excuses for failing to do one’s basic responsibilities do not even merit a discussion.

It is possible that the students do not feel the need to exert extra effort in a relatively benign rotation, compared for instance with the Big Four (Medicine, Surgery, Pediatrics, OB-Gynecology). Benign rotations are seen as time to catch up on the “more important things” in life. Students seize the opportunity to spend quality time at home, book weekend getaways with friends, or party all night without having to worry about patients decked to them. Minimum necessary effort is exerted to be able to get by and pass the rotation, and there is of course no fault in doing just that.

In my time, I was a diligent medical student regardless of clinical rotation. Hence, I often find myself thinking, “Natutunan ko naman ‘yan nung estudyante ako,” or “Ginagawa ko naman nang maayos ang trabaho ko nung intern ako.”

Is it too much to expect more from future doctors training in the national university hospital?

Medical school is no place to nurture mediocrity. Good enough should never be good enough.

As a doctor, to make a patient feel better is the minimum necessary requirement. That is our implicit obligation when patients entrust their lives to our care. But what patients and their families appreciate is the extra effort we make to fulfill this promise:

Sitting down when we listen to them narrate the events and enumerate the symptoms leading to their hospitalization; staying an extra hour to follow up results of blood tests done during the day, and to update them, so that they would not have to stay up all night wondering if everything was all right; dabbing the micropore tape with alcohol and gently peeling away rather than yanking out the sticky tape from their skin; negotiating with Radiology so that imaging studies could be done earlier in patients who need them immediately; not hesitating to take over as nurse/nursing aide/utility worker (e.g., push the stretcher and oxygen tank, inflate the ambu-bag, transfer patient to the stretcher) when there’s a shortage of human resources in health care; giving a genuine smile and a promise of hope as we leave their hospital room to go see our next patient.

But before you can go further, you need to be able to fulfill your basic responsibility. As a medical student, that responsibility is to study well. The pervasive nature of mediocrity is such that medical students who get by with “Pwede na,” “Ayos lang iyan,” and “Bakit ko ba pahihirapan ang sarili ko?” later on become the doctors who deprive their patients the opportunity to receive the best possible medical care at the soonest possible time. Remember that every minute of delay translates, not just to inconvenience at your patient’s end, but to another minute of unnecessary pain, or anxiety, or hopelessness.

By choosing to become a doctor, you make a commitment to pursue excellence, to go above and beyond expectations whenever possible. That commitment starts, not when you pass the licensure exam, but on the day you turn page one of your Anatomy book.

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11 comments

  1. this post deserves a standing ovation. i’m also very much alarmed by the decline in their performance, but what is doubly alarming is that they seem to think this is acceptable. in the clinics, i’ve noticed there’s no shame in giving a lackluster clinical history or an incomplete physical exam. prodding for differentials and management usually is met with blank stares; very few make the effort to at least hypothesize. as an educator, the only thing i can say is “challenge accepted”.

  2. I salute you! I suppose, yung iba kasi (not all) gusto lang maging doctor for the title. Not really all would want to save lives, others do it for the money as a business enterprise…Iilan lang naman talaga ang may passion to do their job well, not for their personal benefit but really for others. Iilan lang talaga ang may puso para tumulong! At salamat dahil mayroon pang katulad mo na pwede naming asahan na totoong ginagawa ang kanilang tungkulin ng buong puso! Sana, sana pamarisan ka ng madami pang doctor…

  3. sana po ay marami pang maging duktor na katulad ninyo. mabuhay po kaya!

  4. Alarming talaga ang mag pa ospital ngaun, kasi baka matapat ka sa doctor lang sa name at di sa puso…. di rin naman pamantayan na pag mahal sumingil ang hospital eh magagaling na ung mga doctor nila! Papaano ba mag tiwala, lalo na kung buhay ang nakasalalay? kailangan bang, hingan ung mga doctors ng kanilang college grades para lang tayo mag tiwala, hindi ba pwding yong mga school na ang mag sala at kung san sila mag re residente? pwd bang wag ipasa ung walang compassion at tyaga at dunong? Pwd bang 1st year palang nang medicine eh isabak na sa training, at ang di matyaga, wag nang tanggapin pa….. kawawa naman kaming me mga sakit, ipangungutang ang pagpapagamot tapos mamamatay lang kasi di marunong ung napuntahang doctor?

  5. There are doctors I now call HMO doctors un hindi man lang chineck ung lalamunan mo pero irerefer ka sa infectious diseases expert when you have given all the real reasons why you got a fever in the first place. T_T I just hope they were wiped into shape and become better doctors because LIFE is not a video game you can play with or pause when you are trying how to cheat DEATH

  6. Although I may not be a good representative of interns as a whole, especially since i come from the “pampered internship” of you know where, I feel so sorry for the intern in this entry. Poor him/her, unknowingly perceived as a mediocre when in reality (only God knows), he could be working 100x as hard just so he could prove himself otherwise. Lahat naman tayo I guess, naisip natin the night before while doing our reports na mukhang “ito na yung best presentation na nagawa ko EVER” pero pagharap sa resident/consultant, marami pa ring butas, marami pa ring gusot, maraming imperfections. But that doesn’t mean na hindi man lang sumubok yung intern na yun.

    Noong nag-code yung pasyente mo na hinatid mo sa Radiology department, hindi ba iniwan mo siya dun? Gusot. Imperfection. Medocrity. Pero in reality, iniwan mo siya to ask for help diba? Maybe this is just a way, yes, in some twisted alternate universe, of asking for help. Dagdag mo pa na resident interns’ monitor ka pa. Baka ikaw lang ang susi para yung “good enough” na hinahanap mo ay maging GOOD ENOUGH para sa lahat. Nakatulong ka pa. :) Nudge. Baka yun lang yung hinihintay.

  7. Hi. I’m an incoming irregular 3rd year med student. I failed Surgery. My grade was near the “lowered passing grade” so I was originally sad. I’ve accepted it already after days of crying. And tonight I was reading your blog and found this article. First time that I felt that it was actually okay that I failed Surgery because my “near to the lowered passing grade” was never good enough. Binabaan na nga ang passing pero bagsak pa din.

    I will be a year late in graduating. Sad, yes, but after reading this, I realized na tama nga naman. Kesa naman naipasa nga ako pero halata namang hindi ko natutunan ang dapat kong matutunan. I will probably enjoy Surgery in my next take (siguro naman na no!)

    Weird ko, bumagsak na at male-late na sa pag graduate pero sumaya when I read this article. Haha

    Thank you.

    God bless.

  8. Nahihiya ako sa sarili ko dahil tinamaan ako sa mga salitang binitiwan mo tungkol sa current system ng medical education. However, this is true. I’m only learning just to pass but I’m blinded about the future. Masyado akong na-confine sa mentality na ayokong bumagsak kaya ako nag-aaral pero hindi ko naman naiintindihan pagkatapos ng mga exams kahit pumapasa ako.

    Nahihiya ako dahil I am mediocrity personified. This is a wake up call, Dr.
    Hence, I will strive to become one of the best doctors in my generation. Someday, five years from now, I wanted to meet you in the wards and shake your hand, saying, “Thanks for helping me to become the doctor who I am today.”

  9. Naranasan ko po yan sa isang malaking private hospital sa Makati.

    Yung interns, parang ang susungit, text lang ng text. Tapos hindi marunong magtusok ng karayom (nakaapat na tusok sa akin), di daw nila mahanap yung ugat ko.

    Samantalang yung older doctor sa room na nag CT-scan, isang tusok lang sa akin, nakuha agad.

    Ewan ko kung nakarating sa management yung feedback ko.

    They should always show empathy sa may sakit, natry ko na ring magpaadmit sa isang maliit na hospital sa QC, pero lahat sila mababait, from OB, anaesthesiologist, nurse up to the janitors, pati yung may ari ng hospital bumibisita.

  10. The system has changed. Most medical schools somewhat pamper their students. I think it was already mandated that interns are no longer allowed straight 24 hour duties. And at my alma mater, I don’t know if this is still the case, Residents are no longer allowed to give demerits to clerks and interns. So medical students can now coast through, without too much effort. Naniniwala ako na yung mga paghihirap na dadaanan mo habang nasa med school ka pa ay ang magtutulak sayo na lalo mo pang pag-ibayuhin ang sarili mo. Makikita mo ang mga kahinaan at pagkukulang mo.

    I was also tasked to be the interns monitor during residency. I try to instill in my interns to always excel in everything that they do. Hindi naman para sa kanila lang yun, kundi pati sa mga pasyente nila. There is no such thing as a benign rotation, I always tell them. Hindi dahil Radiology ang rotation benign na so minimum effort. I can only hope that I was able to get my message through to them.

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