(Publisher's Note: I stumbled upon this one beautiful piece written by Gigi Parreno, a crazy confident neurosurgeon who happens to be my good friend, classmate in UP Med School and during our residency days in UP-PGH, bump at each other frequently in the OR and hallways doing all those "same shit different days" stuff. You gotta love this lady's wit and humor. You can read her original article written here. )

Every year for the past 4 years I would write an essay to enumerate remarkable events or ideas that helped define the number of years I've lived on earth. When I first started, I never thought it would become a personal tradition. But then, I found the self-reflection so cathartic and truly emancipating. At this point, every numerical addition is a form of appreciation, another symbol of my maturity. So I celebrate it and I embrace it.

I would say that this year I have been awed at the butterfly effect that has lead me to where I am, so much so that in a figurative sense, I momentarily stopped flapping my wings and made a reconnaissance of my environment. I needed to stop in order to find my direction. After all, I have already lived half of my life and I certainly would like to make the next half more productive, more fulfilling, more glamorous. It was the right thing to do and I am glad I made that choice.

A few months into my neurosurgical residencyl, I remember a conversation I had with Andy Kanner while we were scrubbing in the OR's ante-room. He asked me, "Aren't you excited about this?" So I told him that I was very tired but yes, every run-of-the-mill craniotomy makes me excited in some way." He mentioned a quip from a TV series which said that participation in brain surgery is a very uplifting experience, better than taking drugs. I said that my take on that would be that as a resident, even if it looked like all energies were sucked out of me from working endlessly, I was still thankful for the fact that we had come that far. "Look, med school duped us into painstakingly memorizing useless information including the life cycle of parasites, among other forms of torture. But, after enduring all that, here we are actually doing the most exciting form of stuff which the regular doctors would never come to experience and at most – observe." Then we entered the OR and did the surgery more vivaciously.

During one of my breaks, I did a Grey's Anatomy DVD marathon. It was in a fictional setting but still, I was amazed that it depicted most of the experiences that I and my co-residents were going through. I could relate to Meredith Grey's alter ego. Clearly, my life was less complicated than hers and I didn't have a Jewish best friend named "Christina". Likewise, I relished the fact that I was the only girl in macho territory. How cool is that? Anyway, regarding the things she said, or what the screenwriters put in her mouth, these were my rants. I couldn't agree more.

At some point I told Andy that he looks like someone I know but I couldn't figure out who. "Okay," he said, "just go to me again once you remember." When the Eureka moment came, I almost burst, "Andy, you look like Patrick Dempsey in Grey's Anatomy!!!" He innocently replied, "It's funny that my wife's friends keep on telling me the same thing."

Hahahahaha!

Henceforth, Andy Kanner, you shall be officially referred to as tadaaa… McCreamy.

Oh yes, those were the days indeed… for every day, Haim, the brawniest and tallest of us, would enter the residents' room and say, "Same shit, different day. Once you go black, you never go back." What a wise remark! He was absolutely right. Now, all I have are memories. Of course, I wouldn't want to go through the residency thing again. It belonged in my youth and right now my priorities have changed. Let me repeat that, my priorities have changed. Yet I can't help but I feel sad. I miss the shit – or whatever Haim referred to it.

McCreamy, thanks for the very empowering email you sent me last week. It was a surprise to know that you are still interested. We have to finish what we have started. They are at least 6. Let us make it happen this year and I really mean it. Seriously.

As I turn over a new leaf and prepare to boldly blaze yet another trail this is my long overdue official closure to that phase and I dedicate this to 35 people in Facebook who have been part of it.

35 Mary Grace Anatomy
Seriously? Seriously!

1. Kaloy Aleta – This is not alphabetical but Trauma was my first rotation and you were my boss. Never fear, Dr. Aleta is here.
"Each of you who comes here today, hopeful, wanting in on the game. A month ago you were in medical school being taught by doctors. Today you are the doctors. The 7 years you spend here as a surgical resident will be the best and worst of your life. You'll be pushed to the breaking point. Look around you. Say hello to your competition. This is your starting line. This is your arena. How well you play, it's up to you."

2. Aviad Rosenberg – You are kind-hearted and you will be a great surgeon!
"I can't think of any one reason why I wanna be a surgeon. But I can think of a thousand reasons why I should quit. They make it hard on purpose. There are lives in our hands. There comes a moment when it's more than just a game and you either take that step forward or turn around and walk away. I could quit. But here's the thing. I love the playing field."

3. Ioanna Retsou – I dedicate this quip to you because you always see new things with childlike awe and wonder.
"That was amazing! You practice on cadavers, you observe and you think you're gonna know what you'll feel like standing on that table. But that was such a high! I don't know why anybody does drugs."

4. Andy Kanner – Thank you for your wisdom. As what I said, WE WILL MAKE ALL OF THEM HAPPEN THIS YEAR. Now allow me to replay my own drama...
"It's not easy for me to be away from the OR. It's not easy for me to sit in front of you and any other authority figure for that matter, of not being able to give you the exact answer you wanna hear. I'm the one with the answers. I'm always the one with the answers, but right now, sir, I don't have any. How do you keep your edge, sir? Because I've watched you and you've been doing this a long time and you're clean. You're focused. Nothing gets to you. The thing is, sir, I was like that until I got here, until I actually started doing this job. Now everything is fuzzy. You see, sir, this is the point, because I can't tell you what happened in that room. I can't tell you and before I could have – no guilt, no loyalties, no problem. Before, I wouldn't even have been in that room. I wouldn't have gotten involved. I would never have frozen in surgery and I would have told them what I thought they should do. I had an edge, sir. I had an edge and I've lost it and I need it. I need it back. So if you could just tell me how you keep yours and how not to be affected. I know I could be a great surgeon. So if you could just give me the answers, I would really appreciate it."

5. Sheryl Castro-Flores – You will always be the heroine.
"Every patient's story starts the same way. It starts with them being fine. It starts in the "before". They cling to this moment, this memory of being fine, this "before", as though talking about it may somehow bring it back. But what they don't realize, the fact that they're talking about it to us, their doctors, means there's no going back. By the time they see us they're already in the after. And while every patient's story starts the same way, how the story ends depends on us, on how well we diagnose and treat. We all know the story hinges on us and we all want to be the heroes."

6. Haim Ezer – Thanks for saving my ass. Did you actually say this?
"Don't mingle with the ER people. They don't know their ass from their esophagus."

7. Haim Ezer – Once again, I dedicate this to you because you are a "tour de force" and you will always be my idol.
"Surgeons – nasty, aggressive, unstoppable; just the kind of people you want to be on your side when you're really screwed."

8. Amy Labor – Sister, I'm so proud of you for taking a leap of faith.
"Several hundreds of years ago, Benjamin Franklin shared with the world the secret of his success – never leave that till tomorrow what you can do today. Sometimes, the fear is just of making a decision because what if you're wrong? What if you're making a mistake you can't undo? Whatever it is we're afraid of, one thing holds true. That by the time the pain of doing the thing gets worse than the fear of doing it, it looks like we're carrying around a giant tumor.

The early bird catches the worm. A stitch in time saves nine. He who hesitates is lost. We can't pretend we haven't been told. We've all heard the prophets, the philosophers; heard our grandparents warning us about wasted time; heard the damned poets urging us to seize the day. Still sometimes, we have to see for ourselves. We have to sleep today's possibility under tomorrow's rug until we can't anymore, until we finally understand for ourselves what Benjamin Franklin meant… that knowing is better than wondering, that waking is better than sleeping and that even the biggest failure, even the worst and most intractable mistake, beats the hell out of never trying."

9. Paul Castillo – Those were the days, my friend.
"You're interns, grunts, nobodies, bottom of the surgical food chain."

10. Revital Barelly – We have accepted it already & I'm glad we lived colorful lives outside the hospital.
"Stop whining. You'd rather be here and you know it. What d'ya got waiting for you at home? Boyfriend? A girlfriend? A pet? Family?
– a bed.
We've got plenty of that in here. I don't feel sorry for you. This is who we are. This is our lives. "

11. Udi Miller – Aroma therapy, Motek, aroma therapy.
"If he doesn't remember me, if he doesn't remember what we are, he's still mine and I'll remember for us both."

12. Elma Laguna – Miga, thanks for catching me during my Lukresia moments.
"Surgeons are control freaks. With a scalpel in your hand, you feel unstoppable. There's no fear. There's no pain. You're 10 feet tall and bullet-proof… and then you leave the OR and all that perfection, all that beautiful control, just falls to crap. No one likes to lose control. But as a surgeon, there's nothing worse. It's a sign of weakness, of not being up to the task, and still there are times when it still gets away from you, when the world stops spinning and you realize that your shiny little scalpel isn't gonna save you. No matter how hard you fight it, you fall and it's scary as hell, except here's an upside to free-falling. It's the chance you give your friends to catch you."

13. Dennis Lorca – Pards, hinay-hinay lang tayo.
"The key to surviving a surgical internship is denial. We deny that we're tired. We deny that we're scared. We deny how we want to succeed and most important of all, we deny that we're in denial. We only see what we want to see. We believe what we want to believe and it works! We lie to ourselves so much that while the lies start to seem like the truth, we deny so much that we can't reconcile the truth right in front of our faces. Sometimes reality has a way of sneaking up and biting us in the ass. And when the dam bursts, all you can do is swim. The world of pretend is a cage, not a cocoon. We can only lie to ourselves for so long. We are tired. We are scared. Denying it doesn't change the truth. Sooner or later, we have to put aside our denial and face the world head on, guns blazing. Denial – it's not just a river in Egypt. It's a freaking ocean."

14. Marlon Lajo - What I remember most about you is summed up in one syllable - BREAST. You were my vice chief in GS 1. (What were you thinking?)
"It's a beautiful day to save lives, people. Let's have some fun."
"The fact is, we all have little superstitious things that we do. If it's not believing in magic statues, it's avoiding sidewalk cracks or always putting our left shoe in first. Knock on wood. Step on a crack. Break your mother's back. The last thing we want to do is to offend the gods. Superstition lies in the space between what we can control and what we can't. Find a penny, pick it up and all day long you'll have good luck. No one wants to pass up a chance for good luck. But does saying it 33 times really help? Is anyone really listening? And if no one is listening, why do we bother doing those strange things at all? We rely on superstitions because we're smart enough to know we don't have all the answers and that life works in mysterious ways."

15. Nurit Bedussa – Someday we are going to be famous apart from already being fabulous.
"The key to being a successful intern is what we give up – sleep, friends, a normal life. We sacrifice it all for that one amazing moment, that moment when you can legally call yourself a surgeon. There are days that make your sacrifices seem worthwhile … and then there are days when everything feels like a sacrifice… and then there are the sacrifices you can't even figure out why you're making."

16. Ido Strauss – It is what it is.
"After a while, the ways of residency become the ways of life.
No. 1 – Always keep score.
No. 2 – Do whatever you can to outsmart the other guy.
No. 3 – Don't make friends with the enemy.
No. 4 – Everything – everything – is a competition.
Whoever said winning isn't everything never held a scalpel.
No. 5 – It's not about the race at all. There are no winners or losers. Victories are counted by the number of lives saved… and once in a while, if you're smart, the life you save could be your own."

17. Evgeny Reider – When time freezes, let's play some music.
"Fifteen minutes. Fifteen hours. Inside the OR the best surgeons make time fly. However, time takes pleasure in kicking our asses. For even the strongest of us, it seems to play tricks, slowing down, hovering until it freezes, leaving us stuck in a moment, unable to move in one direction or the other."

18. Trish Pamintuan-Gopez – You know better.
"Don't take it personally. It's the doctor thing. Four years of high school, four years of college, four years of med school. By the time we graduate we're in our late 20's and we haven't done anything except go to school and think about science. Time stops and we're socially retarded."

19. Ama Asuncion – I believe we will find our place as our dreams come to us.
"At some point during surgical residency, most interns get a sense of who they are as doctors and the kinds of surgeons they're going to become. If you ask them, they'll tell you they're going to be general surgeons, orthopedic surgeons, neurosurgeons – distinctions which do more than describe their areas of expertise. They help defined who they are because outside the operating room, not only do most surgeons not have an idea of who they are, they're afraid to find out."

20. Cecille Cayetano – It's like what you said.
"In life only one thing is certain apart from death and taxes. No matter how hard you try, no matter how good your intentions, you are going to make mistakes. You're going to hurt people. You're going to get hurt. If you ever want to recover there's really only one thing you can say – I forgive you.

Forgive and forget. That's what they say. It's good advice but it's not very practical. When someone hurts us, we want to hurt them back. When someone wrongs us, we want to be right. Without forgiveness old scores are never settled, old wounds never heal and the most we can hope for is that one day we'd be lucky enough to forget."

21. Jojo Melendres – We are stronger and more resilient than we think.
"There's this thing about being a surgeon. Maybe it's the pride. Maybe it's about being tough. But a true surgeon never admits they need help unless absolutely necessary. Surgeons don't need to ask for help because they're tougher than that. Surgeons are cowboys – rough around the edges, hard core. At least that's what they want you to think."

22. Vicky Narcisio – Thanks for all the positive reinforcements.
"There's this person in my head. She is brilliant, capable. She can do chest tubes and craniotomies, run a code without freaking out. She's a really good surgeon, maybe even a great surgeon. She's me, only so much better."

23. Monika Niedermayr - Thanks for being on my side. I miss you, schwester.
"The problem with being a resident is - you feel crazy all the time. You haven't slept in years. You spend every day around people in massive crisis. You lose your ability to judge what's normal in yourself or in anyone else and yet people are constantly asking you to tell them how they're doing. How the hell are you supposed to know? You don't even know how you're doing."

24. Jay Estoya – You're a fixer and you know it.
"As surgeons we are told to fix what's broken. The breaking point is our starting line at work. But in our lives, the breaking point is a sign of weakness and we do everything we can to avoid it. Bones break. Organs burst. Flesh tears. We can sew the flesh, repair the damage, ease the pain. But when life breaks down, when we break down, there's no science. There are no hard and fast rules. We just have to feel our way through… and for a surgeon there's nothing worse and there's nothing better."

25. Remo Aguilar – Pre, I will always agree with you and you know that.
"It takes a certain brand of crazy to come up with an idea like drilling into somebody's skull. But surgeons have always been a confident bunch. We usually know what we're doing and when we don't, we still act like we do. We walk boldly into undiscovered country, plant a flag and start worrying people around. It's invigorating and terrifying."

26. Arik Zaretzki – When something is wrong, everything goes wrong.
"For a surgeon every patient is a battlefield. They are terrain where we advance, retreat, try to remove all the lands. And just when you think you've won the battle and made the world safe again, along comes another landmine."

27. Tal Shahar – Do we have a choice?
"It's intense what happens in the OR, when lives are on the line and you're poking at brains like they're silly putty. You form a bond with the surgeons right next to you, an unbreakable indescribable bond. It's intimate being tied together like that. Whether you like it or not, whether you like them or not, you become a family."

28. Grace Maaño – Fed Ex me what I Fed Ex-ed you so we can put an end to this.
"If life's so hard already, why do we bring more trouble to ourselves? What's with the need to hit the self-destruct button? Maybe we like the pain. Maybe we're wired that way… because without it, I don't know. Maybe we just wouldn't feel real. What's the saying? Why do I keep hitting myself with a hammer? - because it feels so good when I stop."

29. Thaddy Averilla – A big hug to you.
"Medicine doesn't lend itself well to the making of friends, maybe because life and mortality are in our faces all the time; maybe because in staring down death everyday we're forced to know that life, every minute, is borrowed time, and each person we let ourselves care about is just some more loss. For this reason, I know some doctors who just don't bother making friends at all. But the rest of us, we make it our job to move that line, to push each loss as far away as we can."

30. Zvi Ka – Thanks for trusting me to screw, I mean, putting at least 3 odontoid screws. I miss you already, I could cry.
"Choosing who gets the first solo surgery is not just about surgical skills or who’s logged the most hours in the OR. It's about the highest form of trust – the trust to put a patient's life in one of our residents' hands."

31. Tanya Lara & Cecil Dajoyag – Let's always outrun ourselves - whatever that means.
"Every surgeon I know has a shadow, a dark cloud, a fear that follows even the best of us in the OR. We pretend the shadow isn't there, hoping that if we save more lives, master harder techniques, run faster and farther, it'll get tired and give up the case. But, like they say, you can't outrun your shadow. Every surgeon has a shadow and the only way to get rid of the shadow is to turn off the lights, to stop running from the darkness and face what you fear - head on."

32. Lilia Jose – You go, girl! "To be a good surgeon you have to think like a surgeon. Emotions are messy. Tuck them gently away and step into a clean, sterile room where the procedure is simple. Cut. Suture. Close."

33. Leo Ona – I'm missing you in the middle of the Pacific Ocean.
"My mother used to say this about residency, "It takes a year to learn how to cut. It takes a lifetime to learn not to." Of all the tools in the surgical tray, sound judgment is the trickiest one to master. Without it we're all just toddlers running around in 10 blades."

34. Shmuel McBlow – Move on and move up, palangga.
"Surgeons are all messed-up. We're butchers – messed-up, knife-happy butchers. We cut people up. We move on. Patients die on our watch. We move on. We cause trauma. We suffer trauma. We don't have time to worry about how all the blood and death and crap really makes us feel. It doesn't matter how tough we are. Trauma always leaves a scar. It follows us home. It changes our lives. Trauma messes everybody up. But maybe that's the point. All the pain and the fear and the crap, maybe going through all of that is what keeps us moving forward. It's what pushes us. Maybe we all have to get messed-up before we can step up."

35. Jaynee Saure – Cheers!
"We made it through this day!"

I must admit, I'm a bit compulsive and sometimes painstakingly freaked whenever one of my closest person get sick or is undergoing a surgical procedure. In our family, I'm the only medically inclined person. Being a go to medical guy in a family felt like a whooping responsibility. Yes it is. The three or four surgeries my mom and sis went through plus the numerous getting sick moments of other family members exact a heavy toll on my stress scale. Not even my MD could ever down play such effect. On the other hand, being an MD tips the balance towards near compulsion and attention to details. Why? Frankly, I don't know.


Of course our training helps, especially in the part where you plaster an emotionless face to keep cool. I've mastered that art I can even harbor the burden of my patients and still cut and sew cold thereafter. Yes,we play the hands of god to heal. For that we need a calm fluid sewing hands As one good surgeon would tell me, you can never be a real surgeon unless you went through the knife yourself. Then suddenly it dawned on me. The closest thing (yet) for me to go under a knife(god forbids) is for my closest people to go under the knife. Right now, for the nth time my mom is.

Her past surgeries were all emergencies. The decision making is emergent, the preparation is shorter and the choices close to nil.You're left to a single emergent choice and then pray she'd wake up outside of the slim "margin for error". So you'd think a minor elective surgery (like cataract) is plainly the opposite of the former? Better preparation, more choices and therefore less risks? Heavens no! With such wider margin for error comes the greater responsibility and risk of not missing any slightest detail. You bought only time to prepare, and therefore reduce the risks. But after that, it is still a surgery. If you miss something on the preop, given the longer preparation you have chances are the results would be a catastrophic guilt for the family. In a closely knit family culture of th e Filipinos, the guilt is pretty much an issue I believe.

So never mind if my mom is diabetic with beginning retinopathy. Never mind if she has had 3 major surgeries before and countless other hospital admissions due to some sickness. Never mind she survived all of those. When your face by this same predicament and even on better circumstances, no surgery is still minor. Especially, if it's your mom is on the receiving end of a surgeon's knife.

So I go on with my usual compulsion to detail,  to my often obnoxiously redundant reminders of doing this and that pre-op. To most this might be an overkill, but If I were the patient, I'd love my surgeon to do so for me. That extra effort gives me a little security about my surgeons care for me.


This is one of the good  insights I learned from my mom's procedures. You feel for your patients, you put yourself in their situation and imagine the best option your surgeon can offer. I always apply them to my patients. I teach this to my residents. Stressful? Yes it is. But who said the life of a surgeon is easy anyway?

So thank you mom. For undergoing the knife for me. You help mold a better surgeon in me.

SurgExperience, the online surgical grand rounds,  is up already in Scan Man's Notes. Surgexperience 310 enumerates a plethora of blog post that will definitely raise you brows on issues- from politics of health care to semantics of weird care!

This question was thrown to us by one former orthopedic mentor during our lively deli-beer-ations post surgery. The discussion came about as we were thanking them for extending time and effort to do an instructional course on their field of specialty. I added that these orthopedic courses should bring up the level of our general orthopedics training and entice some residents to go on a sub specialty training. I added that this is one of the training  thrust of our department  Commending our training program, he then posted these question to us:

1. Does your locality need  super specialist orthopedic surgeons? Do we have sufficient orthopedics cases to sustain this super specialist field?
2. How many (percentages)of these sub specialty cases are done by generalist orthopods themselves?
3. Having trained in a general orthopedics program, can do these cases even without sub specialty training?

The question went further into this. "Do you need a super generalist (should mean a generalist with a higher level of skills and expertise on all areas of orthopedics) or a super specialist (capable of doing rare cases but couldn't do other general orthopedic surgeries) orthopedic surgeons?

The super generalist is commonly a product of an institution with a multi specialty orthopedics in place. The various sub specialty rotation gave these residents an "edge" receiving a "higher" level of training in all orthopedic sub specialties. Some institutions only have a few of these sub specialty training and thus a general orthopedic can only gain more skills by training elsewhere where a specific sub specialty training is available.

For sure, we wanted our program to produce better orthopedic surgeons, a super generalist in a sense. A generalist with a higher and broad level of skills not just in one orthopedic sub specialty but in all other as well.To do that, we need to complement our teaching staff with orthopedic sub specialist, a kind of irony but necessary step towards achieving this goal.

In just about a year and half of teaching orthopedic residents, I became interested in finding out which of the more familiar teaching styles works best for our crop of trainees. Honestly, I'm still continually experimenting.

The unique set up with which medical-surgical training programs thrive is continually changing. With the influx of medical information everyday, a program has to adapt to the call of time and for greater efficiency in preparing this 'padawans into full pledged surgeons.It is not simple as it seems however since in this unique set up and unlike the usual academic, lab rat experimentation, a mistake might cost someone else life.

The "Master-Apprentice" method ( probably the more popular and is what I'm familiar with) involves  the "master" (attendings) showing the "apprentice" (residents) his way of doing things (skill) for a certain given situation or problem. Such teacher-student relationship is basically anchored on the assumption that the master is more experienced and adept than apprentice. This is usually an "I teach, you follow" approach to learning. One advantage of this approach is the specific skill imparted by the master to his apprentice for any given orthopedic problem. The obvious disadvantage is its limited applicability and the temptation to spoon feed a resident.

The rapid influx of modern technology and a deluge scientific evidence paved the way for a more radical, and holistic approach to learning in orthopedics. To the end of my training I was deliberately hammered by mentors to think rather than learn a specific skill, to criticize the validity of any information presented and above all, develop a logical framework for decision making process in any given orthopedic problem. Skills and techniques came in later as my mentors believe that modern technology will techniques change every 5 or so years. I am not an expert on education or teaching styles, but the latter method seems to work best for me. To my understanding, this sort of teaching style fall into the Socratic method of teaching. I'm really not interested into that. What I'm interested now is, if it'll work too for my residents?

In every opportunity I have with our residents, be it conferences and pre ops, I focus on continually challenging their minds,  make them think harder, analyze a given situation,  criticize an evidence, present facts properly and then develop a sound decision making process. Obviously, I'm not a fan of residents trying to impress attendings with techniques and implants when he can barely utter a word on the biomechanics involved in those implants. Often, the common excuse for residents (this is awful) is the absence of patients  logistics and financial support common among government hospitals. I actually do not contest that. What we want for residents however, is to incorporate these specifics into his decision making process so he can plan ahead for his patients surgery Lastly, I wanted my residents to empathize with their patients. One common question I throw in during pre-ops is this

If you we're the patient, what would you want your surgeon do to you?

 Usually this type of questioning gives the residents an idea as to the best option for the patient!

All of these teaching style have one thing in come though. To pass on knowledge to the new generation of orthopedic surgeons . In short, were training them to be surgeons not residents.


Will these teaching style work for our current residents? Personally, I don't know.Not yet, but perhaps in the future.