May 19 is World Hypertension Day.  How do you combat this disease?

H – Have a balanced diet.  Not just fruits and vegetables, but a delicate variety and balance of carbohydrates, fats, and proteins as well.  And yes, just a little taste of sweets and fatty foods once in a while to relieve stress, but don’t overdo it.

Y – Yearly cholesterol monitoring.  Even if you don’t feel any symptoms, it is good to have your blood cholesterol and triglyceride levels monitored annualy starting at age 35.  Remember: high cholesterol is directly correlated to increased risk for heart diesease and stroke, and it could escape detection if not monitored.

P – Pressure check.  It doesn’t take much effort to run to the nearest health center once in a while for blood pressure monitoring.  It also does not hurt to have an electronic blood pressure monitoring device at home.  Just make sure it is always calibrated and the batteries are not worn out.

E – Exercise.  Be active and sweat a little.  This will strenghten your heart muscles and make your blood vessels more compliant, leading to better circulation.

R – Relax.  Avoid getting stressed out.  Remove all your hang-ups, hurts, and hatefulness.

T – Talk to your doctor.  Take medications when needed.  Treatment must not be delayed to avoid complications.

E – Ease up on the alcohol.  Binge drinking stresses the heart and leads to heart failure in the long run.

N – Na.  This is the symbol for sodium, which is present in salt.  Avoid too much salt, because it retains fluid and overloads the heart muscle.

S – Sleep.  A rested mind with adequate sleep keeps epinephrine levels down, which reduces vasoconstriction and improves blood flow to the tissues.

I – Identify your health history.  If you have family members with hypertension, be more vigilant.

O – Omega 3 supplementation.  Population studies and clinical trials provide compelling evidence that omega-3 fatty acids have cardioprotective effects.  One gram a day may be all that you need.

N – No to smoking.  It does not just prevent hypertension, but most other degenerative diseases as well.




May is Cervical Cancer Awareness Month.  What must one know about this disease?

C – The affected organ in cervical cancer is the cervix.  This is not located in the cervical area of the spine (the neck area), but the lower third portion of the uterus that opens into the vagina. The narrow opening referred to as the cervical os closes to help keep the fetus in the uterus until birth.

E – Epithelium.  This is the thin layer of cells on the surface of the cervix.  The changes in these cells are monitored when one undergoes a Pap smear.  It is important to detect early changes to the cervical cells which may lead to cancer, so a Pap smear is a very important diagnostic tool.

R – Rich less affected.  Most people who die of the disease come from the lower income classes.  This is because those from affluent societies have better access to screening tests.

V – Virus.  The causative agent of cervical cancer, called the Human Papillomavirus (HPV), is one of the most common sexually transmitted viruses in the world.

I – Intercourse.  During unprotected intercourse, the virus may be transmitted.  Thus, sexual promiscuity is a risk factor for the development of cervical cancer.

C – Common.  Cervical cancer is second most common cancer in women.  It affects about 16 per 100,000 women per year and kills about 9 per 100,000 per year.  Approximately 80% of cervical cancers occur in developing countries.

A – Acetic acid.  Visual inspection of the cervix with acetic acid allows doctors to directly see lesions and other changes in the cervix.  The health practitioner simply swabs acetic acid, the active ingredient in vinegar, on the cervix and looks for areas that change color.  This is a very important procedure for screening among those who have limited access to a Pap smear.

L – Lugol’s iodine.  Although this reagent, together with acetic acid, is less specific than Pap smear in the detection of cervical cancer, it is more sensitive.  This means that more false positive results may come out which can lead to overdiagnosis and overtreatment.  Public health workers, however, believe that the risk for overtreatment is acceptable, considering the greater risk of dying from the disease.

C -Colposcopy.  If the Pap smear result is found to be abnormal, a physician may order this test for better visualization of the cervix.  He or she may also do a biopsy for suspicious lesions.

A – Anemia.   Iron deficiency and tumor bleeding are common causes of anemia in cervical cancer. The presence of anemia is a negative prognostic factor, and its control and treatment improves disease prognosis.

N – Nutrition.  Although some studies on cervical disease and diet suggest that intake of dark green and yellow vegetables, beta-carotene, and vitamins C, D, and E can prevent cervical cancer, these studies are still inconclusive.  The best way to prevent cervical cancer is immunization with human papillomavirus (HPV) vaccine. The bivalent HPV vaccine (Cervarix) prevents the two HPV types, 16 and 18, which cause 70% of cervical cancers.  The quadrivalent HPV vaccine (Gardasil) prevents HPV 16, 18, 6, and 11.  Gardasil prevents genital warts and also protects against cancers of the anus, vagina and vulva.  Both vaccines are administered in 3 doses.

C – Chemotherapy. Chemotherapy is used to reduce tumor growth during the later stages of cervical cancer.  Chemotherapy medicines may be taken by mouth (orally) or injected into a vein (intravenous, or IV).

E – Eva Peron.  The second wife of former Argentina President Juan Peron died of cervical cancer.  Evita, as she is more popularly known, was the first Argentine to undergo chemotherapy for the illness.

R – Radiation therapy.  Radiation treatment is given during the early stages of cervical cancer.  It is given as external beam radiotherapy to the pelvis, or via internal radiation or brachytherapy.


Health care systems

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“You were born to win, but to be a winner, you must plan to win, prepare to win, and expect to win.”

Zig Ziglar

I just attended the opening ceremonies of the Philippine Academy of Family Physicians (PAFP) Annual Convention.  This year’s theme, “The Family Physician: C.H.A.M.P.I.O.N. of Filipino Families”, aptly describes the mission of the academy.  In a nutshell, the acronym  C.H.A.M.P.I.O.N. signifies doctors who share Common values  whose Collaborative efforts result in the creation of Health Policies that benefit others in an atmosphere of Academic  Excellence.  Family doctors must also Manage health care resources as Primary gatekeepers practicing cost-effective care without compromising Patient Safety.  Information Technology is also utilized to deliver Overall holistic care, with New knowledge being generated through research studies.

While the mission is full of idealism and passion for the healing art, the question still remains:  Can Health And Medicine Persevere Inspite Of Negativity?  Are our dreams of a better country hopeless in the face of the brain drain that still prevails, luring the best and the brightest doctors of the land to practice outside the Philippines?

In my opinion, here are the steps that must be taken to truly upgrade our health care system.

1.  COMPENSATION for physicians must improve.  Our doctors only earn an average of Php 20,000 ($450) a month.  And I say AVERAGE, which means some earn even less on a monthly basis.  Call center agents earn even more than some physicians.

2.  HMOs must bring their act together.  Our health maintenance organizations have policies that leave much to be desired – late payments, low coverage amounts for members, and too much meddling on the private practices of doctors.  Hopefully, HMOs can become more accessible to the general public, and be more physician-friendly.

3.  ACADEMIC overhaul.  The Philippine Medical Act of 1959 is now outdated.  We must start rethinking policies on Medical Education, Physician licensure, and the practice of medicine in the country.

4.  MEDICINES and drugs must be closely monitored.  The Cheaper Medicines Act needs some rethinking.  A lot of the generics drug out in the market are sadly lacking in bioequivalence studies.  The Food and Drug Administraion must look out for companies producing substandard drugs.

5.  PARTNERSHIPS must be strengthened.  The government and private sector must work hand in hand to improve the health care referral system.  Doctors must also learn the art and science of relating to fellow doctors, government institutions, and political leaders.

6.  INSTITUTIONS offering health care must be provided the attention it deserves through better funding.  The national budget allocates a mere 3% for health care.  It is not enough to keep our government hospitals and health centers clean, safe, and efficient.

7.  OVERCOME OBSTACLES in preventive care.  Immunization is just one aspect of disease prevention.  More important is patient education.  A major obstacle to progress is lack of knowledge.  We must empower communities to be responsible for keeping their constituents in the pink of health.

8.  NATIONALISM must be strengthened.  We must love our country and its people.  In particular, if the government subsidizes a doctor’s education, it is but right for the doctor to give back to the community.  Our patriotic duty to this country must be balanced with our need to progress and prosper.

In the final analysis, to be a champion, we must not just plan.  We must act.  Our plans may not be perfect, but action beats inaction.  After all, champions are crafted once they step into the field of battle to gain experience, not when they are asked to sit back and watch.


The art of medicine consists in amusing the patient while nature cures the disease.

Patient in ECMO

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Much has been said about making decisions and pursuing actions based on sound evidence.  In medicine, doctors are urged to use the best available evidence and not to rely on hearsay or unsubstantiated claims.  Today, with all the technology and equipment available, it has become faster and easier to collate data and execute decisions based on the data gathered.

Evidence-based medicine is a decision-making model that supposedly enables us to make critical decisions. It requires meticulous data gathering and research before making healthcare decisions. Such decisions include clinical decisions about choice of diagnostic tests, treatment, or risk management for individual patients, as well as policy decisions for groups and populations.

However, evidence-based medicine has its limitations.  It may be able to answer queries on probabilities of benefit or harm, but it cannot completely explain details on mechanisms or people’s feelings.   Thus, evidence-based medicine is helpful for deciding whether to carry out certain procedures, but it is not very helpful for finding out how a patient feels today, or why a particular atom or behaves the way it does inside the human body.

Many patients have multiple diagnoses and problems. Diagnosis alone is a poor predictor of treatment outcome. Personality characteristics and social circumstances influence therapeutic response.  While evidence is important, we must remember  that we treat human beings with emotions, fears, and anxieties.  There are also other factors to consider such as finances and social support systems.  All these come into play when making treatment plans, and clinical experience plays a big role in holistic healing. If medical management were solely based on statistically measurable standards of evidence, then our training programs will no longer need experienced physicians.  Just give every student access to the Cochrane library and they will be able to treat a disease.

The personal qualities of the physician have an important bearing on patient satisfaction.  Sophisticated clinical expertise with regard to an individual patient needs to be balanced with evidence. It is my belief that too much emphasis on a narrow range of acceptable evidence oversimplifies the complex nature of clinical care.  Medical care must not come to a point where a patient would rather log on to a computer and follow the process flow.  After all, medicine was, is, and will always be a relationship business.



The Lexus and the Olive Tree

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A great democracy must be progressive or it will soon cease to be a great democracy

Theodore Roosevelt

Another day of legal hearings on the true condition of ex-president Gloria Macapagal Arroyo are on the table today.  The bickerings between personalities go on, citing constitutional rights, human rights, rights to confidentiality of medical records, and whatever rights come to the mind of the orators.  While this is ongoing, other issues remain.  The Maguindanao massacre continues to progress at snail’s pace.  A new province in the Bicol region is being created, apparently with the goal of resolving some political territorial issues.  The problem of insurgency in isolated sections of Mindanao (which I think is a beautiful place and is relatively peaceful in most areas) persists, and there is no end in sight.  All these are placing a dent on our democratic institutions.  Is something wrong with our people?  Or is the constitution on which our democracy is based flawed in the first place?

In The Lexus and the Olive Tree, Thomas Friedman coined the statement called “MIDS”, or Microchip Immune Deficiency.  This microchip, in political terms, may represent a country’s system of government as defined by its constitution. He says that this is a disease that can afflict any bloated, overweight, sclerotic political system in the post cold war era.  Friedman states that government needs to put in place processes for the democratization of technology, finance, information, decision making and power. They need to improve productivity, wages, quality of life, knowledge use, and competitiveness in order to survive the onset of globalization. If a country fails in doing this, they will not be able to compete, and its roots could be traced to a populace that is dictated upon due to lack of education.

I believe in progress.  But for progress to happen, there must be an educated public.  Sadly, our teaching institutions are deteriorating.  No Philippine University was able to make it in the list of the top 300 universities in the world.  We are losing our MDs and PhDs to other countries.  Our research output leaves much to be desired.  Students tend to cease educating themselves after getting diplomas and focus on economic upgrades instead, which is more “showy” and “cool” than intellectual upgrades.  I have a feeling that too much materialism and capitalism is creeping in, without the necessary moral and educational foundation to support and sustain economic progress.

Let us put an end to systems based on personalities political clout.  Instead, let us educate ourselves on the technologies and ideologies needed to sustain a government that is both accountable and effective.  The Philippine populace is too hardworking and talented, and I believe that it would only be a matter of time before we realize our dream of being at par with the world’s best in terms of economy, education, sports, and natural resources.  But this could only happen if we put emphasis on improving our educational systems and putting the right teaching infrastructure in place.

After all, if democracy is a numbers game, we must make sure that everyone is equipped with the neurons to make a wise choice.


William Osler (1849 - 1919), Professor of Clin...

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“The physician’s goal  is “to cure sometimes, to relieve often, and to comfort always.”

–  Sir William Osler

Just recently, Hall of Fame boxing champion Joe Frazier passed away due to Liver Cancer.  Smokin’ Joe was Muhammad Ali’s nemesis in the “Thrilla in Manila“, one of the greatest heavyweight boxing matches of the 20th century.  In his final days, with curative treatment taking a back seat, news went around that Joe was under hospice care.  It brought a smile on my face, seeing how hospice care is now starting to emerge as a practice.  However, we may still need to strengthen research and information dissemination regarding hospice and palliative care among those outside the medical community.

Below are some of the latest research articles on hospice and palliative care.

  1. A study was done regarding the use of cancer screening procedures among patients with advanced cancer.  Such tests include mammography, Pap smear, PSA, and colonoscopy.  It was concluded that a number of patients with advanced cancer continue to undergo tests that produce little clinical benefit. This shows that those who are not familiar with palliative and hospice care principles are exposed to unnecessary tests that neither prolong life nor improve the patient’s quality of life.(Sima CS, et al.  Cancer screening among patients with advanced cancer.  JAMA. 2010 Oct 13;304(14):1584-91. )
  2. Palliative Care results in a 43% reduction in ICU admissions among patients with advanced disease, and a $464 reduction in direct hospitalization costs. (p < 0.001).   (Penrod JD, et al. Hospital-Based Palliative Care Consultation: Effects on Hospital Cost. Journal of Palliative Medicine. August 2010: 973-979)
  3.  A prospective, multisite study of 343 patients with advanced cancer revealed the following:

a.  Patients whose spiritual needs were largely or completely supported by the medical team received more hospice care

b.  High religious coping patients whose spiritual needs were largely or completely supported were more likely to receive hospice and less likely to receive aggressive care

c.  Spiritual support from the medical team and pastoral care visits were associated with higher Quality of Life scores.

(Source: Balboni, TA et al.  Provision of spiritual care to patients with advanced cancer: associations with medical care and quality of life near death. J Clin Oncol, 2010. 28(3): p. 445-52.)

4.  The reasons why patients do not enroll in a hospice care program include patient and family misperceptions regarding hospice care, lack of knowledge regarding hospice care services, and concerns regarding access to hospice care services.  (Why Don’t Patients Enroll in Hospice? Can We Do Anything About It? Elizabeth K. Vig, Helene Starks, Janelle S. Taylor, Elizabeth K. Hopley and Kelly Fryer-Edwards)

5.   Patients with cancer who died in an intensive care unit (ICU) or hospital experienced more physical and emotional distress and worse Quality of Life at the End of Life (all P ≤ .03), compared with patients who died at home with hospice.

6.  ICU deaths were associated with a heightened risk for posttraumatic stress disorder, compared with home hospice deaths

7.  Hospital deaths were associated with a heightened risk for prolonged grief disorder (21.6% [eight of 37] v 5.2%, compared with home hospice deaths.

8.  Subjects who had living wills were more likely to want limited care (92.7%) or comfort care (96.2%) than all care possible (1.9%).  This shows that advance care planning is crucial in providing direction for care at the end of life.  ( Silveira MJ et al.  Advance directives and outcomes of surrogate decision making before death.  N Engl J Med. 2010 Apr 1;362(13):1211-8.)

So what are the implications of these studies?  This just shows that being cared for by a hospice and palliative care practitioner at the end of life results in better quality of life, decreased medical expenses, and better social and spiritual support for patients and their caregivers.

It’s high time that we give hospice and palliative care the importance that it deserves.


Gloria Macapagal Arroyo, President of the Phil...

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“I am not convinced of any exceptional reason, circumstance or justification for us to grant request. There is no immediate and compelling necessity for the former president to seek treatment abroad as attested to by Health Secretary Enrique Ona…”

–  Justice Secretary Leila de Lima on her decision to disallow former President Gloria Macapagal Arroyo to travel abroad


So it’s final (or so it seems).  The Aquino government, through Justice Secretary de Lima, has decided to bar Congresswoman Gloria Arroyo from leaving the country.  The condition for which the former president is seeking treatment is called HYPOPARATHYROIDISM.

What is this disease all about?  To understand it, I have created a mnemonic to explain some of its intricacies.

H – Hormonal Problem.  It is due to decreased secretion of parathyroid hormone  or PTH.  PTH is required to maintain adequate calcium levels in the blood.

Y – Why does it happen?  The most common causes are accidental trauma to the parathyroid gland due to neck surgeries and autoimmune destruction of the parathyroid gland.   Uncommon causes include immobilization and lithium use.

P – Potentially serious.  If left untreated, it can lead to death.

O – Osteoporosis or softening of the bone tissues occur in hypoparathyroidism.

P – Pseudohypoparathyroidism, where PTH levels are normal but body tissues are insensitive to PTH, are associated with mental retardation and bone deformities.

A – Abdominal Pain.  Hypoparathyroidism can lead to cramping of the abdominal muscles.

R – Rare disease.  The incidence of hyperparathyroidism increases with age. In persons over the age of 65 years, hyperparathyroidism occurs in one out of every 1,000 men and in 2-3 out of every 1,000 women.

A – Autoimmune invasion or destruction of the parathyroid gland is the most common non-surgical cause of hypoparathyroidism.

T – Thyroid surgery can cause hypoparathyroidism.  This happens due to accidental removal or trauma to the parathyroid gland during thyroidectomy or other neck surgeries.

H – Hypocalcemia.  Decreased parathyroid hormone levels lead to a decrease in blood calcium levels.

Y – Why is calcium important?  Calcium is important for the formation of bones and teeth, blood clotting to diminish bleeding, and the contraction of muscles (including the heart muscle).

R – Renal or kidney reabsorption of calcium is promoted by PTH, which will result in an increase in blood calcium levels.

O – Ophthalmologically speaking, it can also lead to cataracts.

I – Idiopathic, or unknown causes of hypoparathyroidism, have also been documented.

D – Vitamin D synthesis in the body is aided by PTH.

I – Intravenous injection of calcium gluconate can be administered in severe hypocalcemia.

S – Seizures.  When left untreated, hypoparathyroidism can lead to tetanic convulsions due to decreased blood calcium levels.

M – Muscle Cramps and spasms are common.  If it occurs in the muscles of the larynx, it can result in breathing difficulties.


Was the Justice Secretary right in refusing treatment?  Send me your feedback.  Now that you know what hypothyroidism is, you be the judge.


The parable of the talents, as depicted in a 1...

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“The toughest thing about success is that you’ve got to keep on being a success.  Talent is only a starting point…you’ve got to keep working that talent.”

Irving Berlin


Great talent is hard to find.  Even more difficult is developing it.  I have seen a number of talented prodigies in my life who somehow fell short of expectations.  What does it take to cultivate talent and live up to its full potential?

T – Test your talent.  Michael Jordan had talent.  Manny Pacquiao had talent.  But both were tested through adversity.  They were never scared to compete against the best in their respective sports, and that’s why they’re successful.  If you want to develop talent, don’t stay away from difficulties and trials.  Face them, overcome them, and have the courage to test yourself to reach your goals.

A – Activate your talent.  Don’t keep it.  Or else, it might be taken away from you, just like what happened in The Parable of the Talents.

L – Leverage your talent.  Your talent must be enhanced.  Sharpen the saw.  The day you stop improving is the day you start deteriorating.

E – Expand your talent.  Great movie stars who last long in the business find ways to reinvent themselves.  Be creative and discover new ways to use your skills.

N – Nourish your talent.  Take good care of your health.  Get adequate rest and relaxation.  You need to always be at your best to maximize your potential.

T –  Teach your talent.  Whatever you learn in the course of developing yourself must be shared with others, so they can learn from your experiences.

As a physician involved in educating medical students, I try to live by this motto:  Teach And Lead Everyone to Nourish and Treat.  I believe that every medical student who really desires to be a good physician can make a difference.  With enough passion and determination, even someone with average intelligence can make use of their God-given talent to create a lasting legacy.


the human atmosphere

The Human "Aura"

“I didn’t want my body to be opened…I didn’t want to be violated in that way.”

–  Steve Jobs on his decision to pursue alternative treatment

I just read an article which claims that Steve Jobs regretted his decision to undergo alternative medicine treatment for his pancreatic neuroendocrine tumor, which resulted in his death a few weeks ago.  According to Walter Isaacson, who has written a biography on Steve Jobs, by the time the former Apple CEO made a decision to discontinue alternative treatments, the tumor in his pancreas had already spread to surrounding areas.  Thus, from a supposedly good prognosis, his condition deteriorated and proved to be fatal.

The relatively new revolution called Alternative Medicine  has evolved over the past few years.  Just like Steve Jobs, there are individuals who opt to try alternative treatments to cure common and not so common illnesses.  The claim of alternative medicine practitioners is that it is safe and it works. While most people accept that conventional medicine is essential for emergency treatments, some sectors believe mainstream treatment is less effective when it comes to disease prevention, chronic disease management, and even in cancer therapy. These are the realms where alternative medicine is usually practiced, and it has supposedly earned millions of dollars for its business proponents.  In fact, a number of large tertiary hospitals, both public and private, have started to offer alternative medicine services.

So how does alternative medicine claim to differ from allopathic or conventional medicine?

First, alternative medicine practitioners claim that their practice is more holistic, treating patients as a whole individual instead of breaking them down into organ systems.  According to them, too much specialization has crept into allophathic medicine practitioners.

Secondly, alternative medicine says that it is less aggressive in treating disease, which means that it does no rely on a “quick fix” approach.  They claim to rely on more gentle modalities, and allow the body to heal on its own.

Third, some sectors maintain that allopathic medicine is based on too many strict rules.  To some, it seems as if the guidelines of allopathic medicine practitioners cannot be violated or interpreted in any other way, for fear of malpractice suits.

Fourth is the assertion that conventional medicine seemingly views the body as a machine, and most disorders are best treated with drugs. Alternative medicine claims to assert that the body is “a network of channels” involving simple energy transfer mechanisms. Impediments in the flow of energy through these channels lead to ailments, and the goal of the healer is to remove these impediments or “energy flow blockers”.

Lastly, alternative medicine alleges that it is more open to participative and coordinated treatment with patients, while conventional medicine is more paternalistic in approach, with patient opinions not listened to or dismissed as unscientific.

How do we resolve these differences in mind-set?  The key is to incorporate the best characteristics of alternative and allopathic medicine in order to enhance health care.  The ability to establish scientific evidence is a strength of allopathic medicine, but some of its practitioners truly pale in comparison to alternative medicine proponents in terms of patient interaction – the “art” of medicine, so to speak.  By combining the science and art of medical management, incorporating both ideologies into the education of future physicians, an integrated and complementary approach would benefit everyone.  Alternative treatments must be researched in order to establish their effectivity through evidence-based studies.  In turn, conventional medicine practitioners must see the whole person and be more  open to conversation to establish a more trusting relationship with patients and their families.


Albert Schweitzer, Etching by Arthur William H...

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“The purpose of human life is to serve and show compassion and have the will to help others.” – Albert Schweitzer

I have always wondered why Medical Ethics does not command the attention it deserves.  In medical school, it is relegated to a minor subject in first year, where simply attending is enough to get a passing grade.  While it is important to develop technical proficiency in the healing art, it is now becoming obvious that medical dilemmas mostly stem from ethical issues, not technical issues.  This is because most medical societies have now created guidelines for sound management of disease.  It is clear, however, that most guidelines cannot answer ethical questions.

A health care professional who does not humbly acknowledge the need to place the interest of patients first is not a true health care professional.  Technical competency must therefore be balanced with sound character.  One of the values that must be emphasized is integrity.  From proper disclosure of medical findings to the conscientious assessment of professional fees, a medical professional must be trusted to make decisions based on the patient’s interest, not on the medical professional’s personal agenda.

This is easier said than done when the training of a medical professional focuses too much on science rather than character development.  It is sad that the measurement of ability during board certification examinations is based almost entirely on the ability to manage and treat illness through diagnostic reasoning and drug therapy.  Communication and ethical behavior are rarely evaluated.

Take the issue of end of life resuscitation, for example.  While it is important to empower a patient’s relatives to make decisions in these instances, it is equally vital to provide adequate disclosure for the patient’s loved ones.  Unfortunately, the skill of breaking bad news is not a common topic in medical education.  In fact, I have yet to find it being asked during board examinations.  In a profession where death and disability is equated to treatment failure, breaking bad news is not deemed to be an essential skill.

Ethical issues are increasing in frequency and complexity.  It is high time for hospitals, physicians, nurses, caregivers, and allied medical personnel to give it the attention it deserves.  Otherwise, it would become increasingly difficult to balance the need for improving the quality of care, containing medical costs, and ensuring the survival of healthcare institutions.