Second-year fellow in adult and pediatric allergy and immunology at the University of the Philippines-Philippine General Hospital (UP-PGH)

When it comes to making decisions, Dr. de Leon believes in keeping an open mind. The danger with subspecialization, she describes, is "the more you study something, the less you [might] know about everything else." She avoids this pitfall by focusing on the patient and not just on the allergic disease she is expected to treat. At the back of her mind always is the possibility that the patient could very well be sick of something else. Despite training as a subspecialist, one must not abandon being a generalist as well, she emphasizes.

Why did you choose this fellowship?

I have allergies and I grew up with allergies. I think most of the time people (doctors) decide on a fellowship program that they're interested in, that they can relate to, or that they really want to know more about.

How is fellowship different from residency?

[Residency] is a little bit of exposure to everything. As a resident, physically your work is really hard and demanding: you go on duty, you see patients nonstop. With subspecialty or fellowship, [the training] is more extensive, pero dun lang sa field mong yon. The patient load is probably a little smaller compared to the general pediatrician but workload is a little more focused on a particular disease entity.

What is the most difficult part of fellowship training?

Maybe the most difficult part is trying to specialize and, at the same time, trying to maintain the fact that you should always remember you're a pediatrician or an internist.

Herself an asthmatic, de Leon knows allergology and immunology are where she can really relate and fit in. Although she's aware allergology is a relatively smaller field than the other subspecialties-there are only about 70 allergologists in the whole country-she has observed that there seems lately a slow increase in the number of children and adults with allergy and asthma, which also decided for her what fellowship to take.

"When you decide on a fellowship program, you also have to take into consideration how many people are practicing," she explains. After all, she says, "[fellowship] is your career, it's your future."

De Leon will complete her fellowship training this December.

 

Dr. Mike Tee

Second-year fellow in rheumatology at the University of the Philippines-Philippine General Hospital (UP-PGH)

After his training in internal medicine, Tee initially thought of entering into an organ-based subspecialty. However, he eventually decided to go into rheumatology as it would not limit his practice to a specific organ system. The specialty offers him an opportunity to learn in depth the different connective tissue diseases without sacrificing the breadth of knowledge required for the practice of general internal medicine. Also, he sees rheumatology's heavy focus now on the biochemical concepts as the biggest challenge of "trying to learn and apply these molecular concepts into clinical practice."

Describe your field.

Almost bordering on multi-disciplinary. The approach to patients with rheumatic disease is necessarily holistic. You cannot approach it otherwise. What's peculiar with rheumatology is that while you're focusing on certain diseases, you do not forget the other disease entities. In fact, one of the more important things to do is to confidently say that "this is not a rheumatologic condition."

Even though your patient load is lighter, isn't there still a certain pressure because you are more closely supervised now by your consultants?

Hindi. The environment is now more like colleagues rather than student-teacher. Maybe in some cases, student-teacher,

lalo na kapag nasa bedside kayo, but as an adult learner, may motivation ka nang sarili. It's what we call self-directed learning, really problem-based. Meaning the patient presents you with the problem, and as a trainee, it's not enough that you ask your consultants anong dapat gawin. You don't get [the solution] by treating the consultants as sole resources. You should always read up, and then correlate the experience of your consultants to that written in the book. Remember, the authors may be experts in the field, but my consultants are also experts in the field.

The lifestyle of a fellow works for Tee. It gives him more free time to be with his family, to take up master's courses, to do research, and to be more involved with a patient support group. Every first Saturday, the fellows of his section facilitates a lupus club, where lupus patients get together to help them cope better with their disease.

"What we really want to do [and to make happen] is to empower patients to know the disease, know the side effects of the medicines, and for their loved ones not to get tired of taking care of them," Tee says in reference to the club's activities.

In February, Tee will be finished with his training.

 

Dr. Jesus Ancheta

Six months into the adult pulmonology medicine fellowship training at the Lung Center of the Philippines (LCP)

Ancheta did not wish to go into surgery. The two most viable options then for residency were pediatrics and internal medicine. Having chosen to go into the latter, he saw a lot of pulmonary cases, and he realized that these cases also happened to be the most interesting for him.

How are you getting along in your fellowship?

Compared with residency the work is lighter. I am enjoying it better than [I did in] residency training.

Why did you want to train at LCP?

Because, here there are a lot of service patients. Private hospitals only have few service patients. In a semigovernment institution, most of the patients come from the provinces. So with that, I can see the usual illnesses of patients coming from the provinces.

Lung Center also has a lot of cases not usually seen in other hospitals. Para na rin siyang end point. So if a hospital cannot manage these kinds of patients, it usually sends them to us. Usually complicated na. Then we try to manage the patients. It's more challenging.

You plan to practice in the province?

(Nods) 90 percent in Isabela (where he grew up). Most of the pulmonary doctors are concentrated here in Manila. In the provinces there are only few. Mas malaki ang chances that I get more patients there [then].

Ancheta also did not wish to go abroad, nor plan to for his practice, which is why his training at the LCP appeals to him immensely despite its rigors and challenges. Unlike so many doctors who would rather go abroad or stay in Metro Manila, his intentions had always been to go back to his home province and practice there.

At the LCP, he explains that not only is he trained in the details of his field, he is also oriented on the problems folks from the provinces would rather can be treated closer to home and not someplace so distant and such a hassle to get to.

With fellowship, he can help meet this need.

Not too many doctors will choose to go into pediatric intensive care. According to Valencia, it's too time-consuming, demanding, and not really family-friendly. "It really entails a lot of sacrifice," she observes.

Married, with kids, why is Valencia then in this field that she says herself is unhealthy for the things she holds dear? Because when she sees her kids healthy and happy, this motivates her to give her best shot at giving the same blessings to other parents.

From serious illnesses or the brink of death, when she manages to do this, the rewards are greater and they give her the strength to stay on.

 

Dr. Gisela Valencia

Second year in pediatric intensive care medicine at Philippine Children's Medical Center (PCMC)

Not too many doctors will choose to go into pediatric intensive care. According to Valencia, it's too time-consuming, demanding, and not really family-friendly. "It really entails a lot of sacrifice," she observes.

Married, with kids, why is Valencia then in this field that she says herself is unhealthy for the things she holds dear? Because when she sees her kids healthy and happy, this motivates her to give her best shot at giving the same blessings to other parents.

From serious illnesses or the brink of death, when she manages to do this, the rewards are greater and they give her the strength to stay on.

Why go into intensive care?

One of the considerations that I had in mind was first the kind of life I envisioned for myself in the future. I like the fast pace of the ICU. I like dealing with patients on a critical level.

Was it a concern for you, in going into subspecialty, you might lose touch with the other fields?

[In intensive care], the kind of illnesses that comes to you is not one system lang. I told myself I want to be prepared to handle such cases. When you're an intensivist, you look at the patient on a generalized basis. You're still a general pediatrician but more on a critical level.

Describe the pressures of this fellowship.

Overwhelming. When cases get admitted in the ER, it's the ER residents who initially manage the cases. When they become problematic, the patients get referred [to a specialist] depending on the system that gets involved. When [the problems] become multisystemic, the patients get referred to the ICU. So we get the toxic cases from the ER and from the wards.

Valencia describes her fellowship to be more than an immersion into its academic and clinical aspects: training goes deep into the spiritual level of being an intensivist. The demands, expectations take its toll on almost everything from a fellow's life. "You have to be prepared and goal oriented," stresses Valencia, especially if you're a woman with a family, like in her case.

After she completes her fellowship in May, it's either a six-month exposure training abroad or straight to practice in her home city in Iloilo.

 

 

Dr. Gregorio Patacsil

Cardiologist, consultant and professor, University of the Philippines-Philippine General Hospital and University of the East Ramon Magsaysay Memorial Medical Center