The Journal of the Philippine Medical Association Vol. 52, Nos. 3-4 March-April 1976

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Part of The Journal of the Philippine Medical Association

Title: The Journal of the Philippine Medical Association Vol. 52, Nos. 3-4 March-April 1976
Issue Date: Vol. 52, Nos. 3-4 March-April 1976
Year: 1976
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extracted text: Journal of the PHILIPPINE MEDICAL ASSOCIATION NURSES' AND PATIENTS' WEAR • OPERATING ROOM AND WARD LINEN ACCESSORIES Available in various colors and sizes. The most complete line of high-quality hospital linen. See o. caii us at GTI GARMENTS INTERNATIONAL CORP. (Linen Division) r Rodrigue * Ave. Ema., Libis. Murphy. Quezon City • Telephone Numbers 79-67 96 • 78 79 11 to 23 • 79-89-55 • P.O. Bom 2470. Manila Persa ntin® the antithrombotic prevents the formation of arterial thrombi Availability: ampoule 10 mg/2 ml. 25 mg. tablets 75 mg. tablets packs of 25’s packs of 100's packs of 100's The best days begin with BIO M EDIS quality-processed specialties ... AMBRACYN tetracycline hcl * 500 Capsules * 250 Capsules * Syrup * Drops * 250 Vials BIOGESIC paracetamol * Tablets * Liquid * Drops FUNDAMIN-E Tablets FUNDAMIN Syrup COHISTAN Expectorant SKELAN Capsules DIATABS Tablets DIPHERYL * Tablets * Elixir AZO-METANDELAN Tablets METANDELAN Tablets REVALAN glaphenine * Tablets HEMARATE Tablets HEMARATE Liquid NALGESTAN Tablets PENSYN ampicillin trihydrate * 500 Capsules * 250 Capsules * Syrup * 250 or 500 Vials The high potency and well tolerated broad spectrum antibiotic therapy. Safest analgesic-antipyretic for prompt and sure relief of pain and fever. Therapeutic-dose Bl, B6 and B12 vitamins plus vitamin E. Pleasant-tasting B-Complex formula with high-dose Iron. Reliable and safe control of dry, irritative or allergic cough. A potent musculoskeletal analgesic with anti-inflammatory and muscle relaxant actions. Highly effective and safe therapy of specific and non-specific diarrheas. Cough-suppressant, mucolytic-expectorant and bronchodilator-decongestant. A specific urinary tract antiseptic-analgesic. A urine specific anti-bacterial compound giving a continuously bactericidal urinary tract antiseptic. Provides prompt analgesic action in a wide range of painful conditions. One-a-day, powerful hematinic and metabolic formula. A full range hematinic and appetite stimulant. The total nasal decongestant for specific cold relief. Broad-spectrum antibiotic with bacterial activity. VISPAGEN * Tablets Specific, rapid-acting and potent visceral anti-spasmodic. BIOMEDIS? INC. All around skin therapy QU4DRIDERM CREAM/OINTMENT ■ ANTI-INFLAMMATORY, ANTIALLERGIC, ANTIPRURITIC ACTION QUADRIDERM CONTAINS CELESTODERM-V TODAY’S LEADING TOPICAL STERIOD ■ ANTIBACTERIAL ACTION QUADRIDERM CONTAINSGARAMYCIN BACTERICIDAL AGAINST STAPHYLOCOCCI AND MAJOR GRAM-NEGATIVE PATHOGENS ■ ANTIFUNGAL ACTION QUADRIDERM CONTAINS TINACTIN FUNGICIDAL AGAINST ALL COMMON TINEA INFECTIONS ■ ANTIMONILIAL ACTION QUADRIDERM CONTAINS IODOCHLORHYDROXYQUIN ANTIFUNGAL ACTION AGAINST CANDIDA ALBICANS BOTH CREAM AND OINTMENT ARE AVAILABLE IN 5 Gm. TUBES SCHERING CORPORATION (PHILIPPINES) INC. A subsidiary of SCHERING CORPORATION P. O. BOX 238 COMMERCIAL CENTER. MAKATI, RIZAL D-708 BLOOMFIELD. NEW JERSEY JOURNAL OF THE CONTENTS PHILIPPINE MEDICAL ASSOCIATION Volume 52 Nos. 3-4 March-April 19 7 6 EDITORIAL Medical Alumni Societies 39 Augusto J. Ramos, M.D. ORIGINAL ARTICLES Chemical Factors in the Etiology of Coronary Heart Disease 41 Domingo M. Aviado, M.D. Non-Preoperative Percutaneous Transhepatic Cholangiography 49 Eugenio A. Picazo, M.D. A Two Year Experience with Vasectomy in the Philippines 57 Pedro M. Reyes, Jr., M.D., F.A.C.S., F.A.A.P. Status of Pediatric Education in the Philippines 67 Fe del Mundo, M.A., M.D. Annual Report of the PMA National Treasurer 84 RE-ENTERED AS SECOND CLASS MAIL MATTER AT THE MANILA CENTRAL POST OFFICE ON OCTOBER 29, 1974. JOURNAL of the PHILIPPINE MEDICAL ASSOCIATION AUGUSTO J. RAMOS, M.D. Editor-in-Chief RAMON R. ANGELES, M.D. Associate Editor HILARION C. DE DIOS, M.D. Budneae Manager EDITORIAL BOARD CORNELIO G. BANAAG, JR., M.D............................. Psychiatry EMMANUEL M. ALMEDA, M.D. ............................... Otolaryngology AVENILO P. AVENTURA, M.D. Cutdiovostulct Surgery MANUEL N. BORJA, M.D............................................. Oncology EDUARDO R. de la CRUZ, M.D.................................... Family Medicine CARMELO V. ENCARNACION, M.D. ..................... Publid Health ENRIQUE L. ESQUIVEL, JR., M.D................... ......... Uroligy EELXX. A. ESTRADA, M.D. ........................................ Pediatrics ROMEO V. FAJARDO, M.D.......................................... Ophthalmology ROMAN S. IBAY, M.D............................................ ... Pediatric Surgery PERPETUA REYESJAVIER, MJ). .............. ........ Dermatology JESUS C. de JESUS, M.D............................................... Pulmonary Surgery PERPETUA S. LACSON, M.D................ ................... Hematology LEON R. LOPEZ, M.D..................................... .......... Radiology ROMEO C. MONTES, M.D............................................ Compenaation Medicine TEODORO P. NUGUID, M.D........................................ Colon Rectal Surgery FRANCISCO M. PASCUAL, SR., M.D.......................... Pharmaceutical Industry JOSE M. PUJALTE, M.D............................................ .. OrtMpddics PEDRO M. REYES, M.D................................................. Surgery ERNESTO S. RIVERA, M.D.......................................... Pathology BURGOS T. SAYOC, M.D............................................. Plastic Surgery RENATO Q. SIBAYAN, M.D......................................... Neurorurgery BENIGNO M. SULIT. JR., M.D.................................. Anesthesiology ENRIQUE V. TALENS, M.D..................................... . Military Medicine JOSE G. TAMAYO, M.D................................................ Obstetrics & Gynecology Note: The Individual members of the Editorial Board represent tbolr respective specialty. Garamycin GENTAMICIN SULFATE > CREAM/OINTMENT other antibiotics Packaging: GARAMYCIN (gentamicin sulfate) is available as 0.1% Cream in 15gm. tubes and 0.1% Ointment in 5gm. tubes. A logical first choice in topical antibiotic therapy ■ bactericidal against Staphylococcus, Pseudomonas, Proteus and other bacterial organisms frequently resistant to ■ virtually free from sensitization or irritation ■ equally effective in stubborn as well as simple skin infections ■ unsurpassed potency resulting in rapid, complete clinical cures SCHERING CORPORATION (PHILIPPINES) INC. a subsidiary of SCHERING CORPORATION U.S.A. P 0 BOX 238 COMMERCIAL CENTER. MAKATI. RIZAL D-708 KENILWORTH. NEW JERSEY GAR(c/o)-76J-PH(CI)-1 No other single antibiotic dermatological preparation has a. wider range of effectiveness • For the treatment of all conditions arising from emotional over-reactions to stressful situations and conflicts • As a necessary adjuvant therapy to relieve anxiety in all cases of somatic illnesses for faster recovery LE80TM„ PHILIPPINE MEDICAL ASSOCIATION OFFICERS 1975-76 ANTONIO C. OPOSA, M.D. President PROTAC1O R. SOTTO, M.D. Immediate Past President ERNESTO V. FERREOL, M.D. Secretary CARMELITA B. CUYUGAN, M.D. Vice-President for Luzon HILARION C. DE DIOS, M.D. Treasurer FORTUNATO P. CATOTAL, M.D. Vice-President for Mindanao & Sulu LOLTTO Sm. TUMBOCON, M.D. Vice-President for Visayas COUNCILORS-AT-LARGE PRIMITIVO D. CHUA, M.D. FELIX J. JARDENICO, JR., M.D. DISTRICT COUNCILORS TEOF1LO FLORENDO, M.D. Cagayan Valley District FELINO C. PALAFOX, M.D. Northwestern Luzon District FRANCISCO M. PASCUAL, SR. MD. Central Luzon District ROMEO C. MONTES, M.D. Manila District ELVA G. PENA, M.D. Central Tagalog District MANUEL J. SALAZAR, M.D. Southern Tagalog District ERNESTO P. CRUZ, M.D. Rizal District ROMULO P. NACIONAL, M.D. Bicol District EMILIO C. MACIAS, n, M.D. Central Visayas District RAFAEL ORNEGA, M.D. Eastern Visayas District TELESFORO J. DELOS REYES, M.D. Western Visayas District ORLANDO V. PRADO, M.D. Northern Mindanao District ENCARNACION LUMANTAS, M.D. North-Central Mindanao District BELTANI A. CLEMENTE, M.D. Southern Mindanao District RICARDO LI. OCHOTORENA, M.D. Western Mindanao District ••• Effectively improve coronary Hood flow in coronary insufficiency Figure 1 was taken before and Fig» 2 was taken after the administration of 5-mg. ISORQIL sublingually. Significantly, the artery is filled slightly more distally, and its diameter is incieased after administration of the drug. (Sewell, W.H.: The Medical and Surgical Management of Coronary Insufficiency, a motion picture, on file at AyersQ Current investigations suggest that the symptoms of coronary insufficiency (angina pectoris in particular) result from inadequate oxygen supplies to the heart. The disparity between oxygen required and oxygen available can be resolved by improving coronary artery flow and by reducing myocardial oxygen requirements. ISORDIL does both. ISORDIL dilates coronary arteries and collateral blood vessels, improving coronary blood flow, and markedly reduces venous return, resulting in decreased cardiac output and myocardial oxygen requirements. Presentation: No. 1100-Sublingual 5 mg., bottles of JOO tablets No. 1101-10 mg., bottles of 100 tablets No. 1102-Tembids« LA. 40 mg., bottles of iCO tablets •Trademark tor Sustained Action Tablets ISORDIL isosorbide dinitrate effective in theory effective in fact, effective in clinical practice tree '■cmstcmo numnah f A Trademark AN ESSENTIAL ELEMENT IN THE SUCCESSFUL THERAPY OF SERIOUS BACTERIAL INFECTION Delay can be critical get the 24 hour head start ....while the culture is being plated GARAMYCIN INJECTION ** * Simplified Dosage Guidelines for Garamycin * Injection (For Intramuscular Administration) PATIENTS WITH NORMAL RENAL FUNCTION &DULTS 60 KG or LESS%. ' (132 LBS. or LESS) DOSAGE ONE 80 mg. VIAL 3 times daily DOSAGE ONE 60 mg. AMPULE 3 times daily If calculated on an individual weight basis, the recommended dosage of GARAMYCIN Injection for adult patients with serious infections is 3 mg/Kg/day, in three equal doses; life - threatening infections, up to 5 mg/Kg/day in three or four equal doses. CHILDREN, in moderate or severe infections, 3 to 6 mg/Kg/day, in three equal doses. INFANTS AND NEONATES (premature and full-term neonates, one week of age or less), 6 mg/Kg/day, in two equal doses; INFANTS OLDER THAN ONE WEEK, 6 mg/Kg/day, in,two or three equal doses. FOR INTRAVENOUS ADMINISTRATION A single dose of GARAMYCIN Injection may be diluted in sterile isotonic saline solution or sterile 5% dextrose solution and may be infused over a period of up to 2 hours. A single dose of GARAMYCIN Injection undiluted may also be given directly into a vein or I.V. tubing slowly over a period of 2 to 3 minutes and may, if necessary, be repeated every 8 hours. USUAL DURATION OF TREATMENT, ALL CONDITIONS: 7 to 10 days. Qourpiwr. corporation (PHILIPPINES) INC. a subsidiary of SCHERING CORPORATION U. S. A. Skin x3 UltraTan5<3 in anergic and inflammatory dermatoses three simple distinctions for logical therapy with Ultralan 3eping skin conditions ed a base with a high iter content Skin conditions which are neither weeping nor very dry need a base with a balanced fat/water content Very dry skin conditions need an anhydrous fat base Ultralan Cream Ultralan Ointment Ultralan Fatty Ointment new is base allows exudate flow off freely so speedj up the drying out of s skin and helping the aling process. This base protects the skin from drying out and lightly lubricates it with out clogging warmth or moisture. This base keeps moisture in the epidermis and facilitates the penetration of the active principle. n nt - cream - fatty ointment sffective corticoid prepara>r the topical treatment of natory and allergic skin ons >sition i ointment: . contains 2.5 mg fluocortind 2.5 mg fluocortolone te. i cream: . contains 2.5 mg fluocortrimethylacetate and fluocortolone caproate. i fatty ointment: . contains 2.5 mg fluocortind 2.5 mg fluocortolone ite. Indications The Ultralan preparations are indi cated for virtually the complete range of inflammatory and allergic skin conditions: Ultralan ointment with its universal base for nearly all types of skin disorders. Ultralan cream with its low fat con tent especially for acute and sub acute processes and for application on visible skin areas, e. g. on face. Ultralan fatty ointment with its wa ter-free base for dry skin. Contra-indications Tuberculous processes in the region under treatment; vaccinia, smallpox and chickenpox. Possible side-effects When large quantities of Ultralan are used or when extensive skin areas are covered with an occlu sive dressing, systemic absorption may occur. In rare cases, the skin might become atrophic after long-term and high-dose appli cation of Ultralan or other fluor inated corticoids. Special notes If Ultralan is employed in infants and children up to 3 years of age, in skin folds or in areas covered with napkins or rubber pants, duration of therapy should not exceed 3 weeks. In mycosis, locally acting anti mycotic agents are indicated. When Ultralan is applied in cases of secondarily infected processes, additional administration of locally acting chemotherapeutic agents is indicated. Dosage and administration In general, initially twice or three times daily in a thin layer. After re cession of the acute symptoms, one daily application is sufficient. In case the skin should dry too much under treatment with Ultralan cream, transfer to Ultralan oint ment is recommended. Ultralan fatty ointment must not be used in weeping processes. When Ultralan is used on the face it should not get in contact with the eye. For further details please consult our scientific literature. Presentation Ultralan ointment: Tubes containing 5,10 and 30 g Ultralan cream: Tubes containing 5.10 and 30 g Ultralan fatty ointment: Tubes containing 5.10 and 30 g Schering AG Berlin/Bergkamen represented by BERLIMED PHILIPPINE CORP. P. O. Box 331 Commercial Center Makati, Rizal D-708 01571 U 8433 II Oct. 73 Published Under the Supervision of The Executive Council JOURNAL of the Philippine Medical Association VOL. 51, MOS. M M*RcH-APWL, 1974 E 1) IT OR 1 AL _______________________________ MEDICAL ALUMNI SOCIETIES Alumni Societies of Schools particularly those of higher fatTlfrtg pfy an important role in shaping the future of the various professions and eventually of the country. They provide the leadership that could ef fectively influence and accomplish this role. Recognition of such leader ship brings alumni to the stewardship of local or national medical organiza tions, specialty societies, medical institutions, and government health ser vices where they distinguish themselves further. There are also the greater number of alumni that asMUMt prominewee in th * even challenging field of medical practice. From all these, the people and the country bene fit. It is therefore, always a happy occasion for almon * grtlups to look forward meeting every year during our PMA National Conventions, Region al or Component Society Annual Meetings, and Medical School Homecomings. To renew acquaintanceships, to reminisce, to greet old friends, and to make new ones. Indeed, it is a source of great pride to be long to a Medical School that has nurtured worthy and successful alumni. Alumni Societies are grateful and have responded quite generously to the needs of their mother institutions and occasionally, certain individual alumni have given philantrophically. However, our Alumni Societies can still do more. May I suggest that endowments for professorial chairs, grants for research, continuing scholarships for deserving medical stu39 40 Ramos March-April, 1976 J. P. M. A. dents, donations for laboratory instruments and equipment, and teaching aids be given priority. There is somethine; uniaue that the PMA has made actually possible which the Medina! Schools have not. It has nrovided the numerous oc casions whp’“ atnmni meet other a1?'«-r->5 and more importantly, alumni work with other alumni. This is the PMA! A. |. RAMOS, M.D. Greetings: to the DELEGATES and MEMBERS 69th PMA ANNUAL CONVENTION APRIL 28 TO MAY 1, 1976 BAGUIO CITY Tinactiri (Tolnaftate) CREAM,5Gm /SOLUTION, 10 ml The first truly fungicidal drug for topical use VANDOL OINTMENT the ideal soothing ointment for family use diaper SUNBURN abrasions minor burns ROUTINE NIPPLE CARE OINTMENT TIN/VAN-1- 76 J-PH(FI) A Two Year Experience with Vasectomy in the Philippines * *A Program Supported by Pathfinder Fund, Inc., Boston, Massachusetts. PEDRO M. REYES, JR., M.D., F.A.C. S., F.A.A.P. INTRODUCTION VASECTOMY is of maximum usefulness in the male whose desired family size has been attained and whose marital partner is still young and unwilling to undergo the inconveniences and uncer tainties of conventional contraceptive practices. The sterilization counterpart in the female, no matter what technic is used, involves entry into the peritoneal cavity and therefore carries a potential ly serious risk. Vasectomy, as has been developed in this program, is a short, painless, low cost, procedure with a high success rate (100% of all patients returning for semen examination), low complication rate, and virtually without side effects. There have been a total of 690 acceptors during the last 2 years of the program and a review of our ex periences wiU serve to crystallize some thoughts on how the program can be rendered more effective, particularly in relation to the overall program of the government towards population growth rate control. Inertia of the Initial Acceptance of Vasectomy. Educational, cultural, and religious factors have, in the past, limited the ac ceptance of vasectomy in the Philippines as a family planning technic. The pro gram was intended to gain entry into a heretofore poorly tapped source of fer tility control — the male half of the marriage partnership — representing 50% of all actively reproductive individ uals. Although the program had been planned months before, Its operation started only on November 1, 1973. The venue of the vasectomy program was a suite on the third floor of the Institute of Maternal and Child Health Building of the Children’s Medical Center at 11 Banawe, Quezon City. Partitioning of the alloted space created a waiting room — reception room, an office for inter viewing prospective acceptors, and an operating room complete with an ope rating table and overhead operating lamp. Actually, the Vasectomy Clinic Was part of an Advanced Family Plan ning Technology Clinic (an euphemistric name for Voluntary Sterilization Clinic) in which the female counterpart was as signed to Dr. Restituto Buenviaje, who did the female sterilization by transva57 58 Reyes, Jr. March-April, 1976 J. P. M. A. ginal tubal resection. The office staff of the whole clinic consisted, initially of only one nurse, later re-enforced by the addition of a licensed midwife. The Project Director of the Program initial ly at its most difficult first year was Dr. Fe del Mundo. The vasectomy program was given a quota of 200 acceptors for the first year. Optimism rode high at the start of the program, since the Institute of Maternal and Child Health had over 390 Family Planning Clinics all over the Philippines with 144 of these in the Greater Manila Area and surrounding provinces, all of which were potentially large sources of acceptors. Disappointingly, only 2 pa tients came for vasectomy during the first 4 months of operation of the clinic? Realizing that acceptors were not forth coming from the Family Planning Clinicsj the clinic staff and some concerned staff members of the I.M.C.H. began their own motivational campaign. Sor ties were made into different quarters for informational seminars. The first targets were the municipal councils of the suburban towns of San Juan, Ri zal; Quezon City; Pasay City; Caloocan City; and Mandaluyong, Rizal. Abrupt ly, in March, 1974, 6 acceptors came. Each month since then, the number of ac ceptors increased progressively (See Chart), so that by the end of the pro ject year on October 30, 1974, there were 37 acceptors more than the quota of 200 The Importance of a Continuous Motivational Campaign. The second year of operation of the Vasectomy Clinic was allo ted 450 ac ceptors. During tho first month (No vember, 1974) 59 acceptors came. Sub sequent months showed regular fluctua tions in the number of acceptors. Each month showing a decline in acceptors was followed by a motivational cam paign, causing an increase in the subse quent months. During the latter half of the 2nd year of operation, a precipitous drop in the number of acceptors had to be countered with informational semi nars conducted by Mrs. Alice Area, the Clinic Nurse, mostly in industrial firms with a high male population. This ex perience during the second year con vinced us that a continuing motivational canlpaign is necessary for a steady stream of acceptors. Spreading the Popularity of Vasectomy During the first year of operation of the Vasectomy Clinic, a visit was made to Gasan, Marinduque, on the invitation of the town mayor and his wife, so that interest in vasectomy may be awakened in the area. During this visit, which was on the last week-end of August, 1974, 13 acceptors submitted for vasectomy, and a local health officer was trained in the technic so that continuity of the pro gram in the area would not be disrupted. This pattern of itinerant surgery and concomittant training of a physician in the area has been repeated more often during the second year of operation, when visits were carried out in the following allotcd to the vasectomy clinic. places: 1. Bacolod City November 23-24, 1974 — 27 cases 2. Angono, Rizal April 2, 1975 6 cases 3. Angono, Rizal August 4, 1975 9 cases 4. Pasig, Rizal August 9, 1975 11 cases 5. Novaliches, Rizal August 30, 1975 7 cases 6. Angono, Rizal September 24, 1975 1. case Vasectomy 59. VjVjrp * ? . Nor >4 • Fig. 1. Graph shows difficulty of initial operation and need for continuous motivational efforts to insure success of the program. 60 Reyes, Jr. In each of these places one or more trainees were on hand to utilize the pa tients for training. In each place, care was exercised so that the initial experi ence of the community with vasectomy was pleasant. The procedure had to be fully accepted and not discredited by in curring unpleasant complications. The Vasectomy Clinic as Training Center. The Institute of Maternal and Child Health, recognizing the potentialities of vasectomy as an effective fertility con March-April, 1976 J. P. M. A. trol tool, entered into a program of train ing rural physicians to do vasectomy, with the Vasectomy Clinic as its pri mary training center. Groups of 2 or more physicians were sent to the Va sectomy Clinic for practical training in the operation. A minimum of 5 assisted vasectomies and 5 actually performed operations were required of each trainee and at the end of the training schedule, a certificate was awarded. Physicians trained in vasectomy at the Clinic sponsored by the I.M.C.H. are listed below: LIST OF PHYSICIANS TRAINED ON VASECTOMY 1st Quarter: July, Aug. Sept. ’75 F.Y. — 1975-76 July 7-11, 1975 1. Dr. Antonio F. Dioneda (C) Dioneda Family Planning Clinic Balogo, Sorsogon July 14-18, 1975 1. Dr. Sotero A. Escarilla, Jr. Iriga City Puericulture & Family Planning Center, Iriga City 2. Dr. Eduardo C. Enojado Naga City Puericulture & Family Planning Center Naga City July 21-25, 1975 1. Dr. Dominador N. Braganza (C) Guinobatan Puericulture & Family Planning Center Guinobatan, Albay 2. Dr. Vicente E. Borre (C) Virac Puericulture & Family Planning Center Virac, Catanduanes 3. Dr. Ernesto S. Antolin (C) Balanga Puericulture & Family Planning Center Balanga, Bataan August 4-8, 1975 1. Dr. Tadeo D. Cortez (C) Nueva Ecija Doctor’s Hospital & Family Planning Clinic Cabanatuan City 2. Dr. Tiburdo S. Madas (C) Mayor Joaquin Macias Medical/ Surgical & FP Clinic Sindangan, Zamboanga del Norte 3. Dr. Lolita R. Tudayan (C) Training Division Institute of Maternal & Child Health, 11 Banawe, Quezon City August 11-15, 1975 1. Dr. Apollo Q. Duque (C) San Fernando Norte Puericulture & Family Planning Center Cabiao, Nueva Ecija 2. Dr. Roque C. Alba (C) Santiago Puericulture & Family Planning Center Santiago, Isabela August 18-22, 1975 1. Agerico L. Tecson Candaba Puericulture & Family Planning Center Candaba, Pamnanga 2. Dr. Aida M. Gatchalian (C) Bo. Kapitolyo Puericulture & Family Planning Center Pasig, Rizal Volume 5S Nos. 3-4 August 26-30, 1975 t. Dr. Virgilio L. Morales (C) Naguilian Puericulture & Family Planning Center Naguilian, La Union September 2-6, 1975 1. Dr. Estrellita M. Fullantes (C) Juan Sumulong Memorial Puericul ture & Family Planning Center Tanay, Rizal September 9-13, 1975 •1. Dr. Magdalena V. Catalan (C) Family Planning Physician E. Rodriguez Memorial Hospital & Family Planning Clinic Marikina, Rizal •2. Dr. Ma. Eliza Tech Veloso (C) Family Planning Physician Pasig Puericulture & Family Planning Center Pasig, Rizal ♦3. Dr. Rosalinda V. Viado (C) Family Planning Physician Baranca-Ibaba Puericulture & Family Planning Center * Mandaluyong, Rizal September 22-26, 1975 1. Dr. Virgilio M. Orillo (C) Family Planning Physician Bo. Washington Family Planning Clinic Surigao City 2. Dr. Maximo D. Soliman (C) Family Planning Physician Tanza Puericulture & Family c — Certified — Trained in the field by itinerant team Vasectomy 61 Planning Center Tanza, Iloilo City 2nd Quarter: October, November and December 1975 October 6-10, 1975 1. Dr. Samuel J. Babol (C) Babol’s Family Planning Clinic Matalam, North Cotabato 2. Ramon V. Blancia, M.D. (C) Blancia Hospital & Family Planning Clinic Molave, Zamboanga del Sur 3. Dr. Rene S. Sison (C) Sison’s Medical & Family Planning Clinic Valencia, Bukidnon October 6-10, 1975 (continuation! *1. Dr. Diosdado C. Asuncion (C) Municipal Health Officer Zambales (Masinloc) ♦2. Dr. Salvador V. Fune (C) Municipal Health Officer Sta. Cruz, Zambales ♦3. Dr. Lauro B. de Jesus (C) Municipal Health Officer Castillejos, Zambales ♦4. Dr. Bulan F. Roste (C) Municipal Health Officer Cabangan, Zambales October 21-25, 1975 1. Dr. Isabel O. Henares City Health Officer Bacolod City 2. Dr. Pedro S. de Guzman St. Jude’s Hospital Dimasalang, Sampaloc, Manila (Dr. Oscar Estrada & Dr. Lolita Tudayan) The vasectomy clinic has also trained 2 physicians of the I.M.C.H. for iti nerant vasectomy visits to various cities and towns of the Philippines. These phy sicians are Dr. Oscar Estrada and Dr. Lolita Tudayan. Dr. Estrada has since done over 606 vasectomies in over 30 ci ties and towns. Dr * Tudayan was re cruited primarily to train I.M.C.H. Fa mily Planning Clinic Physicians and Mu nicipal health of ficers in the provinces. To date, she has trained 4 municipal health physicians in Zambales province and 3 I.M.C.H. physicians in the Pasig Pueri culture and Family Planning Center in Pasig,1 Rizal. She next expects to go to train 10 physicians in Isabela Province very shortly. 62 Reyes, Jr. An Improved Vasectomy Technic Early in the first year of the Program, a standardized vasectomy technic that would enhance the acceptability of the operation was devised. The technic util ized 2 incisions, was virtually bloodless and painless, and accomplished in 3 to 5 minutes. Standardization of the pro cedure made it possible to train doctors adequately after assisting 5 and actual ly performing 5 vasectomies. This technic of vasectomy was depict ed in photographs, which together with the text of the first year experience with the program, was presented as a scientMje exhibit at the Annual Con vention of the Philippine College of Surgeons, held at the Pines Ho tel in Baguio City in December, 1974 and at the Annual Convention of the Philippine Pediatric Society held at the Hotel Intercontinental in May, 1975. Slides have also been made of the tech nic and these are projected during in formational seminars and lectures of the Clinic Staff. Motivational campaigns are also rendered interesting and convincing by showing these slides. The details of the technic of vasectomy as done in this clinic are as follows • 1. The whole scrotum and penis are rendered aseptic with Povidone Iodine (Betadine Solution). 2. Drapes are placed so that only the scrotum is exposed. 3. The left was deferens is grasped firmly so that the tip of the index fing er is beneath the vas and the thumb over it. 4. Xylocaine 1% solution is injected into the scrotal skin directly over the vas. Infiltration is continued into the tissues around the vas to avoid reflex pain in the abdomen when the vas is ex posed. March-April, 1976 J/P. M. A 5. A piece of gauze is used to press on the skin swollen by the injection un til the vas is easily discerned under the skin. 6. A small 3/4 centimeter transverse incision is made over the skin overlying the vas, making sure that the incision is made at the exact site of the infiltration of anesthesia. 7. A small towel clip with the jaws open just enough to accommodate the vas is used to pick it up and deliver it out of the scrotal skin. 8. The sheath of the vas is then in cised cleanly to expose the vas as a naked tube. 9. The vas is then picked up with the tip of a straight iris scissor. 10. A small straight mosquito clamp is then inserted beneath the vas so that 2 centimeters of it is fully exposed by pushing the clamp beneath the vas al most to the handle. 11. Two mosquito clamps are applied on both extremities of the exposed vas and at least 1 centimeter of vas is ex cised . 12. The cut exposed ends of the vas are ligated with 4-0 silk and the sutures cut short. 13. The vas is then allowed to slip back into the scrotal sac. 14. No sutures are necessary for the skin. Sutures cause pain and abet in fection . 15. The opposite side is similarly treated. 16. Compression on the operated area is applied by the patient’s right hand over a gauze dressing for 2 minutes to establish hemostasis. The simplicity and ease of execution of the operation as devised have result ed in a low morbidity. There were orily Vasectomy 63 VoJunje 52 Nos. 3-j 6 complications out of 69.0 vasectomies done, representing a complication rate of 0.8 of one percent. These complica tions were: 1. Hematoma ..................... 2 2. Swelling (edema) ........ 1 3. Oozing ........................... 1 4. Spermatic cyst ............ 1 5. Decreased libido ............ 1 TOTAL ~6 There were 337 patients out of 690 acceptors who returned for semen exa mination. All these showed no sperms in the semen after 30 ejaculations or 60 days following vasectomy. The success rate of the vasectomy based wholly on 337 patients who returned for semen examination is 100%. ACCEPTOR PROFILE The largest number of acceptors (50%) were in the age group 31-40 years. FIRST YEAR ACCEPTORS November 1, 1973 — October 31, 1974 Age Wife 20 — 25 18 26 — 30 48 31 — 35 64 36 — 40 51 41 — 45 8 46 — 50 1 514- 0 Unknown 47 TOTAL 237 Husband 11 38 71 69 31 13 3 1 237 SECOND YEAR ACCEPTORS November 1,1974 to October 31. 1975 Age Wife Husband 15 — 19 0 0 20 — 24 44 12 25 — 29 108 71 30 — 34 163 123 35 — 39 111 151 40 — 44 20 73 45 — 49 4 14 50 4- 2 9 Unknown 1 0 TOTAL 453 453 March-April, 197* J. P. M. A. 64 Reyes, Jr. The largest group of acceptors had 4-6 children (over 50%). FIRST YEAR ACCEPTORS November 1» 1973 to October 31, 1974 Number of Children: 0 — 1 .................................................................................................. 0 2 — 3 65 4 — 6 142 7 — 9 25 10 4- ...................................................................................................... 5 237 SECOND YEAR ACCEPTORS November 1, 1974 — October 31, 1975 Number of Children: 0 — 1 ................................................................................................. 0 2 — 3 129 4 — 6 ................................................................................................ 265 7 — 9 49 10 4- ................................................................................................... 10 453 The occupation profile of the acceptors FIRST YEAR November 1. 1973 to October 31, 1974 Occupation: Privately employed..................... 90 Laborers ...................................... 42 Drivers ........................................ 33 Gov’t employees ......................... 15. Businessman ............................... 10 Fishermen .................................... 7 Salesmen .................................... 7 Farmers ...................................... 4 Jobless ....................... .................. Vendors ................. . ............... U.S. Navy ............................ Janitors ...................................... Self-employed ............................. Pastors ........................................ Unknown ...................................... Student ........................ 1 < * in in co c m c m Vasectomy 65 Volume 55 Nos. 3-4 SECOND YEAR November 1, 1974 — October 31, 1975 Occupation: Laborers ..................................... 134 Privately employed ................. 91 Drivers ...................................... 68 Gov’t employees ....................... 34 Self-employed .......................... 25 Farmers ..................................... 19 Vendors .................................... 13 Salesmen ................................... 13 Fishermen .................................... 12 Jobless ........................................ 11 Restaurant workers ..................... 9 Unknown ....................................... 6 Security guards ......................... 5 Janitors ....................................... 4 Hospital workers ....................■.. 3 Students ................................ 3 Pastors .................... 3 Almost 2/3 of the patients came from the Greater Manila area and 1/3 came from the surrounding provinces. Some of the latter were done at visits to the provinces. FIRST YEAR November 1, 1973 — October 31, 1974 Patient’s Address: Patients from Manila & Greater Manila area ................. 169 Patients from the provinces ..................................................... 68 SECOND YEAR November 1. 1974 — October 31, 1975 Patient’s Address: Patient’s from Manila & Greater Manila area .................................... 337 Patients from the Province ..................................................................... 116 SUMMARY The vasectomy program of the Child ren’s Medical Center as funded by the Pathfinder Fund Inc. of Boston, Mas sachusetts, has just completed its sec ond year of operation. A total of 690 vasectomies have been accumulated with a success rate of 100% (based on acceptors who returned for semen exa mination) the complication rate is 0.8 of one per cent. The acceptability of the program, which took 5 long months be fore taking off, was to a large extent due to the technic of operation which has made the procedure a short, virtual 66 Reyes, Jr. ly painless bloodless one, with a low complication rate. The clinic has de veloped from one initially geared pure ly for service to one with a training ori entation. Trainees come from rural areas and this augurs well for the adop tion of vasectomy as a practical method of fertility control in the provinces. Vasectomy, however, has not yet reached the stage of acceptability that female sterilization now enjoys, and mo tivational efforts have to be maintained unrelentingly if the movement for vasec tomy is to maintain its momentum. Therefore, a certain amount of the funds for vasectomy programs should go to this particular item. The acceptor profile reveals that the majority of those who submit to the procedure are in the age group 30-40 years. The large majority have over 4 children at the time of sterilization. This trend is still not too favorable for population growth rate control. Motiva tion should therefore be directed towards those with three children or less. The class of present acceptors is on the side of the more educated segment March-April, 1976 J. P. M. A. of the population with a relatively high income level. The informational, edu cational and motivational thrusts of a.iy program for vasectomy must therefore be more vigorously directed at the eco nomically poorer and less educated seg ment of the population who in the long run are the ones who most need vasec tomy for fertility control. The movement to popularize vasecto my as a fertility control measure should emphasize its effectiveness, its low cost, its simplicity of execution with the mi nimum of instruments, and the feasibility of its widespread implementation with out sophisticated training of those who do it in a rural setting. When with drawal of support from foreign fundings deprive the country of what now is abundantly available contraceptive ma terials and devices, we may have to lay more emphasis on vasectomy as a prac tical solution to the problem of fertility control. This program which we are undertaking has given us an insight into the problems of this sterilization move ment in males, but at the same time, it has broken down some of the barriers that had heretofore prevented its ac ceptance . Stauts of Pediatric Education in the Philippines * **Medlcal Director, Children's Medical Cen ter Philippines. 'Read in the Confethance on Pediatric Prob lems in Tropical Countries sponsored by South Asian Regional Seminar on Tropical Medicine and Public Health (SEAMEO), Bangkok, Thailand, November 27, 1975. FE DEL MUNDO, M.A., M.D.— MEDICAL AUTHORITIES and educa tors in the Philippines have in recent years been more encouragingly respon sive than in the past, to the increasing requirements of Pediatrics in the medic al curriculum. It has taken time and ef fort to attain these aspirations for Pe diatrics but now favorable and encour aging trends are evident. In this country, four important con ferences have favorably influenced the teaching of Pediatrics: namely, the Pe diatric Education Seminar of the West ern Pacific Region, WHO, in February 1967 the First and Second National Con ference on Medical Education under the asupices of the Association of Philippine Medical Colleges (APMC) in 1968 and 1972 respectively, with logistic support from the Josiah Macy Foundation: and the Nutrition Seminar for Medical Edu cators in 197?, also under the auspices of APMC. These conferences have, di rectly or indirectly, accelerated revision and changes in pediatric education, with ** fruitful and far-reaching effects. An outstanding factor in the progress of Philippine pediatric education has been the Philippine Pediatric Society, with its annual conventions, its Qualifying Board, and its varied activities to upgrade the teaching and practice of pediatrics. Social awareness and involvement in communities now pervade all disciplines. Medical education in general, but pedia trics in particular, has been very much influenced by this trend. Concern for the rural population has increased, al though implementation of measures in their behalf has not been as fruitful as desired and hoped. In the Philippines, noteworthy is the fact that the nine medical schools (two were opened in 1975), collectively and individually have taken valuable meas ures and formulated revisions and re commendations to upgrade pediatric edu cation . BACKGROUND Significant in justifying changes in pediatric education in the Philippine are day to day observations on trends in the country as well as information obtained from current Philippine Health Statis tics and Demographic Data thus: 67 68 del Mundo March-April, 1976 J. P. M. A Table I. HEALTH AND DEMOGRAPHIC DATA PHILIPPINES, 1973 Total Population Total children under 15 (43% of the total population) Registered Births Ave. birth rate (1963-73) Crude death rate Growth rate Fertility rate Infant Mortality rate 40,219,000 17,385,000 1,049,290 26.1/100 live-births 7.0 2.8% 119.9% 64.7/1000 live-birifchs The latest statistics show a total of 17,385,000 children under 15 years or 43% of the total population, as compared to 25% in developed countries. The average birth rate for the past 10 years (1963-1973) is 26.1 per 1000 popu lation. The figure 1,049,290 represents the total number of births registered in 1973. Of this number, 49 .6% did not have the benefits of medical attendance. Among those who were medically at tended 45.4% were delivered by physi cians; 6.2% by nurses and 48.4% by midwives. In 1973, 23.3% were delivered in hospitals while 76.7% were home de liveries. The neonatal mortality rate is 32.5 per 1000 (Table II) which is 2 to 3 times that of developed countries. It has also been noted that pre-school mortality rate in the Philippines is 60 to 80 times that of Australia and New Zealand. It is accepted that pre-school mortality rates are more sensitive indices of the socio-economic status of a country and the efficiency and organization of child health services than the infant mortal ity rates. Table II. NATALITY STATISTICS, PHILIPPINES 1973 Neonatal Mortality Rate Maternal death Tate Birth attendance Assisted by Physicians Nurses Midwives Place of birth In hospitals Home deliveries 30.3/1000 1.4% 57.3% of births 45.4% 3.9% 24.3% 23.3% 76.7% Volume 52 Nos. 3-4 Although the present maternal death rate of 1.3% was reduced by 83.3% in the past 50 years, this rate is still three times that of progressive countries. Medical Manpower There are approximately 13,600 active physicians in the Philippines today. More than half are based in the cities. Onethird are concentrated in Metropolitan Manila. Overall ratio in 1970 was approximate ly 1 physician per 2,800 population. Mal distribution continues to be a serious Pediatric Education 69 problem and the solution to medical man power loss is far from satisfactory. A compulsory six-month service in rural areas before granting medical licensure may to some extent help our masses. The bulk of pediatric practice in the Philippines is in the hands of the gen eral practitioner. The majority of those who limit their practice to pediatrics or who spend considerable time to children, are registered in the Philippine Pediatric Society and so the membership of this Society may well be taken as represent ing the pediatric manpower supply of the country. Table ni. PHILIPPINE PEDIATRIC SOCIETY MEMBERSHIP 1975 Total Members Classification: Fellows 111 Specialists 109 Active 266 Affiliate fellows 8 Associates 70 Distribution Greater Manila 435 Provinces 129 The maldistribution of physicians who have had additional training in Pediatrics and Child Health is evident. Thus 4/5 of pediatricians are in and around Mani la while 1/5 are spread in the rest of the country. Some countries have reported a ratio of 1 pediatrician to 1000 child ren. In the Philippines the average pro portion is approximately 1:30,000 child ren. Table IV. RATIO OF REGISTERED PEDIATRICIANS TO CHILDREN, PHILIPPINES (1975) Number of Pediatricians Registered in PPS Ratio Greater Manila 2,602,200 435 1:6000 Provinces 14,200,000 129 1:110,000 Total Average 16,802,200 564 1: 29,800 70 del Mundo UNDERGRADUATE PEDIATRIC EDUCATION In recent years both the status and hours allocated to Pediatrics in the me dical curriculum have improved signific antly (Tables VI, VII, and VIII). To a large extent these have resulted from recommendations of medical education seminars and conference previously mentioned. Fundamental Principles One of the guiding principles in thepreparation of the pediatric curriculum in the nine medical schools of the coun try, is the basic objective of a medical school in the Philippines as defined in the First National Conference on Me dical Education, thus: “The basic objective of a medical school is the production of a basic physician, that is, one who is well rounded in all aspects of medicine, who can take care March-April r \97& J. P. M. A of his patients adequately in general practice in his particular environment, and who is all prepared to take up any bianch of medical science after gradua tion.” Another fundamental principle is the realization of a need for comprehensive and continuing care of a growing and developing subject, highly sensitive and vulnerable to the environment. We subscribe to the central concept of pe diatrics and child health as a concern for normal child development; that the stu dent should be introduced to the study of growth and development (physical, intellectual, emotional and social) and those factors which cause significant de viations from the accepted norms. Apportionment of Clinic Hours It is encouraging to note that present ly Pediatrics ranks third (Table VII) in the apportioning of total cHnrc hours and this comes close to Surgery. Table V. *HOURS IN MEDICAL SCHOOLS, PHILIPPINES (197<V Total hours 4,000 ** Apportioned into Basic 1/3 Clinical 2/3 Apportionment of Clinic Hours Medicine 30 — 32% Surgery 20 — 22% Pediatrics 15 — 18% OB-Gyn 12 — 15% Psychiatry & Neurology 10 — 12% EENT 5 — 8% *From the Association of Philippine Medical Cofleges (APMC) *Excluding the 2 months of full clinical clerkship in Pediatrics and the duties at night, also Sundays and holidays. Volume 52 Nos. 3-« Pediatric Education 71 It is also an observation that a good portion of Community Medicine is taken up by Pediatrics since children constitute about 47% of the population in most Table VI. IVTH YEAR 10-12 Medicine Surgical Pediatrics OB-Gyn Psychiatry Community Medicine EENT communities. Further as recommended by the WHO Pediatric Education Semi nar, Pediatrics is integrated with the other clinical disciplines. MONTHS ROTATING FULL-TIME CLERKSHIP1' 3 months 2 — 21/2 months 2 months 1 — 11/2 months 1 month 1 month (extramural) 1/2 — 1 month (APMC) program schedule as follows?: All the medicel schools presently give much more than the recommended 300 hours; some have more than doubled the time for Pediatrics, which also is started earlier, with the basic Subjects. Table VIII. TIME ALLOTED TO PEDIATRIC (1973-75) MCU FEU UP CIM U * E OST swu First 3 years 204 169 137 170 168 197 94 Fotirth Year 2 mo. 2 mo. 2 mo. 11/2 mo. 2 mo. 2 mo. 2 mo. (Clerkship) Total Pediatric hours 650 432 549 Total hours medical curric. 4815 5468 4104 *rrom the Association of Philippine Medical Colleges The number of hours alloted to under graduate pediatric teaching as recom mended by different pediatric education seminars are 300 to 400 hours excluding of the internship period. The 1963 con ference in Manila suggested a minimum Students and Faculty members The student enrollment in medical schools has been reduced in recent years so that classes are now less congested than in the past. Nevertheless there are still more students than abroad * so that three sections per year with 40 to 50 students each, are still observed. Table IX. ENROLLMENT IN MEDICAL SCHOOLS, PHILIPPINES Medical School Univ, of Sto. Tomas Univ, of the Philippines Manila Central Univ. Far Eastern Univ. Southwestern Univ. Univ, of the East Cebu Inst, of Med. Ave. Undergraduate Med. Students Per Academic Year 1968-73 1,250 400 825 1,150 950 850 725 Freshmen Quota 300 None; usually 85-100 200 but will admit 100 in 1974-75 300 100 beginning 1974-75 300 but admits 250-270 200 72 del Mundo The proportion of faculty to students is still unsatisfactory. To some extent this had been improved by affiliating with some accredited teaching hospitals and providing pediatric supervisors from the medical school. This has also increased bed capacity for teaching purposes. Full time staff have been appointed in 4 schools while in 3 schools all teaching staff are on part time basis. The salaries of the staff leave much to be desired and in fact are unrealistic to current cost of living; hence it is not easy to obtain full time staff. Topics, Time alloted, and methods The departments of Pediatrics of the seven medical schools have availed of a list of topics and time per topic as re commended by a Committee of the APMC in its First National Conference on Medical Education (Annex A). De tails as to methods and on what year to take them up have been left to each school. Topics that have been allocated more hours are as follows: Characteristics and Problems of Vari ous Age Periods (up to 14 hrs.) Growth and Development (6 to 14 hours) Physiology and diseases of the new born (6 to 16 hours) Communicable Diseases (20 to 30 hours) Digestive System (4 to 15 hours) The trend is to introduce Pediatrics earlier in the second year, starting with such topics as Growth and Development, Genetics, Nutrition and Social and Pre ventive Pediatrics. Steps have been taken to integrate Pediatrics into some of the basic subjects and other clinical disciplines. Didactic lectures have been reduced in March-Aprlt, 1976 J. P. M. A. favour of bedside and extramural acti vities. Preceptorship of small groups is commonly observed. Assignment with pay patients has been started in at least one school. Health education of parents and teach ing them some procedures in the care of sick children are activities of medical students in the hospital or in communi ty projects. Family planning and maternal and child health have been emphasized both in urban and rural setting so that me dical students now have opportunities to do motivational work and give family planning services. A health center in an urban poor lo cality or in a rural area is now under a medical school and child care in such a center is under a staff of the Depart ment of Pediatrics. Although the past three years have been years of adjustment and revisions to meet the new 4 year medical curricu lum (Annex B), it may be said that there have been aggressive and positive steps to tailor pediatric curriculum to Philip pine needs. Research A deplorable aspect in medical educa tion in the Philippines is the lack of in centives for students or faculty to do commendable research work. Student re search is encouraged in 3 schools and the students themselves have taken the ini tiative of developing a research fund. The Philippine Pediatric Society during its annual convention offers research contents, a motivating factor to do re search. One company awards a yearly research fellowship per school which may be for Pediatrics. Lactogen Full-Protein. The ideal follow-on formula. Protein needs increase in relation to a baby’s age and weight. And because the non-milk part of the diet is usually a most unreliable source of protein, the milk given to growing babies should compensate with an adequate supply of protein. This is why Lactogen Full-Protein is the ideal formula during follow-on time ... when the number of baby’s milk feeds are gradually reduced and weaning foods are introduced into his diet. At full strength. Lactogen Full-Protein contains 3.24 q. of cow’s milk protein per 100 cc. By contrast, most humanized formulas provide only 1.5 to 1.7 grams of cow’s milk protein per 100 cc. COMPARATIVE PROTEIN CONTENTS INITIAL DILUTION FULL STRENGTH LACTOGEN FULL-PROTEIN MATURE BREAST MILK 1.1-1.2 g./1OO cc. MOST HUMANIZED FORMULAS 1.5-1.7 g./100 cc. The protein content of Lactogen FullProtein is above that of most milks suggested for routine infant feeding and meets a baby’s daily protein needs in only two feeds. Take the example of a 6 kg. infant, likely to be 4 to 6 months old. Such a baby will need approximately 12 g. of protein a day. With two 200 cc. feeds of Lactogen Full-Protein, these needs are covered. '* Considering cow’s milk protein to be equivalent in quality to breast milk protein It is clear that the protein supply from the other feeds can thus be minimal without harm to the child. So when a mother starts baby on weaning foods, make sure he gets the protein he needs at his age. Prescribe Lactogen Full-Protein. The ideal follow-on formula. Complete — with a full range of vitamins and iron in physiologically appropriate quantities. What’s all this about protein-calorie malnutrition? AVERAGE WEIGHTS AS PERCENT OF STUART STANDARDS OF BULACAN PRE-SCHOOL CHILDREN AGE (MONTHS) A local study by the USAID * revealed that nutritional deterioration occurs during the first 6 to 11 months of an infant’s life, and is caused mainly by poor weaning practices. While weaning foods, like “lugao”, can supplement a baby’s diet, they are often relatively low in protein — particularly good-quality protein. Monthly data from the same study (see graph above) suggest that the child grows satisfactorily while he is being breast-fed and the supply of mother’s milk is adequate. But after the sixth month, mother’s milk alone, or mixed feeding with rice-based weaning foods like “lugao”, is not enough to support the rapidly-growing infant. What is needed is a guaranteed daily protein supply when such weaning foods could represent 3 out of 5 of the day’s feeds. It is for situations like this that Nestis has come up with an ideal supplement or follow-on formula to breast milk and to humanized formulas... ‘Report of the Bulacan Province Nutrition and Family Planning Program, December 1972. in manuscript form, Nutrition Division. USAID, Manila, Philippines. Votame 52 Nos. 3-4 Evaluation of Students There has been very little change in the evaluation of medical students; we still depend to a large extent on exa minations and recitations and at times evaluation of preceptors. In the clinical years, presentation of cases, participation in conferences and performance in patient care are assessed. A final qualifying examination is given at the end of clerkship. Oral examina tions have been discontinued. The Medical Board Examination to some extent allows individual evalua tion of students and a comparison of stu dents from the different schools. A Pediatric Residency Training Pro gram usually consists of 3 to 4 years training in the Department of Pediatrics of a University hospital or in some ac credited training center or hospital un der a certified Fellow in Pediatrics. As formal residency programs are limited to teaching hospitals in bigger cities, there are not enough opening for all graduates who wish to specialize in Pe diatrics. Therefore, a big number of graduates start a year or two in any local hospital but subsequently leave for abroad. In fact even residents in uni versity and teaching hospitals seldom re main longer than one or two years in the country. Pediatrics is one of the most popular fields among graduates who leave. Unfortunately those who return to practice can be counted with the fin gers. Some information on residencies in the seven Philippine medical schools are summarized in Table X. An example of a residency training program leading to a specialist certific ate of the Philippine Pediatric Society Pediatric Education 73 is summarized in Table XI and the dis tribution of residents’ assignments in the 3 or 4 years residency program is shown in Annex C. It is gratifying to note that those who complete 3 to 4 years under a residency training program in the country succeed as pediatricians whereever they practice, particularly when the practice is outside of Greater Manila. POST-GRADUATE AND CONTINUING PEDIATRIC EDUCATION During the one-year rotating intern ship after the M.D. degree is confer red, a two-month assignment in Pedia trics may be considered as a post-gradu ate course before licensure of practice. This prepares the physician for general practice, of which 40% to 60% is pedia trics. Since 1968 the University of the Phi lippines has given 2 to 3 week annual courses in Pediatrics for practitioners. The University of Sto. Tomas has also given such courses since 1971; the FEU started a Community Pediatrics Course with Community Obstetrics last year. Hie other schools give annually short courses for their own alumni. Medical societies have offered half to one-day courses in pediatrics for practi? tioners. In fact pediatric refresher cours es are popularly requested by practitio ners and the Philippine Pediatric Society has annual courses in different regions of the country. SUMMARY AND CONCLUSIONS While Pediatrics or Child Health has been recognized as an autonomous de partment in all the medical schools in the Philippines for about 50 years now, significant gains have been attained only in the past eight years, following a Pe74 del Mundo Aarch-April, 1976 J. P. M. A. o c b- © b" RIC RESIDENCY TRAINING PROGRAMS IN UNIVERSITY HOSPITALS, PHILIPPINES 1974 a P I 8 >» >• 8 § § s p s s 3 8 8 I CM iH © CM o co £ CD 8 bi 2 to •rA T5 03 CO VI th CD >< a co rH 8 £ O 1/5 3 44 CD CD bi £ § £ w> 0) £ 00 © 00 co CM M 8 t X 8 JS £ 8 •§ £ in CD <s> 40 in CM co $ eM s 8 T5 CM £ 00 CM s T—i 8 O co 8 t-I © £ 8 T? LO gm co * Volume 55 Nos. 3-4 Pediatric Education 75 Table XI. A PEDIATRIC RESIDENCY TRAINING PROGRAM * (3 or 4 YEARS) I. Clinical Training A. General Pediatrics (b. Pay 1. In-Patients (a. Service (b. Pay 2. Out-Patients (a. Service B. Care of Newborn Infants General Nursery Neonatal Intensive Care Unit (NICU) C. Preventive Pediatrics Child Health Clinic School Health Service D. Outpatient Subspecialty Clinics 1. In the hospital Neurology Hematology Allergy Cardiology Radiology Surgery Pathology II. Clinical Laboratory for Pediatric Procedures m. Community Pediatrics — Attend a 3-week Course at the Institute of Maternal and Child Health for training in Maternal and Child Health and Family Planning, prior to — Community Health and Medical service (outside headquarters). 1. San Luis, Pampanga 55 Km. 2. Niugan, Malabon 10 Km. IV. Research and/or Case Report V. Teaching: Tutoring of affiliate medical students •At the Children’s Medical Center Philippines. 76 del Mundo diatric Education Seminar in the Region under the auspices of World Health Or ganization in 1968, two National Con ferences on Medical Education in 1968 and 1972, and a Conference on the teach ing of Nutrition in Medical Schools, the last three assisted by the Josiah Macy Jr. Foundation, through the Association of Philippine Medical Colleges. Worthy of mention among recent changes in undergraduate pediatric education are: — More teaching hours for Pedia trics ] Child Health, above the recommended 300 or 400 hours so that some schools are giving up to 800 or more hours. — Introduction of the subject earlier in the medical curriculum, mostly in the second year or even in the first year. — Full time staff so that only two schools have none; before 1968 practically there were no full time staff in any of the schools. — Classes are small and more ma nageable as a result of a reduc tion of total enrollment for pur poses of accreditation. Whereas there were 200 to 250 students taking up pediatrics per year, the number has diminished to less than half so that there are only 2 or at most 3 sections instead of 5 or 6 sections per class. — Closer relations and integration in the basic subjects as well as cli nical departments are now imple mented. — Community pediatrics is very much emphasized so that extramural teaching and community involve ment have increased strikingly. In March-April, 1974 J. P. M. A this connection: * Medical schools have communi ty projects both in urban poor and rural areas with one center under its charge and a pediatrician staff supervising child care. * Maternal and Child Health and Family Planning have received special attention with the students and residents actively participat ing.. * Nutrition is now taught with greater emphasis and more at tention given to practical aspects and current problems. — Almost all of the Pediatric facul ty members have undergone teacher training courses including live-in and sensitivity training. — Evaluation methods have been de vised which include minimum pass level and quartile deviation; stu dent counselling by faculty advi sers concerning problems on scho lastic performance and related contributory factors; the use of standard performance evaluation sheets, feedback evaluators of the services and staff by the students and periodic assessment of the se nior students totality of knowledge in clinical pediatrics though an oral and written exams at the end of their pediatric training. In the residency training programs, there are more systematic programs. Extramural activities constitute an im portant part of the program. Re idents have been increased an stipends are slightly more reasonable. Evaluation methods have been improved. As regards post-graduate and continnVolume 52 Mos. 3-4 Pediatric Education 77 ANNEX A PEDIATRIC TOPICS AND TIME ALLOTED Subject Matter Time Allotment in Different Schools Rec. by APMC * MCU FED UP CIM UB US® swu Characteristics & Problems of Various Age Periods 4 12 1 1 9 2 14 2 Physiology & Dis. of Newborn 12 16 11 9 13 6 16 8 Social Pediatrics Including Family Planning 3 2 8 3 0 4 5 4 Preventive Pediatrics 2 3 2 4 3 5 2 Growth & Development 10 11 9 10 6 13 14 6 Genetics 3 2 1 5 3 2 History Taking & P. E. 4 2 12 3 6 1 4 Therapeutics & Pediatric Procedures 3 8 5 3 1 3 Infant Feeding & Problems 6 5 6 3 6 12 6 6 Nutrition &. Its Disturbances 6 7 6 2 7 12 6 8 Psychopathologic Problems 3 4 2 4 3 2 Fluid & Electrolyte 5 7 5 3 7 7 7 4 8 Communicable Diseases 25 20 30 Respiratory System 6 15 13 5 11 1 3 4 Digestive System 5 15 10 4 6 9 7 6 Genito-Urinary 5 9 7 4 4 1 3 4 Nervous System & Convulsive Disorders 10 10 6 5 10 1 3 6 Cardiovascular Disease 8 10 9 11 6 8 3 4 Blood & Blood Forming Organs 6 10 6 5 6 4 3 5 Inborn Errors of Metabolism 2 2 5 2 7 2 0 3 Collagen Diseases 2 6 2 3 0 0 3 2 The Skin 2 4 0 2 4 0 1 Musculoskeletal System 2 2 0 3 6 0 2 Neoplasms 2 4 0 6 1 2 2 Pediatric Emergencies 5 2 3 1 1 1 Allergy Immunology 4 0 5 7 4 0 1 Endocrine Glands 5 8 5 7 14 3 3 2 Spleen, Thymus, & R-E System 4 2 5 1 7 1 3 2 Unclassified Diseases 2 2 9 Total Hours 203 161 132 162 101 100 114 *First National Conference on Medical Education. Asso elation of Philippine Medical Colleges 1968. March-April, 1976 J. P. M. A. 78 del Mundo ANNEX B REQUIREMENTS FOR M.D. IN THE PHILIPPINES (1972) — Baccalaureate Degree: 4 years AB or BS — Four years in a recognized Medical School, the 4th year of which is 10 to 12 months full clerkship with 24 hour duties, including Sundays and holidays. — M.D. degree is conferred — One year rotating internship in a hospital or medical eenter accredited by the Board of Medical Education. — Licensure Examination to qualify for practice — Six months of service in rural areas under the auspices of the Department of Health before the Certificate of Licensure is awarded. ing education, the rotating internship after the M.D. degree has added to the practice and experience of the new gradu ate before practice. A rural assignment of 6 months by the Department of Health exposes the new graduate to community medicine and public health, both for service and gain ing experience on practice in less privil eged areas. The problems encountered show that there are still many steps and measures to take before reaching close to satis? factory pediatric education, the principal problems of which are logistics, materials and teaching aids; large classes; lack of full time and more staff resulting in in adequate supervision; and implementa tion of satisfactory evaluation of stu dents, staff, and school. ACKNOWLEDGEMENT The author acknowledges with deep appreciation the help extended by Dr. Jo$q Cuyegkeng, Executive Director of the Association of Philippine Medical Colleges (APMC) for valuable data, in formation and APMC reference books on Medical Education in th© country. Dr. Leticia S. Cordero of the Far East ern University and Dr. Juanita Yadao of the Children’s Medical Center Philip pines, helped gather data from medical schools and some teaching hospitals. Dr. Franz Rosa, MCH Adviser of WHO Western Pacific Region made available some WHO references on medical ed ucation. This paper would not have been pos sible without the valuable cooperation of the chairmen and assistants of Pe diatrics of tliA seven medical schools^ namely: Dr. R. G. Arellano of the Uni versity of Sto. Tomas; Drs. L. Mafrilangan and R. Mendoza of the University of the Philippines; Dr. Pablo Abella of the Southwestern University in Ctebu City; Dr. S. Alikpala of the University of the East; Dr. L. Cordero of Far East ern University; and Dr. Purification Es pinosa of the Cebu Institute of Med cine^ and Dr. Rosita C. Brillaptes of the Ma nila Central University. Volume 51 N.:s. 3-4 Pediatric Education 79 Q < 3 O O rH 03 rd 03 S >> cd S & x Z 's "cd ’S X o •rK .s G & co ci 5 co Radiology Allergy-PGH (2 weeks) Neurology-UE or PGH (2 weeks) X cd Q <u 8 £ > .s 8 5 cd oo co in cd r- <x> CO* 'CH in <D vi L* □ O ’£ o O CD tJ 3 2 <3 on c 'c cd F—< >» ci cx5 ci 80 del Mundo March-April, W7* X P. M. A. 10. Clinical Laboratory 10. Subspecialty Clinics 10. Elective (1 month) Hematology Infectious Diseases Cardiology SLH (2 weeks) I 5 42 c Q I £ Q 2 Volume 52 Nos. 3-4 Pediatric Education 81 Q ■TRIG RESIDENCY TRAINING PROGRAM (THACHING HOSPITALS) Q 8 Q 75 t»n C cd £ ct> O Q r~1 T5 +-> l o £ o T—1 T~1 g CM > Cl in CT) cd T—I 'o5 4-> o J-i o g +-» 0 CO 0 CT> T—1 co 0 LO (N CT> co in cO +-> o +-» in in o in b- co r * S-( cd if i rd Tt< % 2 > 75 cd 3 I Q & o O 0 Cardiology : Cardiovascular : Cardiology — 88 : Cardiology : ER — 4,500 : Cardiology 5/m< March-April, J. P. M. A 82 del Mundo >» s-> b o — E Ct d 2 o O o c £ I. o X tC o .2 o T3 <D CO o to ’co tn 3 6 x> C rt E fl m 4u in o W) o a in T—< 1 fl .2 ’■fl in & a 03 n H4 CO fl in N >» o Oi >-> S ‘fl o +-> CO S fl ^4 X ‘45 o s o E cT o o o o o in o £ r o q o o 5 ?0 o o o o o 00 in | o Ln rH o rH 1 & 1 & 4-» o X •2 o bJO £ o CD o X Cfl 5 < cu t* 3 .2 fl 3 'fl C/1 42 fl 3 c/1 >-» O o o I « to 00 + + w O *01 2 o a o •fl fl *s fl a X fl <D X fl o X fl X <d ’fl 4-» .2 jfl i -M C/1 ■g 'E fl JD E fl 3 *cn C/1 ’43 rH O1 co 05 co in 3 Z <D & fl »8 fl 0 CO oi co in CO . Duration : : s : : : Residency 4 years : 3 years : 3 years : 3 years : 4 years : 3 years Volume 52 Nos. 3-4 BIBLIOGRAPHY ). Cagas, C.R., Purugganan, H.G., and Abrio-Lopez, S.: Pediatric Education in tne Philippines Past Present Future, Phil. J. of Pediatrics, XX.764, 1971. 2. del Mundo, F.: Identifying and Meeting Priorities for Better Child Care In the Philippines, Phil. Jof Pediatrics, XX: 197, 1971. 3. Population. Produced by the National Media Pro duction Center, Manila, Philippines, 1973. 4. Papers and Proceedings of the First National Conference on Medical Education. Published by the Association of Philippine Medical Colleges, Manila, Philippines, 1969. 5. MacDonald, W.B.: Paediatric Education Priorities In Asia and the Western Pacific Regional, Aus tralian Pediatric Journal, Dec. 1967, 3:4-181. 6. Physician and Nurse Manpower Survey Report. Association of Philippine Medical Colleges, 1967. Pediatric Education 83 7. Philippine Health Statistics 1971. Disease Intelli gence Center, Department of Health, Manila. 8. Runaway Population. 1974 World Population Year. Produced by PIEO/NMPC, Manila. 9. del Mundo, F.: A Report on the Pediatric Edu cation Seminar Western Pacific Region, WHO, Manila. February 13 to 18, 1967, J. of the Phil. Med. Asso. 43:12, 976-978, Dec. 1967. 10. Report of the Meeting on Paediatric Education India World Healt hHouse, New Delhi, WHO Re gional Office for Southeast Asia. Oct. 1968. 11 Mettrop, G., M.D.: Future Pediatric Education. Undergraduate and Postgraduate. European Con ference on Paediatric Education. Netherlands, April 22-29. (Handout) 12. Keeve, PJ.: Observations of a Visiting Physician, Phil. J. of Pediatrics, V. XX, 158, 1971. 13 King, M (ed): Medical Care In Developing Coun tries, Oxford University Press: 1966. ANNUAL REPORT OF THE PMA NATIONAL TREASURER February 15, 1976 To the House ot Delegates: As Tam about to end my third year in office as PMA National Treasurer, it is nxv pleasure to report the following: 1. PMA FUNDS — Oar Association is now in a very good financial position. Our Cash on Hand, in Banks, and short term investments have reached the million peso mark. 2. PMA LOT — The total contract price of the 5,019,8 sq. m. PMA lot ac quired from the PHHC was £612,405.40. As of December, 19TB, the total payment made for the lot was £486,058.74. The balance payable in 43 monthly installments of £2,940.62 would be £126,446 J56 to be completed within 3 years and 7 months. However, upon the approval of the Executive Council, we have paid the balance of the loan in FULL on January 15, 1976 in the amount of Fl'WjBB8.81 saving for our Association more than £17,000.00 in interest. 3. PMA BUM-DING — As we have previously reported, all indebtedness to the United Construction Co., Children’s Medical Center, and to Cuasay Suarez Plumbing Services in the construction of the PMA Building were fully liquidated including per sonal loans without interest from Dr. Jesus V. Tamesis, Dr. Fe del Mundo, and Dr. Rosita Rivera-Ramirez. The total expenditures incurred for the construction of the PMA Multipurpose Pavilion was £1,002,413.69. 4. MATEF & DBP FUNDS — Our total disbursement from March 16, 1975 to January 31, 1976 was £162,883.77. Upon the approval of the Executive Council, we have increased the Matef Benefit from £3,000.00 to £4,000.00 starting January 1, 1976. In my opinion, we can further increase the Matef Benefit in the next fiscal year 1976-77. As of January 31, 1976, the total Matef & DBP Fund Is £539,736.51. 5. PMA JOURNAL — We have separated the Journal Fund from the Opera ting Fund upon the suggestion of our Editor. As of January 31, 1970, the total re served fund for the Journal is P38.812.62. 6. PHYSICIANS FUND — As of January 31, 1976, the amount of £165,321.61 of our Physicians Fund are all invested in the money market securities. 7. DOLLAR DEPOSIT — Our dollar deposit in the Bank of Ainerica as of January 31, 1976 is $5,573.80 recorded in the books at the conversion £ftte of £6.00 to U.S. $1.00. At the current exchange rate of £7.30 to U.S. Sl.OOj this deposit would amount to £40.688.74. 8. DUES to the WORLD MEDICAL ASSOCIATION — Due to restrictions on dollar exchange, we were unable to pay in due time our obligation for dues to the World Medical Association. Our totalunpaid dues after condoning some of the previ ous years, is 15,148 Swiss Francs or approximately £35,535.92. It was Suggested by the World Medical Association that during this period of currency transfer difficul ties, wc can pay our dues by opening an account for the World MediCal Association in one of our local banks. We sent follow up letters informing them to submit the necessary papers required by the bank duly authenticated by a Notary Public at the Philippine Consular Office. Unfortunately, up to this time, the requirements were not fully complied with by the WMA. In the meantime, we have opened a separate bank account in the CBTC on January 14, 1976 in the amount of P35,535.82 under the name of PMA-WMA. 84 Volume 52 Nos. 3-4 Treasurer’s Report 85 9. INVESTMENT PORTFOLIO — With the approval of the Executive Coun cil, we have invested a greater portion of the funds in higher interest earning and safe investments. As of January 31, 1976, to total fund in money market placement is P728,505.00. Of this amount, P428,505.00 is MATEF & DBP Fund. 10. SALARIES OF PMA PERSONNEL — Due to the high cost of living, we have increased gradually the salaries of our PMA employees including the 10% ac ross the board salary increase, the P50.00 emergency allowance, and Christmas. Bo nus (1 month salary). 1. Other REPORTS — a) Attended all the Executive Council meetings and submitted in detail, month ly statement of receipts and disbursements with comparative figures of previous months, and monthly balances of cash in banks and short term investments. b) Published in the bi-monthly issue of the PMA Journal, the Treasurer’s Re port to keep members informed on the PMA Finances. c) Remitted regularly component societies’ share in membership dues. d) Acknowledged promptly all remittances received from component medical societies. e) And lastly, I would like to put on record the invaluable support and coope ration rendered by the Accounting, MATEF & DBP, Membership Record, and the Journal Sections in the PMA Staff. (SGD.) HILARION C. DE DIOS, M.D. PMA National Treasurer Republic of the Philippfcies Department of Public Worlds and Communications BUREAU OF POSTS Manila SWORN STATEMENT (Required by Act 2580) The undersigned, HILARION C. DE DIOS, M.D., Business Manager of the JOURNAL OF THE PHILIPPINE MEDICAL ASSOCIATION (title of publication), published Bi-monthly (frequency of issue), in English (language in which printed), at Quezon Qty (office of puWeation), after having been duly sworn in accordance with law, hereby submits the following statement of ownership, management, circulation, etc., which is required by Act 2580, as amended by Commonwealth Act No. 201, NAME ADDRESS Editor: AUGUSTO J. RAMOS, M.D............................... North Avenue, Dil., Q. C. Managing Editor: RAMON R. ANGELES, M.D............. North Avenue, Dil., Q. C. Business Manager: HILARION C. DE DIOS, M.D.........North Avenue, Dil., Q. C. Owner Publisher: PHILIPPINE MEDICAL ASS’N......... North Avenue Dil., Q. C. Printer: SISON’S PRINTING PRESS ...........................536 Quezon Blvd., Q.C. Office of Publication: PHIL. MEDICAL ASS’N................. North Avenue, Dil., Q. C. If publication is owned by a corporation, stockholders owning one per cent or more of the total amount of stocks: Bondholders, mortgages, or other security holders owning one per cent or more of total amount of security: In case of daily publication, average number of copies printed and circulated of each issue during the preceding month of ................................... 19........... 1. Sent to paid subscribers ......................................................... ......................... 2. Sent to others than paid subscribers ................................. ......................... Total................... ......................... In case of publication other than daily, total number of copies printed and cir culated of the last issue dated, January-February, 1976. 1. Sent to paid subscribers ......................................................... 10,000 2. Sent to others than paid subscribers ................................. 200 Total ..................... 10,200 (SGD.) HILARION C. DE DIOS, M.D. Business Manager SUBSCRIBED AND SWORN to before me this 6th day of April, 1976 at Manila, the affiant exhibiting his/her Residence Certificate No. A-3876454 issued at Quezon City on Jan. 13, 1976. (SGD.) RODRIGO C. MANAOG Postal Inspector NOTE: This form is exempt from the payment of documentary stamp tax.