I should be finishing my readings in preparation for clinic this afternoon, but after reading most of the day yesterday (it was an international holiday for people living outside the USA), I guess I am entitled to spend some time writing.
Besides, I spent an illuminating morning with Dr. Jose Mayagoitia Witron, MD, FACS over at Mexicali General Hospital. While he was telling me what he doesn’t do: (no uniport laparoscopic surgery, and not a huge amount of bariatric surgery), what I observed told a very different story.
I didn’t follow Dr. Mayagoitia to the operating room. Instead – I accompanied him to a teaching session with his medical students, who presented case studies – and I observed Dr. Mayagoitia instructing his students in the ‘Art of Medicine’. This skill is fast becoming a lost one in today’s emphasis on the science of diagnostics, and laboratory testing. But not here, not today – and not with Dr. Mayagoitia.
He believes strongly in the physical examination and all of the wealth of information that it provides. He also believes it is an underutilized tool to connect doctors with their patients. As he explains, too often doctors become too busy ordering tests – which separates the doctors from their patients – instead of listening to ‘the person in the bed’. (My terminology not his). So during his students case presentations – the emphasis is on the story (the clinical history), the patient’s life (background, social settings, diet, habits) and the clinical physical examination. Students aren’t allowed to talk about, or ask questions about diagnostic results such as radiographs or serum analysis until the story and the physical findings have been throughly discussed and examined in detail.
Even then – he challenges them – to use more than their eyes – to engage their brains, and their other senses.. “What about the description of this surgical scar? Does it seem a little large for an appendectomy?” he asks.. “What about it’s location?’ he challenges**..
“What about the differentials? What other diagnoses should we consider? he asks. “I know you think the diagnosis is obvious – but give me some alternatives,” he coaxes. “What else could be going on? Tell me why you don’t think that it’s X” he asks – making the students review and explore the other possible causes for this patient’s abdominal pain. “Could it be Z?” he asks.. “Why not? What else would we see?” he states in reply to a student’s mumbled answer..
Then, only then, do we review the labs, and the films – the more tangible aspects of the practice of medicine. Those results that students can see easily, (maybe too easily) and tempt them into abandoning the ‘art’ of medicine and patient care. But he doesn’t allow it – and quickly steers the conversation back to the displayed pathology to this pathophysiology and symptomatology of the patient in question.
As someone who still struggles with the physical skill of percussion – this entry into the art of medicine hits home. It is an art, and a woefully underappreciated one.
** Please note – these quotes are my best approximation from my translations during the case presentation, and may miss nuances.
About Dr. Jose Mayagoitia Witron
Dr. Mayagoitia is more than a clinical instructor – he is a respected professor of surgery at the Universidad Autonoma Baja California (UABC) and has been teaching medical students for over 20 years. He also teaches surgical residents and has been doing so for over fifteen years. He gives lectures daily at the University, in addition to his busy schedule as the Supervising Surgeon for the Intensive Care Unit at Mexicali General, and private surgical practice (with evening clinic hours).
He speaks in clear, unaccented English (my southern accent is thicker than any accent he might possess) which may be as a result of his fellowship training in San Diego. He completed his general surgery residency right here at Mexicali General after attending UABC).
He remains active in the research community as a supervisor for resident research projects including two ongoing projects worthy of note: a new study looking at the treatment of open abdomens, (from massive trauma, infection, etc.) and a study looking at the early initiation of enteral feedings versus delayed (72 hours or greater) in surgical intensive care patients.
He, along with his wife, Gisela Ponce y Ponce de León, MD, PhD (a family medicine physician and instructor at the UABC nursing school) recently presented a paper on obesity research in Barcelona, Spain.
He does all of this in addition to a steady diet of general surgery (cholecystectomies, appendectomies, bowel surgery (such as resections) and the occasional bariatric surgery. As one of the lead surgeons at a major trauma hospital** – he also sees a considerable amount of emergency and trauma cases.
He reports that on the last – bariatric surgery, he has mixed feelings. While it has become a popular staple for the treatment of obesity and obesity-related complications – he questions it’s role in a society that steadfastedly ignores the causes. “I wonder if we will look back one day and realize that we [surgery] did a real disservice to our patients by doing so much of this.” So, while he does perform some bariatric procedures, he is very selective in his patients. “It’s not a quick -fix, and they are going to be dealing with this [changes from bariatric surgery] for the rest of their lives so they [patients] need to understand that it’s a lifelong endeavor.” When he does perform bariatric procedures, he prefers the gastric sleeve, which he believes is more effective [than lap-band, and smaller procedures] but less devastating in terms of complications and dramatic life alterations.
Dr. Jose Mayagoitia Witron, MD, FACS
General surgeon, Fellow in the American College of Surgeons
Av. Reforma 1061 – 6
Mexicali, B. C.
Tele: 686 552 2400
** He reports that Mexicali General, as a public facility, sees about 80% of all traumas in the area.