Prudence and Madness

In today’s times when the average person is often bombarded by images and news of “bad” hospitals “detaining” patients who cannot pay for hospital bills and “evil” doctors who are money-hungry or out to “kill” patients, people have begun developing a general mistrust of doctors.  It is as if every doctor they’d encounter will give them haphazardly done medical service and then squeeze out all the money from their pockets.  And this growing mistrust of doctors is hindering our efforts to improve our country’s provision of health care.

I never thought that I’d be seeing such overly-suspicious and stubborn patients until one 24-hour duty in a hospital emergency room, I encountered one.  Well, actually, she’s the patient’s “mother”.  Being in the Philippines, we have come to “accept” the fact that Filipinos have developed the bad habit of going to the emergency room seeking outpatient clinic services (follow-up consult after treatment of urinary tract infections, requesting lab referrals for pre-employment physical exams because they don’t have the “time” during the weekdays, which is rather unbelievable because it’s a pre-employment medical exam and it means they’re jobless so they have all the time available, etcetera).

In this case, the overly-suspicious and stubborn person (which I will call “Mara”) brought her 4-year old “son” because of some coughing, cold, and a low-grade fever.  After some tests, it turned out that the kid has only a mild respiratory tract infection.  I prescribed a 7-day course of Amoxicillin 250 mg/5mL syrup 5 mL every 8 hours and a paracetamol for fever.  Mara argued that the dose I prescribed was not enough.  I asked her why she thought so.

Here’s how our conversation went (translation is italicized and enclosed in parenthesis):

Mara:  Sigurado ba talaga kayo diyan sa nireseta ninyo?  Hindi ba under-dose ‘yan?  Dati kasi 7.5 mL ‘yung pinainom ko sa kanya.  Di ba dapat ganun din ang ibigay ngayon? (Are you sure about your prescription?  Isn’t it an under-dose?  I used to give him 7.5 mL.  Isn’t it that is what should be given now?)

Me:  Amoxicillin din ba ‘yung gamot na ginamit dati?  250 mg/5mL din ba ‘yung formulation? (Was the drug used Amoxicillin?  The formulation was 250 mg/5mL?)

Mara:  Amoxicillin din ‘yung dati.  Sigurado ako.  (It was Amoxicillin.  I’m sure of it.) 

Me:  Based kasi sa weight ng anak ninyo ngayon na 19.5 kg, dapat 5 mL lang ang ibigay.  7.5 mL is more than what is usually given.  Baka nag-lose siya ng weight?  Actually, mabigat pa din siya ngayon for his age.  (Based on your son’s present weight, which is 19.5 kg, only 5 mL of Amoxicillin should be given.  7.5 mL is more than what is usually given.  Maybe he lost weight?  Actually, he’s still heavy for his age.)

Mara:  Hindi naman siya pumayat.  Ganyan pa din naman siya katulad ng dati.  (He did not lose weight.  He’s still the same.)

Me:  What was his weight?

Mara:  Hindi ko matandaan.  (I don’t remember.)

Me:  Well, nakita ninyo naman na tinimbang siya ngayon. 19.5 kg siya.  And eto, ipapakita ko sa inyo ‘yung computation na ginagamit namin para i-compute ang gamot na ibinibigay.  (Well, you saw that your son was weighed and it is 19.5 kg.  And here, I’ll show you how we compute the medications that we prescribe.)

(Author shows Mara the formulary and computes the dose of amoxicillin using a calculator in front of her.  Author shows her the final computation, as outlined on paper).

Me:  See?  5 mL lang.  Ang dosage kasi ng amoxicillin for mild infections is 20-40 mg/kg of body weight/day lang.  ‘Yung sa anak ninyo nasa 38 mg/kg of body weight/day.  So tama lang ang dose.  ‘Yung sinasabi ninyong 7.5 mL, dose na para sa isang bata na may 28 kg na timbang.  Or kaya para lang sa may mga severe infections, tulad ng ear infections.   Baka may ear infection siya noon kaya 7.5 mL ang ibinigay?   (See?  Only 5 mL.  The dosage for amoxicillin for mild infections is 20-40 mg/kg of body weight/day only.  Your son’s dosage is in 38 mg/kg of body weight/day.  So the dose is correct.  The 7.5 mL dose is applicable for a kid weighing 28 kg or for those kids with severe infections, like ear infections.  Maybe he had ear infection at the time that’s why 7.5 mL was given?)

Mara:  Hindi ko matandaan.  At saka wala naman akong alam sa pagcompute compute na ‘yan.  Basta alam ko 7.5 mL ang kailangan.  ‘Yun ang sabi ng doktor.  (I don’t remember.  And I don’t know anything about computations like that.  What I know is that 7.5 mL is needed.  That’s what the doctor said.)

(Author’s thoughts at this time:  Well, she already knows that she’s not knowledgeable about computing dosage of drugs.  Then why does she keep disputing my computation?  And what’s so difficult to understand about the computation I showed her?  It’s only multiplication and division!)

Me:  Well, kung ayaw ninyo maniwala, then don’t take the prescription and magpa-second opinion kayo sa ibang doctor.  (Well, if you don’t want to believe me, then don’t take the prescription and seek a second opinion from another doctor).

Mara:  Eh 7.5 mL nga ho kasi ang kailangan.  Sigurado ako!  (But 7.5 mL is what is needed.  I’m sure of it!) 

Me:  Kung sigurado po pala kayo, then bakit pa kayo nagpunta dito?  If you are asking me na isulat diyan sa prescription ko na 7.5 mL ang ibibigay, well, hindi ko gagawin.  5 mL lang ang tingin ko na kailangan.  Ipinakita ko na sa inyo kung paano ko na-compute ang dose pero ayaw ninyo pa din maniwala.  If you are not convinced, then you are welcome not to pay my professional services and just pay for the hospital fee of using the emergency room.  Pero hindi ninyo puede kunin ‘yung prescription.  What I can only say is that if you do not trust the doctor, then why still seek her services? (If you think you are so sure, then why come here?  If you are asking me to write 7.5 mL in my prescription, well, I won’t do it.  I think only 5 mL is needed.  I already showed you how I arrived at the final dose, but still you refuse to be convinced.  If you are not convinced, then you are welcome not to pay my professional services and just pay for the hospital fee of using the emergency room.  But you may not take the prescription I wrote.  What I can only say is that if you do not trust the doctor, then why still seek her services?)

Sige, papirma na lang po dito sa emergency room form ng bata… print down your full name, write your relationship to the child and then sign above your printed name. (Okay, just sign here in the child’s emergency room form…print down your full name, write your relationship to the child, and then sign above your printed name.)

Mara:  Saan ho?  (Where?)

(Author pointed to the space where she has to sign.  Mara printed her full name but hesitated to write “mother” after her name.)

Me:  Di ba ho kayo ang nanay? (Aren’t you the mother?)

Mara only mumbled.

Me:  Isulat ninyo po kung ano po ang relasyon ninyo sa bata, kasunod nung pangalan ninyo. (Write down your relationship to your child right next to your name.)

Mara only scribbled something unreadable next to her name and then signed the form.  She put her bundle of one hundred peso bills tied with a rubber band on the table in front of me and dropped two one-hundred peso bills on the table.

Me:  Ano po ‘tong nakasulat?  Hindi mabasa eh.  You don’t pay here.  You pay at the cashier.  (What’s this written here?  It’s unreadable.  You don’t pay here.  You pay at the cashier.)

Mara did not answer but only stamped out of the ER, her son in tow.   All the emergency room staff sighed relief.

I find it insulting that patients will still dispute the credibility of my prescription even after I explained to them how my prescription is correct.  It’s like showing a buyer that the product he’s buying isn’t expired by pointing to the expiration date clearly stamped on a sealed product and yet the buyer still refuse to believe that the product isn’t expired.  It’s not being responsible or aware of health management anymore.  It’s already over the top.  It’s an obvious insult to my credibility as a doctor.

I can deal with patients with some mistrust on doctors.  Be rational and reasonable with these people by showing that you’re doing everything you can and they’ll cooperate.  But I just can’t stand someone who refuse to use his/her brains.  I’ve exerted effort to make her understand in the level that she should but why can’t she do the same?  That’s even the least that could be expected of her, since it concerned her “child”.  I’ve already explained to her what she needed to know to understand that my computation is correct and in terms that I know she should understand (I mean, at her age, she could at least know how to add, subtract, multiply, and divide, right?).

She’s not exactly illiterate, since she can understand what was written in the form she signed and she can write her name clearly.  What I don’t understand up to now is why couldn’t she just write her relationship to the child.  She could just have written “Bantay” or “Katiwala” or “Kapitbahay” if she isn’t the mother.   Why can’t she disclose that information?

Those are questions that were left unanswered.

Sometimes, these are the kind of patients that zap my energy in the emergency room, more than the real life-threatening cases.  It drains me physically, mentally, and psychologically.  And for what reason?  Just because they are stubborn and they refuse to see reason.

I would have understood if it were a senile elderly or a young child.  But a middle-class, middle-aged woman?  With glittering jewelries all over her body and a tied up bundle of one-hundred peso bills?  Come on.