Prudence and Madness

Although I don’t think I’m a blogger well-established enough to feature the writings of another blogger, still I’d like to take this opportunity to share with your another doctor’s perspective on the status of the health care system in the Philippines. This just goes to say that not few doctors (and not only me) see the terrible dilemma our country is facing regarding our health care system and that doctors are raising their voices to be able to let the whole country know that many changes should be done soon, if not, now.

Here’s Dr. Carl Dwight Demetria’s take on the issue (as posted in another forum):

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Health care in the Philippines is dying.

And for me, it is a slow, painful death. Like a hemorrhaging patient with advanced TB, who neglected to take the needed but annoyingly long anti-Koch’s medications.

We could run the merry-go-round of declaring who is the more righteous: the pragmatist who believes that “the best provider is the one who leaves”, or the apologist/optimist who generalizes medical students as rich, and can tolerate a few more years of drought before
they hit the big time in local medical practice.

But the prospects for our patient named Philippine health care is necessarily colored by our personal experiences as doctors. Even as we slowly espouse evidence-based medicine in our human patients, in social problems such as this one we inevitably fall on our own emotion-colored glasses to see the picture.

So to add to this discussion I return to what I have experienced in my short stint as a doctor.

Even while studying in the State University, there has always been a distinction between the ‘haves’ and the ‘have-nots’. This delineation can be noticed once somebody initiates a discussion about future plans. The ‘haves’, either by virtue of a sizeable war chest, an inheritable clinic practice, or extensive networking, are almost always cocksure about their plans for the future: residency in PGH, or taking the USMLE.

The ‘have-nots’, who have struggled silently to get through medical school, are not as sure as to their future plans. The lack of a medical Economics class does not help matters.

As they approach the clinics, they all see first hand the innards of a government hospital, and its one oft-repeated saving grace: the richness of clinical material called patients. Otherwise, the bureaucracy cripples everything from supplies to having enough nurses to the imposed, but subtle, monstrosity that is termed ‘hierarchy’. Only a few would dare express delight at this set-up, declaring their fealty to the hospital and the corresponding willingness to sacrifice ‘few’ years to train there. Most would be silently waiting for the day that they could break free from the hospital’s grip.

The class finish internship and pass the medical board exam. Predictably, only a few apply to PGH and even fewer apply to regional hospitals. I was one of them. I was able to convince my parents that the application to a nearby regional hospital would be less taxing on family resources and would be comparable in training.

Culture shock one was when some consultants made apparent their dislike of all people from PGH, having been conditioned by an arrogant but brilliant senior consultant that “PGH is the best.” Culture shock two was realizing that a lot of residents, at least in the hospital I worked in, were so overwhelmed by patients that the notion of ‘training’ is beyond them already. Culture shock three was seeing seniors abuse their authority to have unethical liaisons with medical clerks.

Culture shock four was realizing that, in a hospital 1/5 the size of PGH, I was doing the work of three, maybe four residents, plus the department secretary, for Salary Grade 16, a little over P12,000 a month. I was the only applicant, so I was the only first year resident for that year. The consultant staff was able to interview another applicant in the middle of the year but for some reason they rejected a perfectly suitable candidate who is now performing well in another department.

I had to leave because I lost weight, had night sweats, and a nagging cough that won’t go away.

After spending a fortune on treatment, I applied for the next year to PGH. My parents were convinced by my claim that this up and coming specialty would be my ticket to a better future. After all, as an intern I enjoyed hanging out with the ER residents.

It was not long before I got a taste of nasty hospital politics. With rounds that were designed to humiliate residents in front of their patients, who would later reject any attempts by the beleaguered resident to treat them. With senior residents having vendettas against junior residents, disabling any efforts towards becoming a cohesive duty team. With a certain resident not being used to having his mistakes pointed out, and engaging the nurses, residents from other services, and support staff in protracted arguments because he is right.

Even if we were to ignore hospital politics as some of us are wont to do, there are other problems to contend with, none less frustrating. The volume of patients are such that on any given day the ER sees double its rated patient capacity. Most patients are indigent and the hospital supplies are so meager that there are days when there is no Epinephrine, Atropine, or plain saline solution. The recently renovated ER, designed to have airconditioning, is oppressively hot as the aircon units are always broken due to the sheer stress of cooling double the number of patients than it was designed for.

This gatekeeper specialty also is placed in low regard by the ‘established’ specialties, to the extent that the residents bear the brunt of arguments and unreasonable demands from counterpart residents.

All this for Salary Grade 18, or P15,841 per month before tax. Other people with less training and less responsibility earn more, especially in call centers.

The end of my sojourn was an abrupt one - I experienced anxiety attacks at the workplace, which was well documented. As news of me taking medicine for this, I was gently told that there would be potential legal liabilities in the event that a patient under my care turns sour and uncovers this detail about me. I was also asked if I could continue training, and if I was 100% capable of continuing.

Of course, some of us would argue that they have experienced the same thing, endured the same B.S., and survived. I tip my hat to you. Maybe I wasn’t cut out to be a doctor in the first place - with all my idealism for reasonable working conditions and salary.

But how does this sob story translate to our health care system dying? Isn’t this a rant by a discontent doctor who could not deal with the supposed injustices that most residents in government hospitals deal with everyday? Dear reader, if you were able to see the subtle signs pointing to overcrowding and lack of supplies and personnel, kudos to you.

In my exit interview, when I was asked about the one thing the hospital could improve on, I told them these two things needed to be addressed to improve services. But, on the other hand, addressing these may be beyond the realm even of the supposedly caring hospital administration. These pervasive symptoms of our health care system, which are alluded to time and again in headlines like “Doctors’ Exodus Continuing To Hurt RP” or “More Secondary Hospital Closures”, could not even be addressed by Drs. Flavier and Estrada in the Senate, or the many doctors in the House of Representatives.

That is why, even as we doctors individually pine for better pay and working conditions, the poor Filipino’s problem of being turned away by a full government hospital should be a cause for alarm.

But what hinders us from turning this into a rallying cry, a sort of cedula-burning shout for revolution, is apathy.

Apathy not only of a lot of practicing doctors, who may be overloaded with all their responsibilities to family and friends. Apathy by the whole Filipino nation at large.

In a nation that magnifies the latest Pinoy Big Brother evictee, or the newest cellphone, or the juiciest current tsismis, surprisingly very few people are taking notice that our health care system is not working. Fewer still are taking personal action, either by saving up for the eventual catastrophe (because you know government, even with all its PhilHealth promises, will not pay all of your hospital bills) or living a cleaner lifestyle (because our Spanish-inspired, American junk food-laden diets will kill us faster than you can say “Ako ay Pilipino”).

We could always blame the unreasonable senior doctors clinging on to their lucrative practices, or indifferent hospital administrations, or inept and out-of-focus local and national governance and health policy. But even if, by some stroke of luck, I get a check equivalent for 5% of Philippine GNP to spend on health care, not all of my problems would be solved overnight. It would be like feeding an irritable baby fixated on the nice, flashing, out of reach cellphone.

I hope that in time our countrymen would be more sensitive to their health needs and that government would do the same. But, for now, I realize that my quest for equitable working conditions and just compensation will not be seen within a Philippine hospital.
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Postscript: I may not be as fortunate enough to have chances of going out of the country. Not for lack of trying, but I guess it’s not yet time for me.

Best regards to everyone.
Carl Demetria

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I will be featuring articles like these whenever I encounter one (of course, with permission from the author/s).

Like Dr. Carl, I’m starting to hate hospital politics. It just holds back the doctors from doing their job well. Also, doctors are not taken cared of here in the Philippines. I want to let everybody know that doctors here, especially those in residency training, do not have allowances for sick leaves nor do they have healthcare benefits (aside, of course, from the fact that most colleagues wouldn’t charge them professional fees when they are treated by them. But who pays for laboratory tests and other procedures?). Hospitals where these doctors train do not provide for healthcare benefits. But come to think of it, doctors in training should be ones who have healthcare insurances since they’re the ones with the most exposure to different infectious diseases and other possible causes of trauma. Just try working (”moonlighting”) in a provincial hospital emergency room and you’ll know what I mean about “possible causes of trauma” (some insanely upset patient or relative could just suddenly point a gun at you).

It is important to raise the awareness of everyone regarding the plight of our doctors and of our health care system. At times, I think that most people regard doctors as machines and do not think anymore of them as being capable or in need of basic necessities and the usual wants that ordinary people have.

I want people to realize that doctors are human, too. Like them. Perhaps this is one of the keys to the solution of our country’s problem in health care today.

And maybe I could use this blog to bring this realization closer to most people. Hopefully, I’d be able to do that.

Addendum: I do hate the fact that a certain newspaper have rejected the articles I’ve submitted several times. I have a suspicion that they do not want to publish articles encouraging doctors to leave the country. I do notice that most articles by readers that they publish in their column are all about some “lofty” encouragement that doctors ought to stay in this country and not leave. I don’t know what to make of it. I thought there should be a balance of opinion in printed media?