Tuesday, June 26, 2007

Milestone

This is my 200th post. Well, give or take a few since I deleted some test posts back in the day. This is not really a cause for celebration, but I decided to remodel my blog with a new theme.

I spent the early part of my mornings tweaking an existing theme, Erudite, from Jashan (I Blog - You Blog). I was having trouble with longer post titles cramming together, and found out that the only practicable fix was to widen the line width of the post body. So you will notice that lines in posts are a little far apart, but it is necessary for the occasional long title whenever my brain cooks up some esoteric title. I was never good at headline making during my school paper days.

I hope that someone would come and give me tips on optimizing the current design. But for now, or at least 200 more posts, this design would serve its purpose. Featured above are Rei's Unit 00 from Neon Genesis Evangelion and Chii from CHOBITS.
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Last Wednesday I was able to obtain the much coveted Iloilo City Police Clearance. Something good happens after all the effort, and I usually forget to be grateful; but this time, I am truly happy that all those walking and asking around amounted to something after all.

I am working on a lot of things right now, and in part to quell the criticism that blogs are being made as personal diaries, I am not going to disclose plans that may not come to fruition. However I can say that I won't be seeing the inside of a hospital for now. You could say that I am hanging up my stethoscope for the moment.
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And in closing, I will end this post with a post I originally made for Pinoy.MD and reposted in a mailing list and Prudence and Madness. If you have been patiently reading my rants for the past 6 or 7 months you will see more of the same, er, I mean a sort of critique based on my experiences and some insights on the macro level.

Health Care In The Philippines Is Dying

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 a '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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