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The business of caring

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“Doctor, I have been trying to reach you for three days now, but you have not picked up my calls, not replied to my SMS text messages, not responded to my Viber messages,” she said when the doctor finally picked up her call that Sunday morning.

“My BP has been up for one week now — for years it has always been 110/80 — now systolic hits near 160, and my electronic blood pressure monitor shows warnings! Is this bad? Am I in danger of a stroke or a heart attack? What should I do?”

“Just get an appointment through Tele-consult — I have to go now,” the doctor says.

Patient asks, “But wait, Doctor, what should I do now, today — can I take something to bring my BP down? I am so anxious and depressed. I can’t sleep at night, fearful that I might die in my sleep!

“Insomnia can affect your BP. But your BP is within acceptable levels. That is just anxiety — control yourself. I can refer you to a psychiatrist,” Doctor says, noticeably rushing.

Later, Patient sends a Viber message to Doctor, “Sorry for bothering you too much. But my nervousness was really aggravated by waiting for your Viber reply for three days. Thank you for taking my call this morning.” (Patient had not “bothered” [consulted] Doctor for at least 1½ years.)

Doctor’s Viber reply: “Sorry I cannot entertain hurt feelings…this number is my personal number…(where) I expect messages from friends, classmates and orgs.”

Ang sakit naman! How painful that a doctor should cause more pain to his patient by outrightly saying he does not care if his patient is hurting! In the debilitating constant pain of gripping anxieties in the two-plus years of this long-staying, life-threatening COVID-19 pandemic, one’s doctor is like Jesus Christ the Redeemer promising deliverance. And Jesus Christ never turned away anyone who wanted to “touch His hem” and be healed (Mark 5:21-43).

In the Philippine Code of Ethics of the Medical Profession (jointly adopted and approved by the Philippine Medical Association and the Professional Regulatory Commission — September 2019) the Preamble says, “On entering the profession, a physician assumes the obligation of maintaining the honorable tradition that confers the well-deserved title of a ‘friend of mankind.’ The physician should cherish a proper pride in the calling and conduct himself/herself in accordance with this Code and in the generally accepted principles of the International Code of Medical Ethics.”

The basic principles of the Code include:

1.4. Principle of Beneficence. The interest of the patient shall be placed above those of the physician. Societal pressures, financial gains and administrative exigencies shall not compromise this principle.

1.5. Primum Non Nocere. The foremost responsibility of the physician is to do no harm to the patient.

Article III Sec 3.2 stresses: Patients’ Trust. Physicians shall maintain a fiduciary relationship with their patients by displaying competence, reliability, integrity and open communication.

“Pagpasensiyahan mo na (Just forgive),” advised Dr. Santiago del Rosario, president of the Philippine Medical Association (PMA) and other local and international medical groups for many terms in his 65+ years in his profession as a most respected gynecologist and chair-drafter of the Code of Ethics of the Medical Profession for the PMA. He said that maybe the doctor with the hurting words was himself stressed in this dizzying pandemonium of conflicting priorities in the pandemic.

Early in the pandemic, the Philippine College of Physicians (PCP), an umbrella organization of internists in the Philippines (organized in 1953) sent out an advisory to Health Maintenance Organizations/Companies including the government PhilHealth to collect higher fees based on a 50% increase in doctors’ professional fees called the “PF.”

In the advisory, PCP indicated the PF rates for the out-patient face-to-face “F2F” consultation fee (P400 to P600) and for the in-patient daily visit which ranged from P900 to P2,100, quite higher from the then-usual P600 to P1,400 (https://www.philstar.com/ July 5, 2020). The increased PF, applicable to both COVID and non-COVID cases, was bashed in the news and social media, but the increased rates prevailed, observably going up further in the protracted pandemic to P1,000-P1,500, perhaps depending on the fame and reputation of the doctor. Tele-consult fees mirror F2F fees.

Those patients with medical health insurance can claim refunds of the PF and certain other expenses from their insurers, based on a pre-agreed maximum-refundable table of allowable claims. Those without private health insurance can claim certain refunds from PhilHealth, but only those PFs directly connected with listed diseases that need hospital confinement or long medical treatment.

Perhaps the increased PF fees were also needed for the added administrative costs for doctors in this pandemic. There are risks and additional expenses doctors incur when managing patients in the pandemic, like PPE (personal protective equipment) and sanitation of their premises. Early in the pandemic, a dental clinic charged a front-end P3,000 “sanitation fee” to F2F patients, to support the overhauled air-conditioning and filter system and the extensive room and equipment sanitizing for each patient. There are increased “running expenses” in the complicated F2F consultations and even the more complicated tele-consult services, which must be set up with computer systems and hired IT/software consultants and trainers to doctors. Of course, the doctors’ enlistment with tele-consult services includes a membership fee and some income-sharing to keep the system going, and more. And so, the patient inquiring on tele-consult must pay first before asking his question, or electronically pay upfront in full, the PF of his/her doctor even before scheduling an online or F2F appointment, which can mean a waiting time of two to three days to “see” the doctor.

Pre-paid PFs on tele-consult can be refunded naman, with some extra effort with online payment agents.

The hospitals have also increased rentals for doctors’ clinics and use of hospital facilities. The sharing of income between hospital and doctors has been fine-tuned since some five years ago, when the Bureau of Internal Revenue (BIR) force-fitted the rule that all doctors’ professional fees and income (from surgery, procedures, treatments) should all be receipted (including donated/free services to family and friends) and should all be traceable from the hospital’s own operations and asterisked (noted) in the general income statement. Income taxes for individual doctors must be paid directly by the doctor. No escape from the BIR!

The business of caring, as in the conduct of a doctor’s practice of his profession, has indeed been complicated by the vicious dictatorship of the COVID pandemic. Though the physician’s Hippocratic Oath holds up Life and Health, embodied by the patient, as always the first priority, mundane constraints, now including the doctor’s own life and health (and economic survival), can blur moral and ethical issues for the physician. Some groups of doctors are drumming up attention on the principle of “physician’s autonomy,” actually present in the Medical Code of Ethics, Article 3, Sec 2: “A physician should be free to choose patients” and to determine how best to exercise his profession.

For Dr. Santiago del Rosario, age 93 years, the Hippocratic Oath prevails over any mundane self-centered concern. Through the pandemic, and still going, he reports to his clinic M-W-F, noon to 4 p.m., double-masked and wearing a face shield and rubber gloves, to heal those who need his help. And he goes to daily F2F Holy Mass, thanking God for Life!

Amelia H. C. Ylagan is a doctor of Business Administration from the University of the Philippines.


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