January 7, 2003

     "Promises are made to be broken" so it is said - and all too often this is indeed true. Well, promises are supposed to be fulfilled. So why do we make New Year resolutions? If something is worth making a resolve about, why not make that resolve this very day? Remember the cliché "Do not put off tomorrow what you can do today?" Procrastination is a cousin of disloyalty, thus we end up breaking the same old promise over and over again. And the sad fact is, we are just fooling ourselves.

     Nevertheless, a few random thoughts came to mind...allow me to propose three resolutions...

1. I will see patients regardless of their capacity to pay Medicine in our country, as many other things, is a segregated system. Just as there is a different justice for the rich and a different one for the poor, so does medical care. That is why there is a "Service Ward" and a "Pay Ward". It is administratively necessary I am sure, but it is pathetically reminiscent of the caste system of the past or the racial segregation of blacks and whites in America more recently. Might as well label these wards the "Maharlika Ward" and the "Alipin Ward". Things are so bad, that it may be more efficient to have a registration booth outside the Hospital doors, one for "imol" and one for "manggaranon". It is appalling to see people being left to die, because they cannot buy a bag of Lactated Ringers IV fluid, or place a ridiculous amount of money as "downpayment" so their beloved wife or husband can be operated on. What if they have no time to sell their land title, or their carabao, or their wedding ring? What if they have totally nothing? Simple: just sit back and die.

   "I wonder if anyone has done a systematic study to compare medical care between "Pay" and "Service" patients. The latter probably have higher mortality and morbidity and pathetic care at best. Prove this wrong and I’ll buy you a beer."

        I wonder if anyone has done a systematic study to compare medical care between "Pay" and "Service" patients. The latter probably have higher mortality and morbidity and pathetic care at best. Prove this wrong and I’ll buy you a beer.

        So why does the government spend more money for the military and so called "government projects" than for medical care and education? Beats me (except of course, the trapos get a big chunk of it in their own coffers). And where the heck are all those pork barrel funds? A healthy people would be more productive.

        What about medical insurance? The Philippine Medical Association once and many times before dislike this idea. It will of course limit physician earnings by earmarking a standard reimbursement for services. Thus, it never really took off. However, if the amount is preset at a reasonable amount, and properly billed and paid, it will surely benefit the people. There will be better access to care while limiting overcharging. You don’t like that thought, do you? Mukhang pera! And what about Medicare and other means of government reimbursement or subsidy to pay for medical services? It is but a dream. Free medical care with adequate pay for physicians is an anachronism and utopian at this point.

        Let me give you a hint of how medical insurance and Medicare is utilized at the physician level in the United States. Hospital management and medical care includes the concept of LOS (length of stay), DRG’s (Diagnosis related groups) and ICD-9 codes. DRG’s and ICD-9 codes are used to classify disease entities with the varying degrees of severity. Related to this is the expected or standard amount of cost the illness carries. Are you still following me? DRG’s are used in all medical related care in the United States and is used for billing and payments for all types of medical care. For example, if a surgeon performs an appendectomy, the DRG/ICD-9 code would be 1. "Acute Appendicitis" and 2. "Appendectomy". Say the expected payment from Medicare or an insurance company for #1 is P5, 000 and #2 is P10, 000. Therefore, the surgeon will be reimbursed P15, 000 regardless of how long the patient is in the hospital and how difficult the surgery was. If on the other hand the surgeon claims the diagnosis was 1. "Acute perforated appendicitis" and 2. "Exploratory laparotomy with peritoneal washing and appendectomy", he can be paid three times as much because these DRG’s are expected to be more difficult for the practitioner and therefore cost more. This system is good but the flaws include falsification and fraud. The payment may not be fair at first glance, but the physician (or the hospital) can bill the insurance company or Medicare a higher amount if more effort was exerted in the care of the patient. One more example: in a clinic visit, if you see a patient for a simple ICD 9 code of "essential hypertension" you can charge from level 1 (5 minutes spent with patient) to 3 (45 minutes spent). For all these, there must be proper documentation in the chart. Then there is an expected LOS for each diagnosis (i.e. 5 days for open cholecystectomy and 2 days for laparoscopic cholecystectomy). If your patient exceeds this, you lose money. The shorter the LOS is, the more money you get because you can reuse that hospital bed and charge for a new patient.

        As you see, the system is straightforward and specific. Implementation in a country with a free for all system with kurakot everywhere would probably be a nightmare.

2. I will see patients on time Have you at least once, taken a peek at the crowd huddled outside your clinic while you nonchalantly take your time doing what you usually do? In the midst of cavorting or flirting or actually doing real work do you realize that this poor sick patient has been waiting for 4 hours after taking a jeepney and a bus and a tricycle from his sitio which he left before sunrise this morning?

        Not once, in my whole short life have I witnessed a patient actually being seen at a duly scheduled appointment. There is usually a long list held by an impolite secretary outside the clinic, and it is "first come, first served" basis. No appointments. And of course, the doctor, being god, always arrives late. Always. And god is always interrupted by pretty medreps in short skirts. Filipino time is one trait we are infamous of worldwide. What a shame.

        "Triage" exists nowhere in the Emergency rooms either. In the likely event that you do not understand what "triage" means, it is where patients are screened and classified as to severity of illness (take note, not amount of money but severity!). Patients are then prioritized and the sicker ones are seen first.

        Did you know that seconds count? For example, if antibiotics are not given within 2 hours of diagnosis of meningitis, and 6 hours of community acquired pneumonia, mortality and morbidity rise precipitously? In trauma, seconds literally count. There may be no time to give "a prescription for 4 units of whole blood" when the patient is exsanguinating in front of you. How many times have you cringed, or cried, because the ER simply does not stock intravenous fluids or catheters and the blood bank was always empty? And of course, nothing is totally free. Time is of the essence. Seconds may be all you have to determine a death or a survival. So why are we not stocking materials in the ER’s and the wards? We can’t afford them, they get stolen, or the patient simply has to procure them themselves to assure the hospital does not lose profit. Choose your alibi. Pathetic.

3. I will spend more time with my patients Everybody is busy. It has been said that if you want things accomplished, give it to a busy man. This is partially true, because someone who is routinely busy has a system of time management that works and will make time for something needful to do. To a certain extent. But however busy you are, the patient deserves and needs your time. They have already wasted their entire week lying in a dilapidated hospital bed and only get to see you less than 5 minutes a day. And when you are there, you do not actually communicate and make the patient aware of what the heck is going on. Then a sleepy, smelly, disheveled intern is all that they see grumpily telling them what to do or buy.

        One way to improve this is by sitting down. One study has shown that if you spend 5 minutes with a patient sitting down, it will be perceived to be much longer than 5 minutes standing up.

        In this era of malpractice bills and lawsuits, legitimate or ridiculous, the time you spend with the patient can mean a difference. Again research has shown that the chance of getting sued is less if you have a good relationship with the patient and his family: regardless of medical outcome. You do not have to kiss ass. Just spend a little bit more time and be honest, polite and respectful. This is hard for the Filipino doctor-god image, where nurses are treated as chart carriers or microphones to scream at and everybody else is beneath Mount Olympus, including the poor "service patients".

     Well, back to the New Year’s resolution thing. The only resolution to make is not to make one, and just let your yes be a yes, and your no, a no. And make everyday as a New Year, worthy of making changes for the better.

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     The author's e-mail address is at docdan1@pol.net.

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