Where have all the doctors gone?
March 16, 2004
It is despairing to keep reading all these articles everywhere about doctors abandoning their professions to become something else, and going abroad just to eke out a living. Again, not because it is wrong, but because of the failed dreams and expectations of what this job was supposed to bring: prestige and wealth. But because of dire straits in a country that “barely sees them” as a writer puts it, doctors nowadays seldom take pride in their work anymore because of meager earnings that barely resemble “wealth” which previously was assured by merely earning the degree.
We are losing doctors everywhere, everyday.
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"Well, things are not that easy all the time; so we struggle and strive to do a good job and earn more while keeping the prestige. The result? We endanger ourselves of burning our candles at both ends. Burnout.
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The Philippines has over 76 million people. According to recent statistics, there are only 95, 016 registered physicians in the country. This places the physician: patient ratio about one doctor for every 800 persons. In contrast, there are about 337,939 registered nurses, improving the odds to one nurse for every 227 individuals. The ratio is increasing, despite apparently stable medical school and increasing nursing school enrollment. Why? Because nurses and doctors are leaving the country or working in other forms of jobs. The number of patients a doctor could potentially acquire based on the ratio seems promising in terms of getting a busy practice. However, due to poverty and competition in urban areas, more often than not physician earnings are severely limited. All too often, patients end up as charity or pay off the doctor with fruits and vegetables. The picture is bleaker for nurses of course, who end up as volunteers, sales agents or the like and most live off subsistence salaries in distant dilapidated hospitals in the boondocks. Of course, there is very little anybody is doing about this other than empty campaign promises for the upcoming elections. Worse, instead of aiding health professionals, bills are being proposed for mandatory malpractice insurance, raising injury recompense, and other forms of torture forcing medical people to flee this seemingly god forsaken land.
Thus, the mass migration everybody is harping about. As those articles always emphasize, nurses come to the US, UK, NZ, UAE, etc in droves and more of these each year were MD’s, including medical board topnotchers. The articles are right of course. There are currently 32 medical schools in the country and thousands of these graduates do try to take the expensive USMLE and attempt to work in the USA. However, according to ECFMG statistics, only 4,561 certificates were issued to Filipino doctors from 1993 to 2002. As previous articles have mentioned, the test and whole process is indeed Herculean.
In contrast, about 20% of newly licensed foreign nurses in the US each year are Filipino according to National Council of State Boards of Nursing statistics. About 700 Filipinos take the Nursing State Board exams for the first time each year and get licensed. Compare that with 4,561 doctors over 9 years. The nursing route does appear easier. Many of these nursing board takers were probably physicians.
In a big way, despite the fact that the country is losing a lot of good people in the medical field, the migration phenomenon still helps the economy. In 2002, foreign based Filipinos sent P 7.189 B and in 2003, P 5.662 B in terms of remittances. Thus, the booming Balikbayan box and money transfer business.
It does not seem reasonable to blame MD-RN converts and migrants because things are just so hard back home. In Ilonggo, pigahot gid. The poverty rate is now 34% (the poverty threshold is P 11,605 per person annually) according to the National Statistics Office. Our beleaguered professionals have a 10.1% unemployment rate in 2003 and of those working, 15.7% are underemployed. Most doctors and nearly all nurses probably fall into this category. To think of it, MD-RNs too are considered underemployed, but at least would earn a more decent income far from the impossible amount of P11,605 a year.
Switching venues, the US too is losing doctors, primarily because of the discouraging medical malpractice crises as mentioned in prior articles. Medical school enrollment in the US steadily dropped from 1996 to 2002, with only a modest increase last year according to the Association of American Medical Colleges. Also, physicians aged 50 and above are expected to get out of practice sooner. A survey by Merritt, Hawkins & Associates reports: 17% will close or reduce practice, 10% will do non-patient care jobs, 8% will retire, and 7% will work non-medical jobs. Thus, there will be more openings for foreign medical graduates who may want to join the fray and fill the gap. So don’t give up trying to come over still as a doctor instead if it can be helped!
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“My candle burns at both ends, it shall not last the night…” quoted Elizabeth B. Browning, many years ago. These lines I learned back in High School English Literature, and are but one of the few lines of poetry and prose that ever stuck in my head and in my heart. Musing about those words, what toils and woes beset this writer to make her say these? The poem somehow stuck, as these words seemed more apt to us who labor night and day in the business of saving lives.
Much has been said already about sleep deprivation and other medical boot camp conditions during physician education and training. But what happens afterwards, after graduation, when we finally get to practice the art and science of medicine? Our candle gets lit also on the other end.
One end is responsibility and the other end necessity.
With the power of healing comes responsibility. Now that we have no senior to always call unto, we become the captain of the ship. The buck stops at us, there are no alibis, the degree is expected to redeem itself and produce results as expected. Hey, you are the doctor, it is your call, and you are answerable for each life that passes through your hands. This does not cease with being off or being on vacation or transferring practice. You are “pageable”, “textable” and “sueable” because of your Oath till death parts you from it. You are expected to do a good job, doctor.
With the power to earn comes necessity. Doctors too have need of food, clothing and shelter and whatever the profession demands. There is a family to feed, membership and journal dues to pay, and continuing educational meetings to attend. Others desire more, and prefer to frolic in their excesses, vices and ostentatious activities that come along as trimmings of a supposed prestigious job. Thus, there is an urge to rake in the cash, bring in the bacon, see as many patients as possible, and a tendency to prefer clientele who can actually pay for your services. You are expected to earn a lot, doctor.
Well, things are not that easy all the time; so we struggle and strive to do a good job and earn more while keeping the prestige. The result? We endanger ourselves of burning our candles at both ends. Burnout.
Burnout is a work related syndrome characterized by emotional exhaustion, depersonalization and diminished feelings of personal accomplishment (Maslach, Ann Rev Psych. 2001). Studies have reported the incidence of burnout to be between a quarter to two thirds or all physicians at one time or another. The primary consequence of this problem is loss of job satisfaction. This subsequently results into physicians considering to change jobs and reduce workloads. It is also associated with major depression, sub optimal patient care and eventually quitting jobs. Another route where good doctors are lost.
With candles burning at both ends, it is understandable if doctors don’t spend much time with patients anymore, or may appear less dedicated. A study has shown that on average, during a history taking, doctors tend to interrupt the patient within 28 seconds of the patient’s narration. A Centers for Disease Control survey in 2001 presented how much time most doctors spend with their patients: Psychiatry: 32.4 minutes, Cardiovascular: 22.2, Internal Medicine: 19.4, Family Practice: 17.1, Ob-Gyne: 17, Dermatology: 15.8, and Pediatrics: 15.6 minutes. Kudos to the shrinks! However, shouldn’t have the Pediatricians spent more time because of the crying kids and inquisitive parents? That also seems a pretty fast Pap smear and pelvic exam for the Obstetricians. Just a thought, it all actually seemed too much time spent!
Another survey queried older doctors (50-65 years old) on whether they think the new grads are just as hard working as they are. Sixty four percent of them said that the greenhorns are less dedicated and hard working, while only 30% thought that they were just as good. None of the veterans would admit that the neophytes were more dedicated and industrious than they are. Consider this, whose candle burns faster therefore?
So watch out! Lest your candle burn at both ends...
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Views expressed on this column and any other by-lined articles on this site are the authors' own and do not necessarily reflect the views of the organization or its members.
