Saving the Filipino Patient

Earlier this week, a medical intern’s photo of the emergency department of Philippine General Hospital (PGH) circulated online. It showed the triage area filled to the brim, packed with patients lying on bare metal stretchers, fazed watchers, and not surprisingly, only a handful medical personnel. Because of a change in the start of the academic year, the student workforce had been reduced to a third of its usual number. “Madness. We need help. (Crying emoji)” part of the caption read.

I trained in PGH for 10 years: five as a medical student and another five as a resident. The image was not at all an unusual sight. Having been a neurosurgical trainee in the country’s largest government hospital, I know all about endless days and personal sacrifices for the sake of patient care.

While most people in social medial reacted to the photo with dismay and frustration, I noticed that quite a number have expressed either distaste or plain apathy to the situation. It is, after all, fairly easy to dismiss the post as a millennial medical student rant. To shrug things off, just because “Ganyan din naman nu’ng panahon namin” (We experienced the same thing in our time) or “Ganyan din naman sa ibang public hospitals sa Pilipinas” (Even other public hospitals in the country face the same scenario). Ergo, stop complaining?

Therein lies the problem. When we accept the status quo just because that is how things have always been, we deprive the Filipino people of the health care that they deserve. The work in the hospital could always be accomplished at the end of the day, but at what cost? At worst, maybe a few needless, nameless deaths.

The emergency room (ER) photo forces us to at least acknowledge this truth: what we have is a tenuous public health system, perpetually low on resources and dependent on an overworked yet underpaid workforce. It has always been teetering on the brink of collapse, and it would take only the slightest pressure before eventually giving way. Today it is the shortage of medical students. Maybe tomorrow, it’s a mega-earthquake or a virulent strain of influenza.

My colleagues and I have known this all along. We have lived through this horror story every day in training. The reality is that if you are a sick Filipino and you do not have money, you are more likely to get delayed treatment or suboptimal care, and to ultimately die from your disease, compared with your richer counterparts. One does not need a scientific study to prove this. Ask anybody who has ever worked in the Philippine public health system and that person will agree in a heartbeat.

I have seen patients die just because their families could not afford antibiotics or chemotherapy. I have attended to patients who deteriorated in the ward or in the ER, when they could have been more closely observed in a proper intensive care unit. Poor access to timely and appropriate health care also means that many patients present to PGH either with significant complications or their financial resources depleted from previous admission in a private facility. Some have been unlucky to be both.

I have just returned from a year of training in Australia. Working at The Royal Children’s Hospital (RCH), a government-run pediatric hospital similar to Philippine Children’s Medical Center and National Children’s Hospital, that was where I witnessed the great disparity in health care between our country and theirs.

Let me give you two scenarios:

Suppose a ten-year-old boy in Melbourne comes to his parents complaining of headache that has been ongoing for two weeks. His parents bring him to the general practitioner, who requests for a computed tomography (CT) scan of the brain that is done on the same day. The scan unfortunately shows a brain tumor and the radiologist calls the general practitioner, who then gives me a ring to organize hospital admission, I being the neurosurgery fellow on-call.

On the same night, as soon as the patient is admitted, I can organize a magnetic resonance imaging (MRI) scan of the brain and spinal cord to give us a better picture of what we are dealing with. I speak to the family to obtain consent, while the nurses ensure that they have the social and emotional support that families dealing with a new cancer diagnosis often need. No doubt the family will be anxious, but at least, they will spend the night in a well-equipped, comfortable private room.

As early as the next morning, my consultant and I will be operating on the patient. On the following Wednesday, the case will be discussed with a multi-disciplinary team. If it is confirmed to be brain cancer, plans for subsequent chemotherapy and radiotherapy will be made right there and then. It is no wonder that five-year survival rates approach figures I only get to read in journals and textbooks, often even better.

Now, suppose I have an identical ten-year-old boy in Manila with the same brain tumor. When the family presents to the ER, one of the first questions that the parents would be asked is, “Saan po ba kayo magpapa-admit, sa charity o sa pay?” (Would you like to be admitted as a charity or a private patient?) There is often a follow up question, “Magkano po ang dala ninyong pera?” (How much money have you got?)

I used to have a readymade script explaining to families that nothing is free in PGH anymore. CT and MRI scans are not free. Operating room supplies and medications are not free. PhilHealth insurance may be able to cover some of the costs of treatment, but that is not always the case. The parents will spend days and nights running around the hospital to facilitate lab results, buy medications, obtain blood donors, and speak to social service for financial assistance. They will look for the most comfortable cardboard box to lie on, and if they are lucky, they will have a nice little corner away from the sun and next to their loved one.

Busy operating room schedules contribute to delay in timing of surgery. Prolonged hospital stay leads to more complications and worse outcomes. Even if the tumor were taken out completely, the family would still have to find money for subsequent chemotherapy and radiotherapy, leading to unwanted tumor recurrences. It is always frustrating to realize that treatment decisions often rely on financial capacity rather than clinical efficacy.

Perhaps the only thing truly identical in both scenarios is the desire of both families for their child to get better and to return to his previous, normal life, as if nothing has happened. And I have seen that, of course in Australia.

Whether rich or poor, parents bring their kids to RCH, a public hospital, not because they do not have a choice. In fact they do, and they still choose RCH because they believe it is the best hospital to treat their children. I would do my ward round in the morning not knowing which patients were private and which ones were public (Yes, I was told not to call them “charity”). I finished training without knowing where to find the hospital cashier, only because I never had to bring up money when talking to families.

Are you able to get the same level of care in the Philippines? In the big private hospitals, yes. In fact, even in the private ward of PGH, you could. The question had never been about expertise of medical personnel.

Fixing the public health care system for 100 million Filipinos will take time, considerable effort, and genuine leaders who understand that it is an interplay of psychosocial and economic factors that result to 68 Filipinos dying from all forms of tuberculosis (a treatable disease), another 26 getting diagnosed with HIV (a preventable disease), and seven mothers dying from childbirth (not a disease at all) every single day.

The TRAPOs (TRA-ditional PO-liticians) only become aware of the situation in public hospitals when their drivers or helpers need urgent medical care, because if it were their own family, they would of course choose the best private hospital in town. I long to see the day when our government officials would realize that the public health situation cannot be alleviated by intermittent medical and surgical missions, with the ulterior motive of name recall for upcoming elections.

The viral photo may have shown PGH ER, but as pointed out by some netizens, that could very well be in any other public hospital in the country, others no doubt much worse. The local and regional hospitals have to be strengthened both in equipment and human resources in order to decongest hospitals like PGH. It is both hard and unfair to blame Filipino doctors and nurses who choose to work abroad when the opportunities and incentives back home are limited, if at all existent.

It is a gargantuan task, but we have to start somewhere. We begin by acknowledging the shortcomings and failures of the system. Shrugging them off does not create a solution. I have no training in public health and I only have a vague idea on public health funding, but having been at the forefront for so long, I know that we could do so much more for our Filipino patients. And by we, I refer not just to medical and paramedical staff, but to every one who cares enough for this country to continue living in it. Perhaps with President Rody Duterte and Vice President Leni Robredo, there is a spark of hope for the Filipino patient.

Status quo is nowhere near acceptable. If you think it is, I dare you to walk into PGH ER as a patient and lie on that metal stretcher. Perhaps then, amidst the chaos and confusion aggravated by constant humidity and unadulterated human suffering, you will realize that your life is no more important than any PGH patient’s, and that you do not deserve to die a needless death, just because you happened to be poor and Filipino at the same time.

 

Dr. Ron Baticulon graduated from the UP College of Medicine in 2008. He finished his neurosurgery training in Philippine General Hospital in 2014. Statistics on TB from DOH (2010), on HIV from DOH HIV/AIDS and ART Registry of the Philippines (Feb 2016), and on maternal mortality rate from WHO (2015).

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16 comments

  1. I agree with you 100%. I left PGH after Med School and went on to Pediatric residency training in New York. My first rotation was in the wards, where I was surprised to discover that nobody was even close to dying. My first admission was a patient with osteomyelitis that was brand new – no pus coming out of the bone, almost unrecognizable to my PGH-trained eye. My first sentiment was regret. How was I to learn medicine in a place where no one was dying? And then I realized medicine was about keeping people healthy, and not about providing treatment only when they were upon the verge of death. Three more years in Neonatology only further emphasized this. “Sure that kid is going to survive, but will he be able to go to Harvard?” my mentor used to say, meaning the best quality of life and not simply surviving the odds, was the end point. As for doctors, I never understood the point in making them suffer for the sole purpose of suffering. Extending work hours and increasing patient load beyond reasonable expectation and ability serves no one. Our patients deserve better. And just because we and they have managed for decades like this, doesn’t mean we shouldn’t aim to provide them with better. Being a patient is difficult enough, even in the best of facilities. It would be wonderful if our government could help us provide not only care but also dignity to those we serve.

    • Hi Francesca, I felt the same way during my first few weeks in Melbourne. Our patients only died from terminal cancer, or from severe head injuries beyond surgical treatment. I like what you said last. Patients and their families lose a lot of dignity in the process, and nobody cares just because the patient was discharged reasonably well. I suppose it also has to do with the Filipino psyche of being matiisin and resilient. Nakakaiyak talaga when you see the difference in both setups.

    • Pauline Basa

      Even machines can’t perform well if they are not up-to-date and well-maintained. Yet, people expect health professionals to always be at their best. I know we were trained that way because we are handling human lives – but we are human too, and I don’t know why we should be forced to work for 16-24 hours straight duty, or even more, just because we can. It’s not fair for us, and neither is it fair for our patients to receive care that is compromised by our own energy/capacity limitations. We can’t give our best if we will always be forced to perform in our worst

      • It’s primarily a human resource issue. The sad thing is, hindi kasi uso sa Pilipinas ang personal quality time, lalo na pag nasa medical field ka.

  2. Rosalia Ramos

    Dear Doc

    Kailagan po kayo ng maraming Pilipino. Ibanng klase kasi kayong doctor. Kung papalarin po akong yumaman ang unang una ko ping gagawin magdodonare ako ng mga ct scan at mri machine sa PGH para sa mahihirap. Maraming magagaling na doktor sa PGH ang problema po kulang sa facilities. Sana po ngayon may bago tayong president sana unahin niya ang pagsasa Ayos ng PGH. Salamat po sa lahat

  3. The problem with the Phillipines is a macroeconomic one.

    90+ million people living on a relatively small land area with limited resources.

    Australia has 20 odd million people, relatively much more natural resources (gas / minerals) and a matured economy.

    Imagine if the same amount of natural wealth / raw economic output of the phillipines were distributed between 1/4th the number of people. Or the number of visitors to the hospital reduced by 75%.

    Corruption is one thing. But I suspect that even without corruption, macroeconomically, it’s not possible to raise the standard of healthcare without addressing the elephant in the room – population size vs economic output.

    Solution:
    1) The China Method: One child policy, forced abortions, etc.
    2) Family Planning – to drive home the point that having many kids born into poverty is not the way to go. Fewer kids well educated is the way to go.
    3) Readily accessible first trimester medical abortion kits (it’s safer than pregnancy and is like a heavy period).
    4) Condom machines everywhere even in schools.

  4. ppl who commented and wrote this article has nothing to do with the pain of poors….trust me..they are here to show that they were able to go 1st world countries and train there …

    • Hi John, when you go abroad and treat foreigners, you often wonder how come the same thing couldn’t happen to Filipinos. And so when you go back home, you aspire for great things for your fellowmen, because you’ve seen how much more you could give. I’m not applying for a job here, I’m just hoping that people realize they deserve so much more.

  5. “When we accept the status quo just because that is how things have always been, we deprive the Filipino people of the health care that they deserve.” Very true, sir! What we need right now is for the government to acknowledge the immense situation of our healthcare system and for all of us to think of efficient ways to alleviate this. Blaming the doctors, nurses and the rest of the medical staff is just plain absurd.

    Hoping to be one of your students in med school 🙂

    • Hi Ziara, I think we all have a role to play in this. It’s just that if everyone’s happy with the way things are, then it’s the patients who have got so much to lose in the end.

      Hoping to be one of your students in med school

      Perhaps one day. 😉

  6. Eleanor D. Cristobal

    You hit a lot of relevant issues with medical care in the Philippines . I , too , trained at PGH after graduating from the UP college of medicine in 1978 . I have since immigrated and has been practicing on the USA since 1988 . Just like other folks here, I have been back to the Philippines several times to help relatives get medical care there for different issues including surgeries, chemotherapies and even just simple outpatient visits . Not much has changed since I trained there . While it is true we now have better equipped and so called world class hospitals there , they remain mostly unaffordable by most people in the country . The sadness I felt hearing all the conversations of families of the patients who could not afford the obligatory deposit for their love ones to be given care was just too overwhelming . I felt the same anger and frustration about how a lot of Filipinos,some of my friends and relatives included just accept this state of health care as normal . I find this apathy and inaction of the leaders and the governed /populace appalling ! The Filipino people deserve better and should expect more from their elected officials and the government but should be active participants to make this happen . Accepting the status quo and sitting out to change things is a travesty , if I may add.

    • Hi Eleanor, training abroad was a real eye opener for me. I often wondered, how come we could not do the same thing for our Filipino patients? I agree, it isn’t just the equipment and resources, because we do have them. It’s just that they remain accessible only to a select few while the others are forced to remain patient and matiisin. People need to realize that they deserve so much more.

  7. Its not really only in pgh but the whole public or govt hospital.. It can be a disttict hospital or national. Hospital… If all hospital facility is improve then patient care will be improve… But hoping that corruption would be stop then the people who are vip should also be tame (in short or i mean pantay pantay at walang palakasan porket kakilala si governor senator mayor congressman bka president pa banggitin or kng sino pontio pilato banggitin pra mauna sila)… Pro sana din un ibang tao wag abusado…. Kng gusto lhat libre ang consultation at gamot kailangan magtrabaho sila. Un iba nakaasa sa mga kng anu anung programa. Anu un nakatunganga sa biyaya… Pede nmn gwin libre as long as kumakayod. Ibang tao kayod ng kayod umangat sa buhay pro un iba nkatunganga… Kng magiging libre and services sa hospital at gamot dapat lhat ng magulang ay may mga trabaho at nde juan tamad.

    Khit nga doctor na may sakit sna pg tumanda na e maalagaan din sila tulad ng ginawa sa mga pasyente inalagaan nila noon kc ang nangyayari din sknila… Ubos ang pera nila pag sila ang ngkasakit..

    Sana naman un benefits na dapat sa public health services nde kinukorakot o binubulsa kawawa nmn un mga ngppkhirap taz iba nkikinabang…

  8. class D indigent

    I’m a medical student and I gave birth to my 4 yr old daughter in PGH last 2012, I gave birth via CS, I was alone, my dad thought I was admitted for a bed rest because the doctor said i am having a threatened abortion, and the pregnancy was only 6 mos then. Every medical person is really competent, I can’t blame some doctors shouting, it is really exhausting attending to the needs of hundreds of patients, I understand every kind of person inside PGH. I salute every filipinos in that hospital, whether a doctor, a nurse, or a patient, we all survived the chaotic atmosphere but the place is a heaven for someone like me, my daughter and I survived in the hands of the best among the best. I am forever thankful.

    -class D indigent

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Names, dates, and events may have been changed to protect the identity of patients. The stories are not meant to provide medical advice for specific illnesses. The author neither accepts online consults nor gives medical advice online. Please consult your trusted physician.