“Doctor, I’ve been trying to reach you for three days now, but you haven’t answered my calls, haven’t answered my texts, haven’t replied to my Viber messages,” she said when the doctor finally took his call. this Sunday morning.
“My BP has been up for a week now – for years it’s always been 110/80 – now the systolic is nearing 160, and my electronic blood pressure monitor is showing warnings! Is this bad? Am I in danger stroke or heart attack? What should I do?
“Just get an appointment via Tele-consult – I have to go now,” says the doctor.
The patient asks, “But wait, doctor, what should I do now, today — can I take something to lower my blood pressure? I am so anxious and depressed. I can’t sleep at night, I’m afraid I’ll die in my sleep!
“Insomnia can affect your BP. But your BP is within acceptable levels. It’s just anxiety – control yourself. I can refer you to a psychiatrist,” the doctor said, visibly in a hurry.
Later, the patient sends a Viber message to the doctor: “Sorry to have bothered you too much. But my nervousness was really aggravated by waiting for your Viber response for three days. Thank you for answering my call this morning. (The patient had not “bothered” [consulted] Doctor for at least a year and a half.)
Doctor Viber’s response: “Sorry, I can’t hold hurt feelings…this number is my home number…(where) I’m waiting for messages from friends, classmates and organizations.”
Ang sakit naman! How painful it is for a doctor to cause his patient more pain by saying outright that he doesn’t care if his patient is in pain! In the constant, debilitating pain of gripping anxieties over the two-plus years of this long-lasting and life-threatening COVID-19 pandemic, her 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 for the Medical Profession (Jointly Adopted and Approved by the Philippine Medical Association and the Professional Regulatory Commission – September 2019), the preamble states: “On entering the profession, a physician assumes the obligation to maintain the honorable tradition of conferring the well-deserved title of “Friend of Humanity”. A physician should take pride in his profession and conduct himself in accordance with this Code and 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 must be placed above that of the doctor. Societal pressures, financial gain and administrative requirements should not compromise this principle.
1.5. Primum Non Nocere. The physician’s first responsibility is to do no harm to the patient.
Article III Sec 3.2 emphasizes: Patient confidence. Physicians must maintain a fiduciary relationship with their patients by demonstrating 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 during his 65-plus years in his profession as a most respected gynecologist and chair-editor of the PMA Code of Ethics for the Medical Profession. He said perhaps the doctor with the hurtful words was himself stressed in this dizzying pandemonium of conflicting priorities in the pandemic.
At the start of the pandemic, the Philippine College of Physicians (PCP), an umbrella organization of internists in the Philippines (organized in 1953) issued a notice to health maintenance organizations/companies, including the government PhilHealth, to collect higher fees based on a 50% increase in professional physician fees called “PF”.
In the notice, the PCP indicated the FP rates for face-to-face “F2F” consultation fee in outpatient (P400 to P600) and daily inpatient visit which ranged from P900 to P2,100, much higher than the then-usual P600 to P1,400 (https://www.philstar.com/ July 5, 2020). The increase in PF, applicable to both COVID and non-COVID cases, was criticized in the media and social media, but the increase in rates prevailed, visibly increasing further in the prolonged pandemic to P1,000-P1 .500, maybe depending on the notoriety and reputation of the doctor. The teleconsultation fees reflect the F2F fees.
Patients with health insurance can claim reimbursement for FP and certain other expenses from their insurers, based on a pre-agreed table of maximum reimbursements. Those without private health insurance can request certain reimbursements from PhilHealth, but only FPs directly related to listed illnesses requiring hospitalization or prolonged medical treatment.
Perhaps the increase in FP fees was also necessary for additional administrative costs for physicians in this pandemic. There are additional risks and expenses doctors incur when managing patients during the pandemic, such as PPE (personal protective equipment) and sanitation of their premises. At the start of the pandemic, a dental clinic charged a “sanitation fee” of 3,000 PP to F2F patients, to support the overhauled air conditioning and filtering system and extensive disinfection of the room and equipment for each patient. There is an increase in “operating expenses” in complicated F2F consultations and even more complicated teleconsultation services, which must be set up with IT systems and hire IT/software consultants and trainers for doctors. Of course, registering physicians for teleconsultation services includes a fee and revenue sharing to keep the system running, and more. Thus, the patient questioning in teleconsultation must first settle before asking his question, or settle entirely electronically, the FP of his doctor before even making an appointment online or in F2F, which can mean a waiting time. two to three days to “see” the doctor.
Prepaid FPs in teleconsultation can be reimbursed namanwith some extra effort with online payment agents.
Hospitals have also increased rents for medical clinics and the use of hospital facilities. Revenue sharing between the hospital and doctors was refined about five years ago, when the Bureau of Internal Revenue (BIR) imposed the rule that all doctors’ professional fees and income (from surgery, procedures , treatments) should all be receipted (including services given/free to family and friends) and should all be traceable from the hospital’s own operations and marked with an asterisk (noted) in the general income statement. Individual physician income taxes must be paid directly by the physician. No escape from the BIR!
The profession of caregiver, as in the conduct of the exercise of a doctor of his profession, has indeed been complicated by the vicious dictatorship of the COVID pandemic. Although the physician’s Hippocratic oath upholds life and health, embodied in the patient, as always the first priority, mundane constraints, now including the life and health (and economic survival) of the physician, can cloud the moral and ethical issues for the physician. Some groups of physicians insist on the principle of “physician autonomy”, which is actually present in the Code of Medical Ethics, Article 3, Sec 2: “The doctor must be free to choose his patients” and to determine the best way to practice his profession.
For 93-year-old Dr Santiago del Rosario, the Hippocratic oath trumps any mundane self-centered concerns. During the pandemic, and still ongoing, he shows up at his MWF clinic, from noon to 4 p.m., wearing a double mask and wearing a face shield and rubber gloves, to treat those who need his help. And he goes to the daily F2F Holy Mass, thanking God for Life!
Amelia HC Ylagan is a Doctor of Business Administration from the University of the Philippines.