Health Care in the Country is Dying Rating Options

[carlshark]

I will always be a DOCTOR... thats my passion...

That will always be my vocation....

I agree, we all are doctors here by vocation. But, like Fr. Ed Panlilio, some of us might have to take a leave from our vocation due to compelling reasons. Like providing a good life for our family. Or just being tired from the politics that permeates the whole system.

[cv_path]

I will always be a DOCTOR... thats my passion...

That will always be my vocation....

I agree, we all are doctors here by vocation. But, like Fr. Ed Panlilio, some of us might have to take a leave from our vocation due to compelling reasons. Like providing a good life for our family. Or just being tired from the politics that permeates the whole system.

....Because being doctor in the Philippines now became a thankless job with the real risk of being sued if things go wrong. It is a vocation and a passion to reach the needy...in retrospect maybe being a simple social worker or a priest would still fulfill this longing for doing service to the needy without the shadow of doctors being out there for money and prestige...right?

[drhenry4]

Its really not the same... Iba na talaga ngayon, even my elder mentors are seeking greener pastures. It wont take an all in one solution to alleviate our status. Its quite different when you are the head of the family and there are persons relying on you. You can eat a decent meal 3x a day, have a roof over your head, and give the bare necessities in life. Yun na lng ang abot na makakaya natin sa panahon na ito. Ang quality of life na ang deteriorating ng doctors and their families.

Ang makakapag tiis, SALUDO ako sa inyo.
Ang umalis, MAS SALUDO ako... Its not sacrifice doing what you love to do, di ba... but turning back on the things you love to do for the sake of your family is something more noble.

One can be a nurse now....
Others can be a medical transcriptionist...
Or maybe a businessman or a farmer...


I will always be a DOCTOR... thats my passion...

That will always be my vocation....

You will enjoy really where your heart is, we call that passion.
To help one who is at the brink of death but was revived and after patiently followed up thru everyday rounds, he is up and about;
To help one in his illness while cost is a burden, a helping hand of a doctor will lighten him up;
To come up with a right diagnosis after going thru vague history, and limited PE and labs;
To receive a gift unexpectedly from someone after carefully explaining to her the pathophysiology of her father’s disease;
To receive a round of applause from younger colleagues after teaching them the smart approach to a case.

Pag naranasan mo mga ito, nakakalimutan mo talaga panandalian ang kalungkutan na,
sa haba ng clinic hours mo, ito lang ang matatanggap mo;
sa tagal ng itinayo mo sa operating room para sa isang mahirap na kaso, salamat lang ang matatanggap mo;
sa dami ng ni-rounds mo, miryenda lang, wala pa;
sa dami ng inikot mo na ospital, kulang pa ang kinita mo sa gasolina na naubos mo;
at pag dating mo sa bahay mo, di ka makabili ng pasalubong sa anak mo.

Kaya nga, tanong ng mga umalis, “Bakit kailangan kong danasin ang kalungkutan ng aking propesyon sa Pilipinas?”
Kailangan pa ba akong mandaya sa aking buwis?
Kailangan pa ba akong sumingil ng sobra sa pasyente?
Kailangan pa ba akong maningil ng di ko naman ginawa sa Philhealth?
Kailangan pa ba akong manira ng ibang doktor para sa akin maniwala ang pasyente?

Yes, we left the country because we chose our family but...... behind a comfortable house, a nice SUV, an expensive coat and tie, a diamond ring, sceneries from vacations in Boracay, Palawan, Camiguin islands……

We know, deep inside, “I am always a doctor, and that’s my passion.” And that's where my heart is.

[lakaydelfin]

health provider in the country is dying?

lakaydelfin

[lakaydelfin]

Wala na akong maisip pang paraan paano ko gagamutin ang sakit sa hanay ng ating propesyon.Isa rin ako sa umalis sa ting bayan upang magsilbi sa dayuhang bansa bunga ng aking kapusukan noong aking kabataan or dahil sobrang naging magkapalagayang loob ng aking ngayong maybahay.Sa pagsisilbi ko sa mga dayuhan bilang kanilang manggagamot, isa lang ang sinasabi ko sarili ko sa pagbibigay sa kanila ng serbisyo,"ang hinde ko man maibigay sa king mga kababayan sa ngayon ay ibibigay ko sa kanila ng lubusan at umaasa ako na sasambitin nila ng taas noo, Pilipino ang aking Doktor!". Babalik na ako....


lakaydelfin

[cv_path]

Nagbasa ako ng forum lahat tayo me kanya kanyang messianic complex.

This made me smile again after lurking through the thread. I used to have it too and probably have still some remnants in me. The 'idealists' still believe that they have what it takes to revive whatever is left in our healthcare system until reality bites (IMG:http://pinoy.md/ipb/style_emoticons/default/mellow.gif)

[drhenry4]

:
POOLING OF RESOURCES
This might solve half of the #5 problem.
I was thinking of a “pool of resources” similar to HMOs. One with sources of income, not with healthcare, but the funds entrusted to fund managers so that it can maintain a “trust fund” for healthcare services: opd at malls catering preventive healthcare like annual and preemployment medical exams, and opd illnesses, vaccines and drugs, laboratory services; hospitals branches in major cities in the country, doctors from consultants down to interns, with salary brackets, instead of professional fees, of course, salary not based on existing salary grades of the government. Income of these health institutions is revolved or added to the “trust fund”, which must be upgraded annually based on inflation rates, etc. The fund managers entrusted with this “trust fund” will invest it in stocks, bonds, and other securities, not only in Philippines but also in nearby Asian countries, if not America and Europe. Eventually, a “brand new” of HMO will be launched, to finally replace the “cheap” ones.

I know this is just a dream. This needs careful analysis and planning, like feasibility studies. And this will roll up in summary of necessity of all times, FUNDS. Where are we going to get the FUNDS?
That’s why I advocated for the committee that will discuss this in one of their agenda.

I received e-mails regarding this idea. I think these are good opportunities.

This concept sounds good to explore. With these fast changing times, evolving needs of target market (means potential patinets), doctors like us need to go with flow, and create a proactive , strategic plan to incease our niche in the market. Yan daw kasi kulang sa atin, we were not oriented to become business minded. Most of us have that community-based orientation. Di naman masama tumulong, pero tayo rin yong field na napag-iiwanan na.

I have been working as technical adviser on health programs development projects funded by international agencies. I must say, I have been detached from my clinical practice for seven years now; kasi hindi ko kaya maningil ng patients, lalo na kung kita mo naman na mahirap lang sya.

fortunately I have gained new skills along the way ; I can make the design and facilitate strategic planning workshops; I can also facilitate market segmentation- in businees, you package your services to certain segment of the population.

Maybe I can help out with this. and actually we can form a group and apply to become a cooperative. . pwede tayo maka utang sa bank subsidized by the government. In fairness , our government has a number of projects na pwede makatulong sa atin.

I have been thinking of this kind of ventures too, kailangan ko lang ng mga tao who have the same inclination, commitment and interest. Sa tingin ko, kelangan talaga natin ng support ng isat isa. kung solo solo lang, talagang mahirap . Sayang tayo, kasi matatalino pa naman tayo.

I dont know if it's possible to otganize a meeting, mag-eexplore lang tayo, exchange ideas; then hopefully , mag i-strategic planning tayo, then turn it into a concrete action plan.

I need hands here!! "Myrna Hernandez" <myrna_mhernandez@yahoo.com>

greetings! this is erwin samson, a pediatrician from las pinas. i read your email on pooling of resources and i think it is a very good idea. i'm part of a group called carepartners multi purpose cooperative and we do something similar to what you're suggesting. if you want more info on this you can inquire with mr. rey chang at changrp@yahoo.com

[journey]

http://services.inquirer.net/express/07/07...-76997-xml.html

Systems meltdown

July 17, 2007
Updated 02:31:12 (Mla time)
Juan Mercado
Inquirer

What will sear people’s lives more than today’s political dogfights over the Senate presidency or House speakership is the little-noticed meltdown of already faltering health systems.

Town after town has lost vital health care personnel who’ve migrated. And modern hospitals mask the emergence of the threat in cities. In slums, “modern” diseases, like diabetes and hypertension, are surging even before the poor curb “old” illnesses, like diarrhea and tuberculosis.

“A health disaster is impending if nothing drastic is done,” Jaime Galvez Tan, Fernando Sanchez and Virginia Balanon warned at the Antonio Sison Memorial Lecture. Political instability, corruption, under-funding of health over four decades, plus unstanched migration, stoke the crunch.

“Hospitals in Surigao del Norte, Lanao del Sur and and Sulu (and) two in Isabela have no more nurses,” Galvez Tan, Sanchez and Balanon noted. “Two hospitals in Zamboanga del Sur could not operate new wards due to lack of nurses.” They long lost their doctors.

Most doctors gravitate into cities. And the migration stampede, which started in the 1960s, spared no speciality from pediatrics and obstetrics to internal medicine, orthopedic, etc. They streamed toward the United States, Europe and the Middle East.

Figures on doctors, nurses, midwives and dentists vary widely. There are no accurate tallies on those who’ve left, since many bypass official channels. Philippine Medical Association data on physicians is “soft.”

But what has been tracked shocks. The Philippine General Hospital loses almost a quarter of its 2,000 workforce yearly. “Educated guesses” say 7 out of 10 Filipinas who hold Bachelor of Science in Nursing degrees work in 32 countries. “I have a BSN,” brags a former Filipino journalist who drives her nurse-wife to a Chicago hospital. “Binuhay sa nurse.”

Sedated by wow-wow-wee pap, people haven’t looked hard at the consequences. But 5 out of 10 Filipinos die without medical attention. Health professionals attend only 60 percent of births here. The comparative figure for Vietnam is 85, the UN Human Development Report notes. Some 200 Filipino mothers die in every 100,000 births. Compare that to Malaysia’s 41. Kuala Lumpur spends almost double on health (2.2 percent of GDP) what we do (1.2 percent).

The “bleeding” became a hemorrhage since Galvez Tan, Sanchez and Balanon presented their June 2005 study. “The more recent outflow is more disturbing since they’re no longer migrating as medical doctors but as nurses.” An earlier baseline survey revealed that “more than 3,500 Filipino doctors left, as nurses, since 2000.”

Today, the country loses more health workers than it trains. “The large exodus … has been unparalleled in nurse migration history.” Enrollment in 36 medical schools has slumped. “The medical profession is under severe threat of decimation.” If continued, this “overdraft” will tailspin into bankruptcy.

“What falls below the radar of metro-focused media are losses of municipal health workers,” notes former Health Secretary Alberto Romualdez Jr. “This is where a child with dengue or a father with tetanus gets crucial help. But over 100 towns have gone without service for over a decade now. And this emergency will soon erupt in our cities.”

All cities, Plato wrote, are made up of two: a city of the rich and another of the poor. Residents of gated enclaves, like Forbes Park or Cebu City’s Maria Luisa subdivision, can afford services from better-equipped privately operated hospitals. Some are treated abroad -- by Filipino specialists. But these are a tiny minority. They foster what Worldwatch Institute calls “myth of the healthy city.”

The reality is: Vast majority of city residents are hard up. In crammed settlements or slums, they struggle with short rations, polluted water and shoddy sanitation. Economic gaps strap these large populations into health inequalities. Stubbornly high birth rates and migrants fleeing rural indigence are seen in scrawny adults and stunted children of “the ailing city.”

Crowded, under-funded government hospitals often turn away patients. In poorer areas of Davao, Iloilo, Cebu or Sorsogon, only 58 out of every 100 one-year-olds are fully immunized. But the rate is 81 in those high-walled subdivisions with security guards. TB incidence here is 463 for every 100,000 population. It is 208 for Thailand

The health profile of cities show infectious diseases of massive penury, like TB, interlock with the ailments of modernity: heart disease, hypertension. This “double burden of disease” does not follow in sequence, as the West experienced earlier, note Harvard Medical School and World Health Organization Today. They overlap and must be addressed simultaneously. Where will today’s Filipinos get the health personnel and drugs to do this?

“This out-of-the-box situation demands out-of-the-box solutions,” Galvez Tan, Sanchez and Balanon add. To “achieve a rational program of departure of health personnel” and ensure services for citizens, they’ve crafted a 10-point package. The proposals range from enactment of a National Health Service Act to World Trade Organization discussions of health services across national borders.

Cuba devised a health care system for the poor that enables its citizens to live longer than most Latin Americans. Here, kindergarten kids sing the ditty: “Mother, mother, I am sick/ Call the doctor very quick.” For now, the answer is: “Sorry, kid, the doctor didn’t leave a forwarding address.”

* * *

E-mail: juanlmercado@gmail.com

[Doc3D]

DrHenry4's post says it all. From the hardships of a doctor-in-training to the difficulty of having your practice. It's really sad but it is the truth. I am one of those "positive thinkers" who still think that our condition will eventually improve. But seeing things everyday sort of makes me think. I heard of a program that they are giving out scholarships for would-be doctors in exchange for their services for the country. The way things are projected, it's like there are only a few doctors in the country. I beg to differ. There are plenty of doctors in the country, some of which are the best in their fields, but the problem is keeping them here.

(IMG:http://pinoy.md/ipb/style_emoticons/default/waiting.gif) (IMG:http://pinoy.md/ipb/style_emoticons/default/waiting.gif)

[tortuga]

It's quite obvious to see the trend about healthcare. The proposed solutions may be worse than the problem. What is so out-of-the box about National Health Service Act? Sure, forcing graduates to practice in Mindanao will solve the problem. Why nobody raised hell when they decentralized or "devolutioned" or whatever they call it health centers in the provinces? Do they really think a local politician has the health of it's constituents in their hearts?
Why praise the health system in Cuba (a communist country) when they would balk about a nationalized health care system?

[vanguard88]

alam nyo its kinda useless just haring sentiments! walang mangyayari pag atin atin lang usuapan. baket di tayu gumawa ng signature campaign or massive boycot!! KATULAD NG GINAWA NUNG MGA JUDGES DATI NAG MASSIVE BOYCOT KAYA AYUN FROM 25 K NAGING 50 K NA ANG PER MONTH.TINGNAN MO MGA JEEPNEY DRIVEERS PALAGI NAGWEWELGA KAYA KAAGADAGAD MAY TAAS ANG PAMASAHE.


THEY WILL NOT KNOW UNLESS WE AIR OUR SENTIMENTS AND GRIEVANCES.

[stroke1rehab2]

alam nyo its kinda useless just haring sentiments! walang mangyayari pag atin atin lang usuapan. baket di tayu gumawa ng signature campaign or massive boycot!! KATULAD NG GINAWA NUNG MGA JUDGES DATI NAG MASSIVE BOYCOT KAYA AYUN FROM 25 K NAGING 50 K NA ANG PER MONTH.TINGNAN MO MGA JEEPNEY DRIVEERS PALAGI NAGWEWELGA KAYA KAAGADAGAD MAY TAAS ANG PAMASAHE.


THEY WILL NOT KNOW UNLESS WE AIR OUR SENTIMENTS AND GRIEVANCES.

So...
Who would like to organize a countrywide boycott by doctors...including emergency care for more effect...
Of course may mamamatay, perhaps our own relatives...

Going abroad for me was killing 2 birds with one stone...
Saving my family and expressing my sentiments/grievances by boycotting my Philippine medical practice.

[smallville123]

This is really a sad story, but this isn't exclusive to graduates of Medicine. Other fields suffers the same fate: Engineering, Architects or even Nursing graduates like myself. The cost of tuition fees and other school expenses across any courses had significantly gone up on a yearly basis. For nursing, it has more than doubled/tripled since I qualified in mid 90's. Sorry but I don't have a clue on current fees for medicine. The significant difference is it takes ??8 years to graduate as a Doctor as opposed to 4-6 years on other fields.

But even so, now that there's a higher demand in nursing globally new nursing schools have sprouted everywhere. Perhaps, more than what it can accommodate to provide quality training/experience. From my recollection, It was during my college years when there was a significant drop of students in the nursing field from a whooping 30 sections/year down to 8 sections. The main reason being, the significant reduction on the demand of nursing abroad, particularly in the US. Aware of the facts how low the salary was in the Philippines, even in Manila, we carried on. Not knowing if it will ever reopen or if we ever get a job at home once we qualified. Yet, we never lost our hope. Few years later, opportunities came. UK demands soar, subsequently, US reopened again.


My point here is this. So long as you study hard, you have set your goals both short term and long term, you remained focus on what you do and you never loose hope an opportunity will come. It may not be sudden but it will. It may not be a job in US but it could be somewhere else. But if you give up what you have wanted ( especially to those contemplating of taking medicine and those newly qualified) it will never be yours.

Sacrifice will have to be made until such time that you're financially more stable, particularly to those with families. Even here in England, majority of women don't tend to have kids until they are in the very late 20's or early 30's (purely based on what I have witnessed as I don't have a data to present). And if they decide to start a family, they only have 1-2 kids - it's expensive even if schools are free for all (catholic school etc...) except to those who are rich who can afford privately. Even majority of the consultants only have 2 kids because of lack of time. I just hope that this is realised by many more Filipinos in all social classes. Until such time that our country is better off in every way.

I work as a critical care nurse in a well known teaching and research hospital (just guess where I work - Cambridge or Oxford). There is a huge number of South Asian doctors (Indians, Pakistani, Bangladesh) both born here or overseas some of whom are consultants on specialist area. Can this not be tapped by Filipino Doctors. It might be a little difficult now with the introductions of EU law i.e. recruits should come from members of the EU unless otherwise proven that there isn't a qualified one to fill the post. But there are a lot of places to go. This will then give new opportunities for newly qualified ones to gain experience in the Philippine hospitals. Although, not the ideal, but for now this is the only solutions until such time that the economy of our country significantly improved to raise the budget for developments of public hospitals nationwide (from Aparri to Jolo). And when this time comes, the help of those additional doctors who had additional opportunities to gain experience in a tertiary hospitals worldwide would be needed.

I've read in an article somewhere (don't hate me on this if I got it wrong) that the percentage of overseas Doctors come from India as well. There isn't an element of racism against other Asians. My point is, isn't there a high demand for Filipino Doctors in the USA? Are you reaching the annual US immigration qouta for Doctors. (I can definitely say, that this is the case for nurses). Or is it that there is a failure to pass the necessary examinations (USMLE). If this is the case, then the quality of training should be raised. Med schools should be more open minded. Adjust the training where the demand is. This sounds horrible but this is the only way to recover the dwindling recruits into medicine for now. Until such time when both government and Filipino investors realised that other sources of dollars can come not just on exportation of Human resources but equally on goods, online services, tourism and medical tourism etc... Also, the reduction of medicine tuition fees (in your dreams) should be considered. If theres only 5-10 applicants/students per year reducing the tuition fees will attract more students enough to recover the loss without compromising quality.

At last, I’ve found a place I will consider my place.
It has been my urge always to express things on every subject that affected lives of Filipinos, particularly doctors. I’d written them and some stored in the hard disk, most I don’t remember anymore. But now I have place where to share them.

Twenty-five years ago, I was made to believe that my profession would give a decent living besides being prestigious. After ten years, I found out, not only decent living but it is also a noble one. But now, it is deteriorating. It couldn’t give a decent living and for some the nobility is somehow decreasing. I couldn’t imagine why our leaders in our group, our society, our association, had let this happen. Maybe because many in our profession are too much engross in training young colleagues and might have overlooked that the health system must not be entrusted solely on the hands of politicians, particularly DOH. Then I remember in my training, that doctors are trained to be good one, must be smart to diagnose the hardest case, and be a teacher, an educator for the incoming junior colleagues. But many of our leaders were not good planners and it seemed that the future is manageable as a common illness. And now health care is dying. In my alma mater, there was only an average of less than a hundred graduates for the past 10 years because less and less are going to medical profession. Maybe that’s the reason we had less post graduate interns in my last year of residency. But not only that, I remember we were over a hundred applicants in residency training. In my last year of residency, applicants were only less than 20. Worst was in a private hospital in Quezon City where there were zero applicants.

In my training, I was taught of cost effective management, that I would do tests that are indicated only. But sadly, my consultant in his private practice would keep on doing ECG on his patients even it was not indicated, “Just to rule out,” as he always says. Or maybe it is his ECG machine. I remember a surgeon who did advise a cholecystectomy in a patient who happened to have an incidental finding of a < 1 cm stone in gallbladder during an annual exam. His HMO would pay the hospitalization anyway but I knew then, he would still charge separate PF of his own. And there was a pediatrician who would keep on admitting children with colds and cough just to rule out dengue. Then there’s an obstetrician who would advise cesarean sections on her patients undergoing “hard painful” labor and would say, “There is fetal distress” or “The cephalic failed to descend”. These are true cases and did show how the noble profession had become; all because the noble profession has failed to give a doctor a decent form of living.

Nowadays, that the inflation rates are high, to be noble in this profession is to ride a public jeepney going to your hospital of work, to live in an apartment near a slum area because that’s what your income could afford, enroll your son in a public school where their classrooms are under a tree, have your wife deliver your next kid in a public hospital where 3 mothers will occupy single beds, and bring your family in a nearest Pares Mami House for a once a year night out.

So I have to turn down offers of fellowships. But I am hungry for further learning. But I have to choose, pursuit of career or family needs. “Two years na lang” as what my mentor said. “Konting tiyaga na lang.” This myth had been the message of leaders in our society. That after training, things will go smoothly. Really? I saw a PCCP fellow having clinic hours in an HMO paying him less than $4 per hour in a 4-hour schedule. If he could get a slot of an 8-hour, that would only be about over $25 per day, $500 per month, for a PCCP fellow, after a long time… but still, could he get a slot? I also saw a PSGS fellow he came for a referral on acute appendicitis, his only case for the month, only to find out that an HMO will cover the cost and the HMO will pay him $100 for the case after 1 year…..? I met a PSEM fellow actually graduated her fellowship from Singapore doing retainer duties in a new HMO and she hasn’t been paid for a quarter already. Her subspecialty society wouldn’t like to recognize her because a fellow invoked that she was trained abroad in violation of their by-laws. These colleagues are undoubtedly noble, noble in their practice. One was riding a jeepney, another is hardly driving his 5 year old model car which needs to visit a repair shop, and the other was lucky to have a sister who would not be only a driver but also would refill gas for her. So after 2 years more of training and adding titles PSN, or PSG, or PCCP and so forth beside my name, I would encounter similar struggle. And my eldest by then will be in his mid primary schooling, my youngest will be starting her ABC class.

I remember once when I was about to bring my son to his class and while helping him tie his shoes I noticed them with cracks and looked very old. I looked at my wallet and I didn’t have money to buy him a new pair. And I do have a noble profession, one that cannot afford a new pair of shoes for my son. That stroke me and then I said, “Enough with this madness.” Philippines will not give me and my family a decent living. And my family couldn’t wait by hoping that the system will change in a less probability that it would be soon.

And now I’m out of the country, far away from home. For the first time, I saw how Philippines is way far behind its neighbors and I told myself that I should have done this a long time ago. But I’m not late. My struggles will be over this year. But it wasn’t easy for me but as long as my family is ok, then I should be ok, even though I missed them…….. always.

You may not believe but these are generally true:
1. Philhealth is not helping much the poor, then how much more the doctors.
2. HMOs are killing the medical practice. Sadly, medical directors are doctors themselves.
3. High cost of medicines makes the medical practice futile. Medical missions then just became a one-stop-treatment-shop and not management of illness.
4. Most doctors who turned politicians have forgotten that they are doctors, mindful only of patients and not of their colleagues.
5. And everybody has forgotten that health care is a system comprising not only of patients but also doctors, nurses, midwives, med techs, x-ray techs, therapists and other paramedics. All members need to live a decent kind of living.

Because of these factors, many in the health care are leaving the country. And doctors have to be nurses, or a caregiver just for desperation to get out.

And health care in the country is dying.

[drhenry4]

Got this article from Medscape and has similarity with our country's condition: lack of funds.

The Disappearing Doctors

Jane R. Gilsdorf

Health Aff. 2008;27(3):850-854. ©2008 Project HOPE
Posted 07/01/2008
Introduction

The pediatric infectious diseases (PID) team assembles in the hallway for rounds here at the children's hospital where I have worked for twenty-five years. I'm the attending physician during the next two weeks, and the other team members include the PID clinical fellow, two pediatric residents, a medical student, and two pharmacy students.

"Where's Diana?" I ask. Diana, a second-year pediatric resident, is doing a month-long elective on pediatric infectious diseases. On Monday afternoons and Wednesday mornings she is at her primary care continuity clinic. Today is Tuesday. She should be here.

"She was the night float on hem-onc last night, so she's home now," the PID fellow says, using hospital shorthand for hematology-oncology. "She'll be at her continuity clinic tomorrow morning and then here tomorrow afternoon."

"Well, where's Don?" I ask. Don, a third-year pediatric resident, is also taking an elective with PID this month.

"He had to cover the ICU [intensive care unit] today because of some glitch in the schedule. He'll be here tomorrow morning and then gone to his continuity clinic tomorrow afternoon."
Missing Residents

Both residents working with the pid team are elsewhere today. They aren't available to examine their patients, to learn about new symptoms from the parents, to review the results of the most recent lab and radiographic tests, to review the nursing assessments for the past twenty-four hours, or to make recommendations for ongoing care for their patients. The PID fellow tried to do their work today as well as her own.

Residents like Diana and Don—young physicians learning to be clinical specialists—have long been the mainstay of medical care in teaching hospitals. Because residents traditionally worked in hospitals in the name of receiving education and because altruism is a hallmark of doctors, physicians-in-training have provided a considerable amount of clinical care while working long hours for relatively short pay. What's going on here? Why aren't Diana and Don on PID rounds as they were supposed to be? It's the result of cockamamie resident physician work schedules that look more like Bingo cards than a comprehensive system for providing coordinated medical care or educating future medical specialists. The erratic schedules are the unintended consequences of the new rules on resident work hours.

In 2003 the Accreditation Council for Graduate Medical Education (ACGME), which accredits U.S. medical training programs, instituted rules for resident work hours, sometimes called "the eighty-hour workweek"; the new rules limit residents' duty hours to no more than eighty hours a week. These rules govern the working conditions of the 100,000 young doctors-in-training in teaching hospitals across the United States and were developed both to protect patients from potentially unsafe medical practices by sleep-deprived physicians and to improve working and learning conditions for residents. The work rules, among other stipulations, limit both the number of consecutive days in a week and the number of consecutive hours in a shift that a physician-in-training can work; in addition, the rules require rest periods of at least ten hours between shifts.

Nobody wants procedures or important decisions to be made by exhausted, blurry-eyed, muddle-brained doctors, so the intent was to form medical teams that would work in rotating shifts, thus providing the physicians with adequate time off. As a result, several times a day, responsibility for patient care shifts as it is passed from team member to team member. Although several studies suggest that compliance with the new work rules reduces wandering attention on the part of the residents, might reduce actual or near-miss car accidents involving exhausted residents who've worked extended hours, and appears to reduce serious medical errors in ICUs, other studies are ambiguous about the outcomes of the rule changes. Furthermore, the validity of the methods and analyses in these studies and the generalizability of the results are open to discussion. In short, the total impact of the new rules on physician performance and learning, as well as on patient care and safety, remains largely unknown.
Sprinting Through Care

So we begin our rounds without Diana and Don. Today, like every day, we'll design therapeutic strategies for very sick children who have rare or complicated or difficult-to-treat infections. Many of these children have compromised immune systems caused by an accident of nature or by chemotherapy for cancer or by immunosuppressing drugs to prevent a transplanted organ from being rejected. As we walk through one of the wards, a first-year resident stops me in the hallway.

"Dr. G, could I ask you a question?"

"Sure."

"We have a patient with hypogammaglobulinemia and a protein-losing enteropathy. Should we continue his IVIG and trim-sulfa?" The resident has just described, in these few words, a patient with low antibody levels, most likely because too much protein, including antibodies, is passing into his stools. She's asking if the child should continue to receive intravenous immunoglobulin therapy to replace the antibodies and if the child should continue to receive the antibiotic trimethoprim-sulfamethoxazole.

"Well, that's complicated," I answer. "For starters, how old is the child? Why does he have a protein-losing enteropathy, and how long has he had it?"

The resident shuffles the papers in her hand. "Um, I really don't know him very well. I'm just cross-covering because his primary resident is 'post-call'." Translation: She's filling in for the patient's resident physician who was on duty overnight and, because of resident work hour rules, is unavailable today.

"I can't begin to answer your question without knowing the details," I say. "Why is the patient on the trim-sulfa, anyway?"

"Don't know."

"Will you be calling in our team to consult about this patient?" I ask.

"I don't think so. The senior resident told me to ask you about it."

"Well, I can't make recommendations about stopping treatment until I understand the whole situation. Put in for a consult and we'll figure it all out."

Is she a bad resident for asking me for a recommendation on a patient I don't know? No; like all residents, she has been given responsibility for the care of a very ill patient during the current eight-or ten-or twelve-hour shift, but she didn't take care of him yesterday and probably won't take care of him tomorrow. She doesn't know the full story of this patient's recent illness, doesn't know the long-term plans, and wasn't part of the previous decision making to design the patient's current treatment. This resident is filling an open shift in the schedule, and her goal is to place a check in the box beside the item on her list that says, "Ask PID about stopping IVIG and TMP-SMX."

Is this a bad hospital? No; stop-gap measures designed to provide physician care to all patients around the clock, seven days a week, are found in every teaching hospital in the United States. By limiting the number of work hours of each resident, however, the new ACGME rules have effectively decreased the hospital's resident physician workforce by 25 percent—in other words, a full quarter of them have gone missing.

The problem is that losing 25 percent of the workforce hasn't been accompanied by hiring additional physicians. As a regulatory agency, the ACGME issues mandates to ensure that young physicians receive excellent clinical training; it usually doesn't approve adding increased numbers of residents to a training program just to plug a hole in a hospital's need for clinicians.

A hospital's inability to increase the number of resident physicians isn't the only barrier to improved staffing—most hospitals can't afford increased numbers of residents anyway. At the same time that the new rules have come into effect, the resources to pay for medical care are vanishing. Medicaid and Medicare payments for health care services are decreasing, and insurance payments are following this lead. Furthermore, more and more patients—forty-seven million currently—have no insurance, which means that they don't pay—because they can't pay—the bill. Although so-called physician extenders (such as physician assistants and nurse practitioners) might take on some of the tasks of the missing physicians-in-training, nursing practice isn't medical practice; even advanced practice nurses or physician assistants haven't had the comprehensive training required to be good doctors. In addition, many physician extenders command salaries similar to those of physicians-in-training yet work only forty hours a week; hiring them as replacements would mean a 100 percent increase in costs.
Keeping An Eye On The Clock

We continue our rounds and enter the staff room, where an intern, seated at a laptop computer, is feverishly keyboarding a progress note that documents the current status and treatment plans of one of his patients.

A senior resident enters. "What are you doing here?" she asks the intern.

"Finishing up my notes."

"You can't do that. You've got to get out of here."

"But, the notes…"

"I'll do them for you. Make a list."

"I also wanted to check the rash on the kid with Kawasaki disease…"

"You can't. You've got to go home."

Apparently the intern in the staff room is up against the limits of the work rules and has been told to leave the hospital. There's no wiggle room. The ACGME requires training programs to report the actual hours spent in the hospital; it leaves it up to the training programs to figure out how to get the work done in the time allotted. If the intern continues on duty beyond the dictates of the rules, our training program might be cited for noncompliance. The penalty for too many citations: probation for the training program or possibly withdrawing the program's ACGME accreditation. A training program on probation or without accreditation has an extremely hard time attracting excellent resident physicians.

We proceed to the next ward. There we meet another resident who, earlier, had submitted a request for a PID consultation.

"Let's talk about the boy admitted last night with the neck mass," I say to her.

"Yeah…tell me what to do with him," she answers.

"Rather than my telling you what to do, let's think it through together so you'll understand how to do work-ups of kids with cervical lymphadenopathy."

"I don't have time for that.Please, Dr. G,just tell me what to do."
Unintended Consequences

Besides ensuring excellent medical treatment for patients, the ACGME work rules were intended to keep residents alert so that they could fully engage in the work and education needed to become fine physicians. The rules, however, are backfiring. Residents no longer are able to observe the timing of a patient's response to an intervention; they can't follow the tempo of a fever or the bloom-and-fade cycles of a rash even when, as responsible physicians would, they sincerely want to. Their heads are crammed with the facts they've learned during medical school, but they can't see firsthand the course of a birth or a gall bladder attack or the phases of recovery from a surgical procedure and then integrate those facts into informed decision making. Instead of producing physicians with high professional standards who see their patients through to the end (of labor, of an operation, of an illness, of a life), the current system is creating a legion of shift-worker physicians who leave when the clock strikes a certain hour rather than when the job has been completed.

In evaluating their training programs, residents often ask for increased autonomy. They realize that in the future they'll be solely responsible for the care of their patients, and they worry that without a certain amount of autonomy during their training, they won't be adequately prepared for independent decision making. Yet with their current here-today-and-gone-tomorrow schedules, they can't be given increased autonomy—they won't be around for the next step or haven't been around for the last step. They don't have the big picture.

The children's hospital where I work contains what I consider the world's most precious treasure: children who are the future of our society. The other great treasure in my hospital is the young physicians of tomorrow who will carry forward our medical values, traditions, and practices. The reason that the doctors at my children's hospital are disappearing or aren't there when they're needed is, simply, inadequate resources to compensate for the restrictions of the new work rules and the resulting workforce reduction.

It's always about the money. In terms of the new ACGME regulations and providing medical care for children, we (meaning our society) can't seem to figure out the money part.Yes,to some extent, we might be able to work"smarter" with new technologies and information systems. Yes, we need to figure out how to streamline communication among the many team members. Indeed, we need resources to create real teams.

As we consider how to allocate medical and educational dollars, the question becomes, What's more important than healthy children and well-educated physicians? We know the answer: Nothing. But when the next question is, What are we doing to meet the challenge of having enough doctors for enough hours in all of our hospitals, we also know that answer: Nothing.

Jane R. Gilsdorf, a professor of pediatrics and director of Pediatric Infectious Diseases at the University of Michigan Medical Center in Ann Arbor. She is the author of Inside/Outside: A Physician's Journey with Breast Cancer (University of Michigan Press, 2006). gilsdorf@umich.edu

[limousine]

IMO if all these suggestions don't work, and if we are to be EXTREMELY DRASTIC about it. The "final solution" might be to wipe-out/eradicate all the existing 80million or so population of the Phils (yes, first to go would be the politicians,,,,,and yes, pot-bellied-do-nothing policemen next to go). Replace them with those superior-genetically-enlightened-thinking-out-of-the-box-immigrant-pinoy-population-lineage. Thereby in the process eradicating poverty and deep-rooted corruption. Oh what a world would it be. Utter UTOPIA. lol!

disclaimer: of course im just kidding. (IMG:http://pinoy.md/ipb/style_emoticons/default/tongue_old.gif)

[vanguard88]

di ba pwede pagsabayin ang politician at mga pulis patola?

[cv_path]

I agree ....the main problem in the Philippines aside from the politicians is the attitude of many filipinos in general. Filipinos are generally happy people and really like to relax sometimes bordering on laziness. It's really multifactorial.....the fatalism, extreme sensitivity, too much value on face and of course complete disregard of the laws. The problem is so deeply rooted that it requires 3 or more generations to completely changed it...........

I also totally agree that there is potential among migrant pinoys who after exposure to other nationalities tend to have an out of the box mindset that may actually spearhead the change in our country.

[tortuga]

I agree ....the main problem in the Philippines aside from the politicians is the attitude of many filipinos in general. Filipinos are generally happy people and really like to relax sometimes bordering on laziness. It's really multifactorial.....the fatalism, extreme sensitivity, too much value on face and of course complete disregard of the laws. The problem is so deeply rooted that it requires 3 or more generations to completely changed it...........

I also totally agree that there is potential among migrant pinoys who after exposure to other nationalities tend to have an out of the box mindset that may actually spearhead the change in our country.

Limo was being sarcastic (IMG:http://pinoy.md/ipb/style_emoticons/default/biggrin.gif)
I was home for a few weeks and I'm not as pessimistic as I saw a lot of good attitudes from the younger generations. They tend to follow rules better and have more concerned for the environment and society in general compared to their elders. Maybe it will take a few generations but it may not necessarily mean some form of violent revolution. I just don't like the the noontime television programming there, they look like many of the Hispanic shows in Univision or Telemundo.

[kyuks]

Here's an article I came across. Why Ibon is to harsh sometimes, I think what they're saying here is basically true....but, PHILIPPINE HEALTH CARE MAY BE DYING, BUT IT'S NOT DEAD...and the work to cure the country will continue.

[b]Here’s why ‘08 Philippines budget is anti-poor[/b]
COMMENTARY | By Ibon Foundation

MANILA — Despite the Arroyo government’s claims of a “social payback” in exchange for the reformed value-added tax, health continues to take a low priority in the national budget, according to independent think-tank Ibon Foundation.

Although the overall government health budget in the proposed 2008 national budget grew 24% to P22.9 billion from P18.4 billion in 2007, government hospitals that provide direct service to poor Filipinos have falling allocations. For example, the budget of 55 government hospitals and medical centers nationwide was slashed by 12% to P3.7 billion from P4.2 billion this year.
Meanwhile, allocations for the operation of a dozen special hospitals, medical centers and institutes for disease prevention and control were reduced by P121 million to P2.6 billion. These hospitals include those frequented by the poor, such as the Jose Fabella Memorial Hospital, San Lazaro Hospital and Tondo Medical Center.
Budgetary support for the major specialty hospitals, such as the Lung Center of the Philippines, Philippine Heart Center and Philippine Children’s Medical Center were cut even more drastically by 22% to just P793.6 million. The subsidy for indigent patients was similarly cut by 63%, to P6 million or P10 million less than last year.
Government’s skewed priorities with regard to health spending was further highlighted by the fact that it allotted P1.3 billion in capital outlays for a Health Facilities Enhancement Program likely to be accessible mainly to those with the ability to pay, while a mere P6 million increase was granted for the “Doctors to the Barrios and Rural Health Practice” programs, which work with a mere P42.3 million.


In the proposed 2008 budget, the Department of Budget and Management (DBM) said the health department is one of the top gainers in terms of budgetary allocations. But the increased budget is still inadequate to ensure a satisfactory level of health services for Filipinos, according to Ibon.
Under the 2008 budget proposal, the Department of Health (DOH) is allocated P16.3 billion. Based on an estimated population of 90.5 million for 2008, this means that government will allocate just P180.29 per Filipino for health services.
The low per capita allocation for health is part of a pattern of government’s neglect of the public health sector, said Ibon executive editor Rosario Bella Guzman. The country’s poor, who cannot afford to pay for healthcare and rely on free or subsidized government services, are the most affected by low government spending on health. This is reflected in DOH figures that show that as of 2003, the poorest 20% suffered the most number of infant and child mortality rates.
The poor allocation of the health budget is manifested in the scarce number of public health workers. In 2004, there were only around 4 doctors and 5 nurses for every 100,000 Filipinos.
Thus, contrary to the Arroyo government’s claims of a social payback in exchange for new tax measures, only 17 centavos out of every peso in revenues are allocated in next year’s budget for health, education and housing services.
In contrast, 24 centavos for every one peso of revenues is allocated for debt servicing of interest payments. If debt servicing of principal amortization is factored in, 50 centavos out of every peso of revenues will go to total debt servicing.
Government’s skewed priorities can be seen in other budgetary allocations that are given more importance over health spending: debt interest payments are allocated P295 billion or P3,261 per Filipino. Meanwhile, the Department of National Defense will receive P56 billion– or more than three times the allocation for the DOH.