Commodification of healthcare

The entry of big business and tax accounting into healthcare has become very significant for many reasons.

One, patients have become customers. And that carries the slogan “the customer is always right,” an absolutely weird and completely erroneous phrase that many customers seem to rally around. What if the customer does not want to pay? And in the realm of healthcare, what if the customer is wrong? Fueled by the vast amount of misinformation in the world wide web, how do you handle a patient-customer who refuses a therapy, like vaccination for example, because some porn star claims that particular therapy damaged her child (she’s since been disproven).

Two, the end-goal has moved from cure to profit. Not too long ago, ordering lab workups were based primarily on indication and what was needed in the care of the sick. But with the advent of defensive medicine (welcome ambulance chasing lawyers) and big business into healthcare, physicians are now more trigger-happy with labs than ever. Say you present at the hospital with a Complete Blood Count (CBC) done in another institution. Doctors can question the reliability of labs done outside, and order another CBC. Especially if the hospital is keeping score on how many labs you’re ordering (some really do).

Three, physicians have become entrepreneurs. With the entry of big business into healthcare, starting a practice is no different from putting up a business, with its attendant capex and opex computations, ebitda and amortizations. In Metro Manila most especially, the typical clinic in the major hospitals will set you back at least 3-4M, and that’s not counting renovation expenses. There’s CUSA (common use services area), staff costs (secretaries and stuff), utilities (water, electricity and communication), etc. And with the taxman breathing down the physician’s neck, there’s a lot of accounting happening now. Who’s going to foot the bill?

It has gotten so bad, some physicians in the major private hospitals have resorted to bribery. Commonly, it’s the person in the concierge or the info booth, who tend to direct walk-in foot traffic towards certain doctors. Alternatively, some doctors get secretaries who are related to the info girl instead. There’s this story about a general surgeon who saw his patient in the floors one afternoon. The patient called him out and asked, “Doc, andito pala kayo? Nagpa-opera na ako sa ibang doctor. Sabi kasi ng tao sa info, out of the country daw kayo.” Classic.

The repercussions to healthcare is massive. Referrals to other physicians are based on how that other physician will affect my practice, instead of how much better it can impact patient care. Choosing prescription medicines too. And doctors are dispensing medicines, test kits, and any other value-added service, if it would mean an extra peso in sales. The paradigm is shifting, from patient care above all, to patient care in the background of improving the bottomline.

Supernova

It starts as a cloud of gas and dust, miraculously coalescing into a nebula. Somehow and after a long while, it consolidates into a distinct body, with its own gravity, and shining bright with its own light. The process takes almost forever as the star grows in size and brightness, then, almost abruptly in comparison, growth accelerates exponentially into a red giant, like a colossal plastic balloon about to pop. And pop it does, almost surrealistically, into one awe-inspiring supernova, lighting the heavens with a billion intensity, until just as suddenly, it folds unto itself, into a deep ebony blackhole. In the timeline of celestials, its one brief firecracker, from a ghostly cloud to a bright explosion, and finally to a deep black tombstone marking its former existence.

Physicians are no different. The tough long road through medical school, residency and fellowship, made even longer by sleepless nights and 36-hour duties. You pay your dues and you do the menial tasks, measuring bodily fluids, becoming intimate with human refuse, feeding your patients while you yourself haven’t had a bite. And the day comes, when you’ve passed all the trials, finished all the mind-numbing exams, accepted all the vulgarities and invectives from all over. You’re an attending, and the world is your oyster.  Skies are brighter. Life is much better. You’re in charge.

These are the days that are most suspect.

Many physicians lose themselves, spoiled rotten by the carefree unstructured days, when day and night melt unto each other, conferences give way to even more conferences, out-of-town trips, and society activities. Many fail to see the inevitable, down the road, when life folds unto itself, marking the sunset with an ebony blackhole. Retirement planning is not a matter of choice, but of survival. It’s a gift not afforded to everyone, but squandered by most. And when you realize its upon you, it’s way too late.

Now more than ever. The paradigm of private practice in the Philippines is changing. Threats abound internally and externally, by forces even from within the organization, and will have far-reaching repercussions within a 5-10 year timeline. It’s a brave new world, and those unable to adapt will be swept away by the waves of change.

What is the ether screen?

ether open drop method

If you needed an operation a couple of decades ago, you’d be put to sleep by smelling ether, the same stuff for frogs and dogs. Your anesthetist puts a strainer on your face (also known as a Yankauer mask), covers it with gauze, and drops ether one after the other until you fall asleep. The heat and humidity from your breathing helps to vaporize the liquid anesthetic. Obviously too much is bad, while too little means you’re still awake. Theoretically, as you go deeper, your breathing slows, decreasing ether intake. 

Michael Caine holding the Yankauer mask for the ether open drop

in the movie Cider House Rules

Now obviously, after some time, the ether gets concentrated around the patient’s head, and affects everyone in the vicinity. Your eyes well up, you get sleepy, and movement is affected. Surgeons most critically. For this reason, the anesthetist drapes a blanket over the patient’s chest, like a wall, slung like you would a clothesline spanning the patient’s width. This drape is sprayed with water, minimizing the passing of the gaseous ether towards the patient’s thorax. This blanket-wall acts as an ether screen, preventing noxious gases from reaching the surgeons. One of the many ways anesthetists protect the surgeons and thereby, helping you, the patient.

Today, ether for humans have been effectively decommissioned, and years of research ushered in modern anesthesia, but the ether screen remains, though its importance is no less critical. It now maintains the operative site sterile, and demarcates the working environment for the surgeons.

This blog will invariably attempt to inject some tidbits about that area up north, cephalad from the “blood brain barrier.” Its about musings, thoughts and ideas from behind the ether screen.

Procrastination

Growing up, I always thought of dads to be super brave and organized. Then I became one and I thought, heck, no one’s going to make me enter a pitch black room alone. And I’m still so disorganized. I’d pack my bags a few hours before a trip, often missing one or two toiletries in the process. My room’s still a mess. And let’s not talk about paperwork.

 

Today I needed to get something done. What usually takes me 30 minutes turned into an all-afternoon and up to the early evening affair. And its just paperwork. With a set template. So, a note to my teenage self, there is no magic maturity spell that happens when you cross into adulthood and become a father. What you were in your teens, is the same you a few decades later. Just less hair. And a bigger belly.

“Wasting time is not the same as wasted time.” Yeah right hehehe

I read Odie’s article (first year pedia resident at PGH) and I couldn’t help crying. These pieces often strike a chord. Fact is, I read it thrice over. Or more. Each time, tears came. I don’t know if that has the effect on other non-medical people. But as an ex-resident, its tough not to get affected. And reminisce.

The thing is that pedia’s a specialty that pulls at your heartstrings. There’s something about kids. Whether you have kids or not, by choice or destiny, its impossible not to get affected. Maybe its their innocence. Or the wealth of opportunities for the young. But seeing sick kids and their families are always difficult. One reason why pediatricians are a special breed indeed. (Not counting the challenges of their specialty.. try inserting an IV cath on an infant with the whole family breathing down your neck.)

My story is about a 2 year old toddler named Angel. Her family gets by selling banana-cue. Mom cooks, dad sells.  One afternoon, mom left the kitchen for a moment, while the sugar is being brought to a boil. Angel, curious little cherub, reached for the hot pan, and, feeling the heat, pulled her hand back quickly, bringing the pan and its boiling contents all over herself. But this is the province, where old wives’ tales reign. Angel’s parents doused several cloth diapers with vinegar and promptly applied these to her body. After 4 long hours, with no obvious improvement, the parents decide to make the long journey to Manila. Via public commute. Through the infamous Manila traffic. By the time we receive Angel, she was staring blankly, largely unresponsive. Multiple attempts at securing an IV line did not elicit any cry or whimper. We lost her 3 days later.

This happened over a decade ago, but the memory remains so vivid to me. Thankfully, I remember both the good and the bad. And its for the good moments we always live for, while remembering the few bad ones whose invaluable lessons we honor everyday.

I’ve always wanted to write a blog. And I’ve made quite a few. But I never got around to updating it. I always blamed my busy schedule when in truth, I invariably get lost in surfing tech sites, checking on facebook, or just whiling away the time playing freecell. (Freecell?) That or zuma’s revenge. More to the point, I can’t figure a central theme for my blog. One time I’m writing about travel (ironic, because I hate flying), or traffic, or (gasp!) investing (seriously, such pretense) or just plain nonsense (this I’m good at). Then, I’d forget to update it. I’ll check the stats and no one’s reading anyway.

So, this time, my nth attempt at writing a blog and staying on it, I’ve decided to stay with the theme anything and everything. Whatever the heck I fancy at the moment. Will people read it? Heck, I don’t care. Maybe you’re reading, or maybe I’m just wasting precious server memory. Whatever.