Recently, I’ve been receiving   complaints from patients regarding some attending physician’s “quality” of service. Complaints like, “the doc saw me late already” or “my waiting time is far longer than my physician encounter time“  or “this was not explained to me” or  the difficulty of some patients (or relatives) to talk to their physicians. In most cases, the attending physician’s technical competence is unquestionable, but the patients or relatives sometimes felt they still didn’t receive adequate care or service from their physicians. What must they do?

a patient unhappy with the physician services rendered to him (Photo credits from http://www.art-of-patient-care.com/doctor-patient.html)

I always tell these “complainants’ that any doctor-patient relationship is contractual by nature. Meaning both parties has to agree and deliver their end of the deal to consummate the “contract”. The contract is of course the delivery of health services required by the patient’s current health needs.(Read my perspective of this here.) This may sound simplistic but for purposes of discussion, this “understanding” of a contract should suffice. If one party, does not agree or adhere to the contract, then the relationship could be terminated after due process.

In non- emergent situation,  and if the service is available, patients have the choice on who will be their doctor or what type of service they could avail. That by choosing or agreeing to be under the service of a particular physician, the patient also has the responsibility of paying the services of that physician. That is the contract, no matter how business like it sounds.   In cases where one party felt that other party did not deliver the expected service , he or she may choose to end the contract after duly informing and after paying the services rendered by the physician. (By the way, the physician under certain circumstances and on valid grounds, may opt to terminate a patient-physician relationship too but let’s leave that discussion in my future posts.)  In my practice, I always offer this option to all my patients even prior to our patient-physician relationship.

Problem comes in when patients just change physician services without adequately informing their previous and frequently, their succeeding physicians. Far worse is the situation  wherein patients  “leave” their previous physicians without paying their bills on the pretext of a “bad” service.  This is not good practice either and probably will only harm patient’s reputation also.  In the first place and except in emergency situations or some government health training facilities,  the choice of  any physician is really the patient’s responsibility. Health is the business not just of the physicians and institutions but of the patients as well. If you don’t know any of your physicians in the community, then you cannot blame someone else for receiving a bad service. Remember, that physician  gave his or her professional service and in the context of a contractual form of relationship, that has to be duly paid even if you’ll change physicians.

Patient doctor relationship is based on trust (photo from http://harvardmedicine.hms.harvard.edu/doctoring/patient-doctor/index.php)

So if you want to change your attending physicians for a valid reason, inform your physician of the transfer. Pay your end of the  contract, meaning the services rendered. Cultivate the habit on talking to your doctors. Pour in your concerns on them and seek necessary answers to lingering questions.   But don’t forget to inform the physician if there’s something good also about his or her service that you liked. I always believe no doctor would want any patient to feel bad about their brand of service. Just be honest. If those physicians do not change for whatever reason, that’s their catch. Remember that health community is far more sensitive than we thought on issues like this. These type of service screw ups always catches up someone else ears. If you don’t like them, then do not patronize them. That way, you won’t complain at the end of your contract. That simple.

Or is it? What do you think?

“The essential quality of the clinician is an interest
in humanity, for the secret of the care of the patient is in caring
for the patient.”- Francis Peabody Class of 1907, Harvard Medicine

Once in a while, in our busy and chaotic medical life, a few patients would come by and jerk you off your comfort zone for empathy and go bonkers on  the absurdities of life. They come into your clinic like the usual patients complaining of  this or that disease. The moment you ask these patients about their history however, you pause at one point in awe and be moved for a while. Something hit you and had hit you hard. You are, in medical numbspeak, “infected” with their moving story.

One of my few personal favorites is the story of Mang Pedring. Mang Pedring, is a fifty something bread winner of his family. The father of four and a laborer, he frequents and works part time inside these gambling site to earn his living. He barks (as kristo) in a cockfight,  a tayador in a tumbo (I wont bother expounding on this because I really have a vague idea what this coin gambling is) and a meron in a card game called Pusoy or tsikitsa. He broke his left arm after falling off a motorcycle. He was on his way to the cockpit- the gallery for cockfighting.

A cockfighting match barker or kristo doing his stunt in the game to earn his living (Photo credits to the original owner)

It was almost a month after his injury when he sought consult at my clinic. Prior to this, Mang Pedring went to a number of bonesetters, a doctor, and was actually admitted in one hospital for 5 days. His last closed reduction and casting didn’t went well for some unknown reason (I learned later, that he took off his mold because it felt so tight for him, without consulting his previous doc). What’s worse is, he drained his funds going through all these unsuccessful attempts at “fixing” his broken arm.

Funds, which he revealed, was a pool of money earned from gambling- from the throw in of his fellow gamblers when they learned of his predicament, and (the most disheartening was) what he earned as a cockpit kristo or barker while his right arm is strapped in a sling and a cast. That helpless ironic sight, as I imagined from his story, made me twitch in empathy. I cannot imagine raising my broke arm in an attempt to earn my living, much more do it in a gambling site. He came begging me to fix his arm so he can go back to his ‘work” and earn for his family.

What I was trained of course, is not to give weight on his conflicting circumstances but focus more on his ailment, which is his broken arm. Orthopods were trained well to aim at a holistic treatment of a “broken” patient- to return the patient to his functioning, pre injury status. In Mang Pedring case, to his gambling  “work”.

I owe it to Hippocrates and to mankind to do just that and leave the morality of his gambling work to the society’s judgment. In fact, I never pass on judgment unto Mang Pedring. I simply wanted to bring him back to his pre injury level. Whether his work qualifies (or not) as a job for many of us, that is not my concern and is not what struck me in his story.  It is his struggle to earn a living while still on the mercy of a cast over his left arm. The ghastly scene is further brutalized by having to work as a barker in a cockfight. What suddenly flashed in my mind? A wounded gladiator.

Funds depleted, and totally frustrated at his broken arm, I reapplied his cast ( as a temporary “fixation”) while we where looking for funds for his operative treatment. I said I could help finding a sponsor for his metal implant and negotiate for a “free surgeon”. He only has to look for his medicines needed during the operation. Right there, I saw Mang Pedring’s eyes beaming with happiness. He cried in front of me. Cries, which really whacked me out of my objective senses for a minute. I saw his desperation. I saw his hope. Now his desperation is mine too. His hope, lies in what I could do to ease out his predicament. I have to fix his broken arm. Soon. Fast.

Then what he said (in hiligaynon) before leaving struck me the most:

“I gotta get back  to the cockpit and the tumbuan doc and ask again for a “throw- in” for my surgery. I know people there would help me”

I scratched my head in disbelief. Mang Pedring was and even in dire needs, look up to his gambling and fellow gamblers for help. Whatever our society has passed judgment as morally wrong wouldn’t matter to this guy for as long as it saves his limb and and put food in the table for his family. For once, I thought Jesus, the kristo, was disguised as a gambler. Mang Pedring is and will probably be a gambler. But his aspirations and dreams were similar (or parallel) to the non gambling patients I’ve treated. He wanted to return to his job and feed his family. Whether his method or job is morally wrong to some of us that is not my hemisphere of expertise. I simply wanted to return him to his pre injury functioning level. Period.

After 2 more casting sessions, Mang Pedring didn’t come back to my clinic anymore. While in the process of “pooling” funds for his surgery, he felt his armed healed already and removed his cast. Of course I wanted to confirm that with an x-ray. I also wanted to see if the money he pooled is really safe in his piggy bank and not to the gambling aficionados. I didn’t get that chance. One gambling insider later told me Mang Pedring is back in the cockpit again, without his cast and seem to have a functioning arm. I just smiled. Perhaps my work has ended successfully there.

Perhaps, I made a gamble on Mang Pedring.

(Photo credits goes to Islander in the City, here)

All the hospital and the health care practitioner can do is to consider him/her (the patient’s bills)  “lost income” and deduct it from your gross income for that year. That’s what Magna Carta of  Patient‘s Rights and Obligations of 2008 tells us health care practitioners and institution should do. This  law sponsored by Sen. Pia Cayetano and passed in the 14th Congress says:

Title 111: Declaration of Rights
Sec. 4. The Rights of Patients….

(9) Right to Leave. – The patient has the right to leave a hospital or any other
health care institution regardless of his physical condition: Provided, That
a) he/she is informed of the medical consequences of his/her decision;
b) he/she releases those involved in his/her care from any obligation relative to the
consequences of his decision;
c) his/her decision will not prejudice public health and safety.
No patient shall be detained against his/her will in any health care institution on
the sole basis of his failure to fully settle is financial obligations. However, he/she
shall only be allowed to leave the hospital provided appropriate arrangements have
been made to settle the unpaid bills: Provided, farther, that unpaid bills of
patients shall be considered as lost income by the hospital and health care
provider/practitioner and shall be deducted from gross income as income loss for
that particular year. (italics and highlights mine)

The law clearly says health care practitioners or institutions cannot hold a patient from leaving provided proper arrangements have been made to settle the unpaid bills.  Hope this answers the queries made to me before. I’m not a law expert but clarifying provision (in italics) is rather vague. The operational definition “arrangements” and how to go enforcing it is not also defined in the provisions. Hopefully, the implementing rules and guidelines answers this all.

If you are the health care practitioner, what would you do to patients who leave your service without paying their bills? Leave a comment below and I’m definitely interested to know.

(To get a full copy of the Magna Carta of Patient’s Rights and Obligations , click here (You’ll need a PDF reader like Acrobat))

Yeah. Eight should do it.

That is, if you believe what U.S. Preventive Services Task Force- a government-sponsored expert panel that evaluates preventive tests, is telling healthy adults in the US. This meant that of the countless battery of tests that are included in those “executive” work up, only eight, I repeat-only eight will “likely lead to a better health”. I’m not so sure about what where there basis for choosing this eight but I suspect clinical studies that validate it on a public health scale should be one of them.

Nonetheless, and pending reactions from our public health authorities here in our country here are the “test” and their range of acceptable values as published in Forbes Magazine.

I am not sure how our colleagues in the medical profession will react to this and so our public health officials. I am more interested in its implications towards my well adult patients and the health care cost reduction it will offer. Surely that will go a long way in them digging hard into their pockets.

What do you think?

Who says docs don’t scorn the big screen? The latest edition of The Blog Rounds tells us there’s more to the clinics and operating rooms for the stet users. A menacingly titled edition  “Tell me your top ten moves and I tell you who you are” brings the spotlight to docs and their favorite movies. Doc Mel (The Philippine Daily Idiot) this edition host tried sorting out personalities from the kind of movies listed. At least that ‘s what the host intend to. Read here and you’ll enjoy how movies shaped our doc’s personality.

The next edition of TBR will be hosted by Em Dy (Pulse) and will deal with our hearts health!

The Blog Rounds is a biweekly compilation of the best in Philippine’s medical blogosphere, written by physician bloggers (or the medically inclined bloggers) and hosted on a participating blogger’s weblog. Archives and edition schedules ( plus the host blogger) are listed here. The next edition of TBR will be up this Tuesday, Feb 2 ,2008 7am PST.

Physicians and medically inclined bloggers interested in joining this blog carnival, please contact me through my email kokegulper[at]yahoo[dot]com or any of the participating TBR bloggers. Guidelines and updates are posted here in my website, The Orthopedic Logbook.