Philippines ranks first in the global social media penetration according to a February 2011 market survey by Global Web Index. In this survey, it was also pointed out that asian countries do more ‘content sharing‘ than sharing messages as in other countries (UK, Canada). What is the implication of this survey results to Philippines’ healthcare system?

Philippines tops social media usage globally! (Infograph from Mashable by Global Web Index)

Possibly huge. Possibly positive. Sometimes, menacingly negative.

For Filipino patients, the surge of content sharing and social media usage puts a huge stress on prevailing (or lack of) Philippine laws that govern patient information confidentiality. The lackluster enforcement of such laws, if there is/was, is/are sporadic. One does not need to look further. The gruesome photos (trauma, surgical, etc) that somehow lands on your Facebook wall is a testament to this breach. It’s also not uncommon to read patient blogs, tweets and comments on Facebook that cast doubts on healthcare professionals or or institution’s credibility. Some even lead to sensational malpractice suits.

To healthcare professionals (physicians, nurses, allied medical professionals) the responsibility is even greater. In first world countries, there are stringent rules of engagement for healthcare professionals on how they relate to their patients and to healthcare institutions on social media. Such policy govern healthcare professionals employed in healthcare institutions and who’s social media usage directly or indirectly affects that of his or her employer. In the Philippines , while majority of healthcare professional and institutions  does not seem bothered  yet,  catastrophic consequences still hangs in the future . How many times have you encountered photos on Facebook that are in one way or another health patient or institution related? Too often?

For healthcare institutions, this surge is promisingly positive should they take advantage of social media usage. This study by the Global Web Index for example is a market survey for business entrepreneurs. This could be an area for healthcare institution to reach out, communicate to their clients and improve the institutions online visibility. This is what the Mayo Clinic, Mount Sinai hospital for example is doing crafting their own social media policy to enhance patient – institution communication.

Filipinos spend one fourth of a day on social media network.(Thanks to Dr. Iris Isip Tan for posting this infograph)

But without a policy to govern such social media practices by their employees (internal) or their patients (external), the healthcare institution risks running into so many potential negative social media issues aside from economic ones (employees using social media at the workplace).

As an afterthought, let me share another info graphic about use of health related IT technologies in US (source). Take a look at the social media usage. To think, Philippines is ‘ahead” of US in terms of per population social media usage. I don’t know if Philippines has have similar figures in terms of health related social IT. This should be an interesting research for healthcare markets.

Health related IT technologies usage in US (source)

So to answer this post title-question, I’m making an informal, non scientific survey here. This is open to all medical and allied medical professionals. Please answer the poll and please comment below if you need to explain your answer.

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Thank you for voting!

Copyright secured by Digiprove © 2011 Remo Aguilar

“Hello! And again!” I happily greeted this patient sitting on my clinic chair. He smiled back , albeit sheepishly and said  ”Sorry doc!” . “Don’t mention it, it is your right by the way”.

(Photo credits goes to http://blog.drfirst.com/eprescribing/florida-providers-beware-of-doctor-shoppers/)

I saw this patient about 2 months prior to this consult in one of my other clinic in another institution. He consulted me for a certain orthopedic problem, examined him, ordered the needed diagnostic procedures and appraised him carefully of my treatment recommendations. This including financial considerations and proximity of institutions where we can do the necessary procedures. Then I lost him to follow up.

Mr. X resurfaced 2 weeks after, in my other clinic,  in another institution thinking he was seeing another surgeon. He was surprised as I am that we met for the second time in another clinic and in another institution.  I don’t know if he was just plainly uninformed or he wasn’t very particular physician names, but I’m pretty sure my name was clearly printed on this clinic door. The guy was surgeon shopping and is surprised that so far, he window shopped the same surgeon in two different institution  - me and myself.

That aside, I went on with my routine patient consult gave the same treatment recommendations as before. His surgical problems needed the same surgical treatment. Nothing changed. Went he stepped out of my clinic door, I had this inkling I won’t be seeing this patient again. Indeed, I lost him to follow up. Again!

Until this very moment, when he showed up (again) in one of my other clinic in another institution different from his previous consults with me. I greeted him “Hello, …again!” …He went pale. So the rest of the story goes.

Just how he ‘window shopped for the same surgeon, three times, without him knowing” is mind boggling. But he obviously wasn’t very particular with names. He was shopping for the “surgeon” who will give him the treatment he liked.  It’s unfortunate he ended up with the same specialist three times, in the process.

In a small city where “specialists” is as scarce as physician, “surgeon-shopping” may just be actually “healthcare facility shopping’. So patients, pay particular attention to your physicians names…

Copyright secured by Digiprove © 2011 Remo Aguilar

This question was thrown on me recently by a newbie colleague who was agonizing on whether or not to charge patients for an additional procedure he did to address a complication. I instantly went blank thinking what to say.

when surgery goes wrong...will you charge mr. bean?

In the field of medicine or at least here in the Philippines, there’s really no hard and fast rules on charging professional fees for services rendered to patients. This service for fee setup of our healthcare system is somewhat messy and often embarrassing to patients and doctors alike. The price haggling is totally unnerving. Sadly, this is what plague the professional practice of most physicians here in the Philippines.

Such charging “grey” is even more embarrassing in cases where patients entailed additional services outside of their routine or planned operative procedure. While explaining and appraising procedure risks and complications to patients is a requisite of any informed consent, most patients still think that additional procedures,  should be an additional work for the physician and the healthcare providers alone. Patients or their financiers are not obliged to pay the healthcare providers for the services rendered for these additional procedures. Wherever, that notion came from, the stress on the attending physician(aside from that of managing the complication) is enormous, working on a very limited logistics to address complications. Besides, Docs have mouths to feed too.

This situation is akin to the “heroic” services rendered by physicians to dying patients. Just because the patient dies (despite the doctors valiant efforts to revive the patient), the fees for the physician’s services (resuscitation)  does not “die” with the patient too. Services rendered have to be paid even if the service given did not achieve its original goal (that of reviving the patient). Can this situation be applied to procedures done to address morbidities?

What do you think??

Copyright secured by Digiprove © 2011 Remo Aguilar

Patients with a bantay or 'counsel' photo taken from this site (http://www.umc.org)

It’s not uncommon to see a patient or a patient’s relative bringing along some unrelated individual as “counsel” in your clinic. This counsel is unique among my Filipino patients and such counsel’s role has baffled me ever since I started my medical career. Roles, that to my knowledge broadly range from just plain ambulatory assistant or worst, to a nagging and combative counsel to the patient. I have tolerated such roles before because at times they can be very helpful in educating patients and relatives who haven’t had any time to convene a family meeting on their health issues at hand. But a recent bad experience with a ‘counsel’ pushed me to institute a policy of “no non related guardians allowed” inside my clinic.

My patient was a 10 year old girl who sustained a supracondylar fracture from falling over a park statue where she was playing with her cousins. The kid was brought to my clinic after 3 days, on a makeshift splint and after 3 sessions with a known bone setter in the area. The elbow is already grayish blue in color and is still swollen. The kid is wrenching in pain but  I can still feel the pulses and there are no signs of compartment syndrome. The mom brought with her a “counsel” after the bone setter allegedly ordered an xray. In my setting here, even if we’re already an urbanize city with a tertiary level hospital at that , bone setters are primarily the first one being sought by patients or their relatives when dealing with fractures. It’s even very common to hear bone setters manipulating fractures and ordering x-rays! Anyway, what bugged me that time was the way this ‘counsel’ is disrupting my talk with the patient’s mom.

I was explaining the diagnosis and the treatment options to the mom, baring that a surgery is already needed in her daughters case. I could employ a conservative treatment (if cost is prohibitive to the parents) but the results, which I explained carefully to the mom, would be unacceptable and costly in the end. The ‘counsel” is impolite in drawing attention of the mom, and whispering barely audibles that as I can figure out was a urging the mom not to have the surgery done and bring back the patient to the bone setter. The mother was very much bothered and was in fact becoming inattentive to me because of the constant nudging of this counsel.  As it grew frustrating to me, I looked straight to the counsel’s eye but politely asked the mom what is this counsel’s relation to the patient or the mom. She was a neighbor, the mom told me. She was also the one who brought the kid to the bone setter for manipulation twice! I asked the mom again politely of course, to ask the counsel to leave the clinic now and just wait outside. I also urged the mother to call a family meeting and talk with her husband the treatment options I laidout for the patient.

Well, that didn’t happen. The counsel refused to leave and worst, she kept on annoyingly nagging the patient’s mom.  This prompted me to talk directly at the counsel, ask her that if she doesn’t stop disrupting our conversation, she’d answer for all the complications her constant nagging has brought to the patient’s condition. And she’d be thrown off the clinic’s premises for good!

Then there was this an uneasy silence. Everyone in the clinic knew that my usual cool composure got blown by this annoying ‘counsel’. Everyone was silent for at least 3 minutes. When the counsel was escorted out of the clinic, I apologized to the patient’s mom, not for throwing out the counsel, but for the disruption in our conversation. She just smiled and from that moment on. I know I won another loyal patron.

I have long been an advocate of a no refusal, admit all patients policy for physicians . Any physician is bound by his Hippocratic oath and the law to treat any patient (within the bounds of his skill and expertise) whatever the circumstances of that patient will be. The physician also has the social responsibility of reporting any patient (to proper authorities)  that  may pose danger to any other person or to the society for which the patient belongs.

Lately however,  I’ve noticed a few non-compliant patients pushing limits of our patience and  resources. My case in point.

A thirty something male patient brought to the ER (allegedly from another hospital) for a 2 day old gun shot wound. The GSW entry point is at the postero-medial portion of his right leg, with no exit wound noted. He has a comminuted fracture on the middle part his tibia. On examination, the bullet  slug is palpable on the  postero-lateral side of his knee. I noted a wide area of contused skin from the leg, extending to the lateral posterior of his right thigh. Patient is febrile and have an elevated BP. We immediately started IV antibiotics and  scheduled the patient for an emergency debridement and external fixation of the fracture.  Surgery went well and while the skin contusion did grew to a alarming size, the patient eventually recovered and was on his recovery 5 days  after surgery.  The patient ran away from the hospital without proper discharge procedure and without paying his bills. As we learned later, all patient’s data and circumstances were dubious and the patient is nowhere to be found.  My worst fear is the danger of this patient contracting osteomyletis if ever his fracture isn’t followed up carefully.

If he ever goes back to any hospital, and if you are the physician, what would you do?

The dilemma is much more difficult in government hospitals. In the Philippines, government hospitals are funded by people’s taxes. Funding that are at less than optimal and is finite. Government physicians sometimes sees patients, that for some reason,are rarely compliant. Most often these patient’s’ non compliance results to complications and prolonged treatment. Prolonged treatment siphons physician and hospital resources that could have been allocated to other patients. This is where the decision making abilities of a physician enters and is very crucial. It can actually make or break his career because litigation and malpractice suits isn’t easy to come by.

My take on this? I’d still treat the patient according to what his medical problem requires and to what treatment the patients consents to. But I’m going to document it very carefully and protect myself with detailed consents and waivers. I will also get the opinions of  appropriate legal or social services department. Sometimes, its more with communicating with the patient and convincing them of their most beneficial treatment option. This is not easy. But aren’t we surgeons and doctors now if our job is easy?

I may sound like crap but again, the simple fact remains the same. We are the physicians, the very persons privileged to touch and care for sick people. When we treat patients, we (and the hospital) enter a ‘contract” with that patient. Contract that to an extent, requires both the doctor and the patient to work for the wellness of the patient, for so long as that treatment is not detrimental to others. It all boils down to both parties being aware of their responsibilities in this contract. If one violates this contract, that ceases the existence of the contract and therefore, ceases the doctor- patient relationship.

If you are a physician in this situation, what would you do? If, you are a patient, what do you think should the physician do?