Examining our Crises

We’ve had one crisis after another through the years; our resilience is legend. According to one Alan Robles, happiness is not a goal among Filipinos, it is their tool for survival. Indeed, all sorts of crises have tested our capacity for pain – from natural disasters to economic crises to political upheavals to unprecedented looting of the national coffers. Except for poverty and hunger, which have always been there but masked by the smiling faces of our countrymen who have no prior experience with comfort and security, these crises come in circles, leaving us hopefully sturdier each time but embarrassingly clueless many times. We are better prepared for natural calamities now, but we seem to have little institutional memory with which to avoid the recurrence of man-made ones. It would seem like we are suckers for crises, because crises unite us like no other and always manage to get the best of us! We clearly own the global franchise for crisis resilience. We seem to have no memory of the pain inflicted on us.

Or perhaps we really love pain?

In this era of selfies and individual positioning, where everyone makes uninhibited declarations ad libitum, each from his own point of view and for his own sake – released unabashedly in the social media for everyone to read or watch – the matter of institutional memory, nay, of institutions, themselves, competing for respect and attention betrays a crisis of values. If there is one major crisis that is being overlooked, it is the fact that our institutions have crumbled, and people no longer seem to have regard for the nobility that they represent.

How do we get out of this rut? Where do we go from here?

For one, we need to stop bashing our institutions so that people can trust and respect them again, so that they can succeed in what they are supposed to accomplish. And just like what we do best in times of crises, we need to change how we think! When we think less of ourselves and our self-interests, step back and think more of the country and its institutions, the horizon assumes a calmer hue, and the decisions that we make become sharper and more useful. The acuteness of our cause drives us forward; but acquiring breadth in our perspective can temper our restlessness. We breathe a little easier, make a lot less noise, and create harmony; we become more coherent and more understandable, and, truth to tell, we get things done more quickly and effectively!

I speak in abstraction, so let me cite one tangible issue that lies before us, and attempt to unravel how we have not come to deal with it. It has been labeled as the “health workforce crisis”. The first and appropriate institution to point the finger to is the Department of Health (DOH). Certainly, a lot depends on the quality of the leaders and managers who run the department and the nature of their priorities. But we don’t even have to point the finger at the DOH, because the many things that we can do and should have done through the years have been within the power of the Philippine College of Physicians (PCP), the country’s medical society of internal medicine practitioners, to undertake. If there are approximately 60,000 actively practicing doctors in the country, about 8,808 of them are internists belonging to the PCP. The long and the short of it is that there is a shortage of internists where they are needed, because most of them are in Metro-Manila and the urban centers of the country. Of the 8,808 members, 4,585 (52%) are practicing in NCR. The rest of the remaining 4,223 members (diplomates and non-diplomates) are scattered in the provinces, most of whom stay in the cities. There are just 780 of them in the whole of Mindanao, 795 in Southern Luzon and Bicol areas, 1,580 in the various islands of the Visayas, and 1,068 in the entire Luzon, 589 (55%) of whom are concentrated in Central Luzon. Of the 5,633 diplomates and fellows of internal medicine in the country, 3,193 (57%) are in NCR where advances in technology augur well for professional growth and financial security. Of the 3,175 non-diplomates (either still in training or have not or could not pass the diplomate exams in internal medicine), 1392 (44%) are also in NCR, apparently for the same reasons.

There is also a shortage of primary care physicians (which are what the greatest number of Filipinos need) because sub-specialization is far more seductive to young doctors whose dream of a successful medical practice is defined by technological advances either here or abroad; here being a tertiary medical center in Metro-Manila. Of the 2,101 general internists in the country who have opted to focus on primary care, one would expect many of them to optimize their contribution to the nation’s health by being dispersed in the many smaller islands and provinces of the country. As it turns out, 1063 of them (50%) are in Metro-Manila, where perhaps their generalist orientation would hopefully find relevance as a counterbalance to the fragmentation of care brought about by sub-specialization.

With a fuller grasp of Philippine geography, population density, and the lack of access to health care across the country, it is easy to conclude that, indeed, there is a crisis in the country’s health care workforce – not in number, but in distribution and orientation. The crisis is not so much in the shortage of physicians as in the mismatches between the health needs of the country and the choices that physicians make.

So how has this debacle in the distribution of health care workers come to be, and what can the PCP do that the DOH cannot do? The better question is, what can both institutions do together to achieve a far greater chance of success? It is perhaps wiser not to propose answers but instead ask the tough questions, because when the status quo is challenged, people get so worked up, they react with their hearts and mouths before the thinking process begins, if it begins at all:

1. Why do the medical trainees and practicing physicians inevitably end up in Metro-Manila or the key cities of the country? Why do they prefer to stay there rather than go back to their places of origin? Why do they prefer to look at a foreign land as their next level of engagement?
2. For what, where, and whom are we training our physicians? By what and whose standards do we measure their competence? Competence to practice where and to serve whom? What is ‘world-class’ in most areas of the country where a general internist is most needed? Doesn’t ‘world-class’ to many people pertain to the state-of-the-art tertiary medical centers in Manila?
3. Are the trainees being prepared for general internal medicine practice, or for further subspecialization? How come their training curriculum indicates the latter? How come the diplomate exams are broken down into subspecialty sections, not integrated holistically as the discipline of Internal Medicine should be? How come the PCP and its various committees are run predominantly by subspecialists? How come the diplomate exam questions supposedly for general internists are made predominantly by subspecialists?
4. Is the internal medicine training curriculum, upon which western accreditation standards are imposed, an end in itself, or is there some overarching plan to align it with the health profile of the province – or of the Philippines, itself – where the training centers exist to serve? ? How come the young internists eventually end up in Metro-Manila tertiary centers where most subspecialty training programs are ‘accredited’?
5. Is the training program designed for hospital practice (urban) or ambulatory care (community) or both? How come the accreditation standards are designed almost exclusively for hospital practice? Is the training program geared to prepare its graduates for their respective communities, to address the Philippines’ needs, or to supply well-trained internists to other countries? Would a trainee from Caraga, after having trained in a Metro-Manila medical center where the standards are purportedly high, be inclined to go back to Caraga to practice general internal medicine? Honestly, would Caraga even be in his future plans at all after spending 3 years in a ‘world-class’ tertiary center?
6. Why do many trainees lose their moral balance by the time they finish their residency program? Why does the idea of civic service lose its luster after going through residency training?
7. Why is Metro-Manila such a seductive and illustrious address to the PCP members? Why are the ideal PCP models for the trainees seem to be all based in Metro-Manila?
8. If there is a shortage in the health care workforce in this era of rising non-communicable diseases, why are the endocrinologists hailing the “diabetes specialists’ to court when collectively they cannot even muster the adequate number of trained physicians to handle the diabetes epidemic across the country? Why are the rheumatologists and physiatrists fighting for the entitlement to treat the swollen joints of our countrymen?
9. Why are there violent objections from the younger diplomates of PCP to conferring fellowship status to those exemplary non-diplomate PCP members who have spent decades of their professional lives in the unselfish service of communities in the provinces? Because passing the ever-so-perplexingly-difficult diplomate exams has to separate and distinguish them from these doctors who serve communities where the young diplomates would never ever think of going to?
10. If there is a crisis in the workforce, why is there opposition to ‘brain gain’ strategies that encourage highly-credentialed Filipino internists from highly developed countries to return to the Philippines for good, to add fresh and wider perspectives to the PCP training programs and to serve the country, itself?

These are provocative questions; let the noise begin! The honest answers to these questions lead to the solutions to the crisis – all of which are within the capacity of the PCP to address. Aligning our thoughts and predispositions to the ever-changing realities of human health and development is not going to be easy, but it certainly is worth our attention. One day a strong leader will emerge who will be brave enough to put the mirror in front of our faces, force us to see what must be seen, and then we shall be on the road to solving the crisis. I have always believed that we, Filipinos, can lead and make a difference out there by challenging the way people think and behave. I eagerly look forward to the day when people in positions of influence in our country – in the government as in the medical profession – use their power with more clarity, wider perspective, contagious urgency, and a little less emotion.

I know the day will come. In time.

Comments

comments