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The Covenant, Medical Errors
November 23, 2004
Last September 2004, the Philippine College of Physicians (PCP) urged Filipino physicians to sign a covenant called “Service Above Gain” as a ploy to keep doctors in the country for at least three years. It was a plea upon the consciences of underpaid doctors (and nurses) to make it easier for them to give up jobs abroad. The “PCP hopes their move will ...help staunch the hemorrhage of migrating doctors and nurses.” The appeal was noble indeed and recognizes the compassion of Filipinos, and that the majority of doctors will probably stay behind and directly serve the population in need.
The reason for the exodus of health care professionals is no secret to the PCP and neither to the nation. As can be read in the PCP Newsletter and the packet for the “Covenant”, it mentions that “50 percent of doctors in the country earn less than P20,000 a month. Only the elite doctors, about 11 percent, earn more than P1 million a year, in contrast to what a licensed nurse in the US earns: P3 million to P6 million a year.” It is also further acknowledged that since 2000, about 9,000 physicians have already taken up Nursing to fill up the projected 600,000 deficit for nurses in the United States by year 2010 and 1.2 million in Japan.
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"Each person can only be judged by God and the fruits of his actions. Each person’s decision to go abroad was guided by a myriad of reasons, of circumstances, and a complexity of needs and explanations."
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Recognizing this huge problem, instead of presenting proposals for solutions, a whimpering appeal to sacrifice was instead put forth. The issue was focused on guilt because of personal gain rather than alleviation of the problem. Rather than providing help to survive, to feed one’s family, and live a decent life as a “doctor”, physicians are “asked to spend a portion of their time — say one day in a month — to do charity work” when they literally already serve hundreds of patients for free or a nominal fee. Well, service and good works are good, but your family can’t live off free service. Soon, the doctors and nurses themselves will become charity patients themselves.
Kudos to those 435 who signed the covenant: may you make a difference.
What about those of us who already left for jobs abroad? Are we traitors, less patriotic or apostate to our calling? Without being defensive, the answer would be a resounding “NO”. Each person can only be judged by God and the fruits of his actions. Each person’s decision to go abroad was guided by a myriad of reasons, of circumstances, and a complexity of needs and explanations. It may have been etched by blood and tears or hardships and hunger. At the bottom line, it may be part personal gain but also for one’s family and by keeping our folks fed and housed and educated back home, we may actually be helping rather than giving a disservice to our beloved country.
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Now, what is the situation in the United States for those who still want to come here as a physician? Probably not as bleak as it seems. The number of accredited residency programs and resident physicians has steadily increased in the past several years. There are currently 8,192 Graduate Medical Education programs (Residency and Fellowships) and last year there were 99, 964 doctors enrolled in them. In 2003, there were 29,728 graduates. This year, of 19,392 applicants who matched for residency programs, American graduates comprised about 64%. This means that about 7,000 foreign graduates will be able to work in the United States as resident physicians.
That means 7,000 opportunities to practice as a doctor in the United States! The field is not as wide as it is for nurses, but the grass is probably greener in the long run.
The chance of being hired varies by specialty of course. The easiest routes are still Internal Medicine and Family Practice. The fill rate for Internal Medicine is about 45% for foreign medical graduates and roughly 47% for Family Practice. For Pediatrics, the chances are 30%, 35% for Obstetrics and Gynecology and about the same for Psychiatry. In contrast, it seems much more difficult to get into the surgical specialties.
What happens after graduating a training program? Last year, of over 20,000 surveyed graduates, about 1.9% were unemployed and 1.2% left the United States (250 persons). The latter were probably foreign medical graduates who were unable to find J-1 waiver jobs or decided to bring back home the knowledge they have acquired in America.
As of early November, bills that would extend the J-1 visa waiver program were awaiting resolution by a conference committee after having passed the House and the Senate (the previous program expired June 1, 2004). However, it can be reinstituted by the Department of Health and Human Services and state health departments. It is unlikely that the program will be closed, as it is an important vehicle to get physicians in underserved areas such as inner cities and rural areas. The process seems to be stricter since the 9/11 event, but since 1995 to 2002 the process has sent over 3000 physicians to rural areas alone. So it appears that it is not hopeless after all.
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Shifting gears, another issue is the snowballing medical malpractice crisis. One effective deterrent for taking up medicine here is the cost of insurance premiums. Apart from this, there is a suffocating environment of litigiousness and the stress of defensive medicine. Between 2003 to 2004 there was another 37% increase in average premiums across the board and a resulting 15% loss of physicians due to relocation, retirement or resignation. Few practices could afford >$200,000 a year for Neurosurgery or >$100,000 for an Obstetrician.
The situation is so bad that a Dr. J. Chris Hawk III proposed to the American Medical Association that doctors may refuse medical care to trial lawyers! As tempting as it seems, like a swift and severe ending in a revenge Hollywood action movie, the Association rejected the proposal to avoid more upheaval. Apparently, even trial lawyers deserve medical care, even if they strip physicians of their reputation and hard-earned income in the service of humanity.
How successful are lawyers in winning this multi billion-dollar business? The recovery rates for plaintiffs have increased to about 42% in 2002 according to Jury Verdict Research. That is a lot of money changing hands from doctors to patients and lawyers. The insurance companies pay but the rest of the medical community pay for it in terms of higher premiums so the insurance companies don’t get bankrupt.
One reason that things end up in court is that the state medical boards do not seem to mete out disciplinary actions against erring physicians before they cause more harm. Of 1,000 doctors with complaints, only 3.55 actions are meted out. Lack of disciplinary actions against the “bad” doctors later result to further mistakes such as negligence, incompetency, sexual misconduct or other crimes. Doctors need to police themselves too.
How bad are we doctors? Sure, we save lives, but we are human too. Medical staff errors may be causing the death of about 195,000 people a year in the United States according to HealthGrades, Inc., based on a study of Medicare records in 50 states from 2000 to 2002. The data reported 1.14 million “patient-safety incidents” (commonly known to nurses as “incident reports”). There were 323,993 deaths among Medicare patients over those years, 81% of which can be attributed to the “incident” (a mistake). If extrapolated, this means 575,000 preventable deaths and $19 billion dollars in cost!! It seems exaggerated but if these numbers are accurate, medical errors in the US alone will be the No. 6 cause of death ahead of diabetes, pneumonia, Alzheimer’s disease and renal disease.
If it is actually this bad, no wonder the trial lawyers are having a field day! And if it is this bad in the US, how much more in the Philippines where there are barely enough supplies, not enough lab and radiologic work-up, patients who can’t buy their medicines and now inadequate staff (because they are all immigrating abroad)! It is worse than scary; it is downright horrible. Perhaps those Senate Bills in the Philippines (SB 03, 121, 337, 588,743, and 1720) actually have a good purpose after all: punish the guilty, incompetent doctor. Problem is, it’s not really enforceable and the same insurance crisis may hit the country as well as it did in the US. Moreover, physicians there are mostly already under earning. The solution again should rather be improving the health care system by increasing the health budget, procuring more supplies, catching up with technology and paying the medical personnel more.
This is sounding more like a campaign speech. Enough said. Let’s just end this by saying primum non nocere.
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Views expressed on this column and any other by-lined articles on this site are the authors' own and do not necessarily reflect the views of the organization or its members. For comments, please e-mail the author.
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