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.

As an educated man – and I confidently state that I am – choosing among the many options that present themselves in daily life should be easy. Wrong! The more I know, the more choices I have to consider, and the more effort I have to exert to reach a good decision. Not included in the equation are those factors that color my decision-making process, e.g., the perks that I enjoy but might lose, the relationships developed in the course of my so-called ‘continuing education’, the biases that have evolved over time, and the entitlement that I think I deserve for having invested on what has made me what I am – an educated man. The choices I make may not always be the best, but I doubt that they can ever be that bad!

What if I were an uneducated man, what choices do I have, and which ones can I make? Is it not likely that my lack of education would be attributable to my family’s financial incapacity? If I were not educated, can I make the best choice, and if yes, can I afford it? What would be the best choice then, the one that the learned world endorses to be the best, or the best that I can afford? If I neither have the education nor the funds, what chances are there that I can even make a choice? And is it safe to leave me alone to make a choice given the circumstances of my ignorance and poverty?

One logical solution would be to let the educated man decide for the uneducated and, by association, the poor. Doesn’t it make sense and isn’t it more practical to decide for them rather than to go through great lengths and expense trying to educate them, without any assurance of success? Aha, but isn’t this exactly what has been happening? How regularly do we see this in the name of law and order, in the name of religion, in the belief that what is ‘good for us’ is what is good for everyone? What happens then, when the educated man succumbs to the nobility of his existence as he tests the limits of his influence and acquires the arrogance of his position? (Or is it the other way around – when arrogance lead people to seamlessly acquire the trappings of the educated man?). Being poor becomes equated with being uneducated, and being silent with being powerless. The choices of the educated levitate to the sophistication of world-class standards; the choices of the poor and powerless sink to the banal issue of cost.

So, should the educated man decide for the poor?

Well, as it turns out, the poor is not exactly helpless. Our poor patients stop taking the medicines we prescribe if and when they can no longer pay the price. Under such unfortunate circumstance, a decision is still made! From there, they can decide to stop seeing us altogether when our medical expertise translates into nothing that they can ever hope to benefit from because it is simply beyond their reach! It is their decision – and that decision is simply to drop us from their list of choices! No amount of educated posturing from our end can make them buy what they cannot pay for, or pay for what they cannot sustain. So what difference does it make that we have an arsenal of knowledge that they have little use for?

But certainly, the educated man can do much more! We, doctors, for example, can make it so much easier for our patients to decide by making ourselves a viable choice. Well, the funny thing is that the educated man may not even be able to decide for himself! Just like the wheel of misfortune, the doctor may find himself in the same situation as his patients. For the sake of discussion, if his patients are not knowledgeable enough and, thus, must be protected from the so-called evils of the Reproductive Health Law, neither is his profession noble enough to exercise propriety in prescribing medicines. For a period of time, his silence on issues that affect health care had lumped him together with the uneducated, giving the politicians latitude and a false sense of superiority. He had a serious panic attack when the Cheaper Medicines Bill threatened to penalize him for writing his chosen brands in his prescriptions. As a recourse, he sought refuge in the retention of the provision of the 1987 Generics Law that allows him to write his chosen brands in parentheses alongside the generic names of the drugs he prescribes.

But when the Generics Law was about to be passed many years before that, which required him to include the generic names of the medicines in his prescriptions, he raised hell (Boy, did he raise hell!). Because including the generic names of his chosen brands would do what? That it would make his patients aware that there were other brands to choose from! What an irony! We cringe at the thought of being penalized for making our choice, but how easily we take for granted our patients’ right to make theirs. The paradox of the educated being intolerant of education.

Where does the problem lie? Where it lies is where the solution is. Times are changing; our education no longer grants us the power of indispensability. The decisions we make cannot be ours alone; our patients have as much say as we do. After all, they undergo the diagnosis and treatment, suffer the pain and inconvenience, and at the end, pay for everything, sometimes with their lives! Choices have to be made based on mutual respect, the best being what science can provide and what the patients are ready for and most comfortable with. We cannot decide for them; we decide with them.

Medical practice, indeed the medical profession itself, has changed drastically. From a deified stature of power and respectability, it is now fair game to the mathematical prowess of the tax collector. – no different from any other business enterprise. Throw in the increasing leverage of 3^rd party payors and suppliers; the disruptive innovations in science and technology; the proliferation of substandard and fake drugs; doctors claiming to be what they are not, doing what they are not credentialed to do; medical associations in disarray, run by doctors who cannot lead; the assault of politicians and media on our profession – what we have is a profession on a tight-rope. Let it be resolved, therefore, that our relationship with our patients should no longer be an encounter between the educated and the helpless, but a partnership that enlightens and strengthens both parties against all these things that undermine it.

 The educated man chooses to listen, share, and accommodate rather than call attention to the brilliance of his education. He chooses to sit beside himself rather than on his laurels, because in these times of counterfeits and questionable integrity, laurels are but ornaments that elicit neither attention nor awe and are soon forgotten.

Have you met an educated man lately?