This post is not about a love story or relationship. It’s not about happily ever afters.

It’s about promissory notes.

The kind that patients make if they can’t pay your professional fees.

It’s the one thing that has no financial value. Seriously, if I recorded all the promissory notes of patients who were unable to settle their professional fees with me in the last 30 years of practice, I’d probably have retired 10 years ago with a farm on my backyard or the sea as my view from my balcony.

I owe, I owe so off to work I go.

The medical profession is one of the kindest (if not most amnesic) professionals in the planet. And I say that with conviction. It’s rare you’ll get a doctor who won’t give you a discount, waive a professional fee to the needy, or even perform “miracles” for free. It’s just in our system to “let it go” and let God do the rest. Gratefulness after all is such a joy.

To a certain extent.

Let’s face it.  Doctors have bills to pay.  Need a roof over their head.  Families to raise.  A life to live.

The medical profession is significantly skewed when it comes to reimbursement. (And I’m not talking about those that charge an arm and a leg. I’m just talking about the average Dr. Juan.) Here’s where I put the disclaimer. While we’re a noble profession whose mission is to save lives, heal the sick, provide health care for those that need – we are not a purely charitable institution. That’s why I admire the doctors who dedicate themselves to the Barrios that they work for. Risking life and limb. Sacrificing family and friends. Working in the most dire of circumstances to care, heal and cure. If this selfless journey isn’t enough, I don’t even know what kindness is in this world anymore.

The majority of us do pro bono in our own little ways. There’s the medical missions to far flung areas or depressed communities. (By the way, medical missions for campaign soirees during elections DON’T COUNT.) Seeing the sick people in your community (Yes. When they know you’re a doctor, some of them knock on your doors in the most unholy hours to seek consult OR cry for help because of a legitimate emergency.) Attending to medical concerns while in flight or on the road.  You name it, we’ve done it. And we don’t charge a single centavo to these.  We do it because it is our calling.  And out of human kindness.

When the patients are seen in either out-patient or in-patient, professional fees are in order. There are times when you’re requested to see patients with scarce resources.  Many of us don’t deny the privilege of being able to do good by lending our expertise and touching the lives of the least and the last. I have yet to see a physician who has not waived his professional fees for patients who had to make ends meet.

Unlike other professions, the job doesn’t get done if you don’t settle the staggered dues in the promissory note. For example, you can’t have your house finished if you haven’t given due date payments to your contractor/architect. If you don’t meet the payments, you’ll never get your house done. It’s a common denominator for professional services – services rendered, services paid for. The form of payment (staggered vs. one at completion of all services) will differ.

Those affiliated with HMOs don’t have less burden in collecting promissory payments. After all, the HMOs will reimburse their fees after the patient is discharged, albeit, months later and for a pittance. Nevertheless, as the Chinese would say, “pakyawan naman“. That’s of course until the patient’s hospital limit has been breached. And the patients are on their own – for both the hospital bill and the professional fees.

In the Philippines, majority of out-patient and in-patient health care remain out of the pocket. Fees would range depending on the specialty or subspecialty of medicine seen. The generalist and family physician is usually the primary physician in the rural areas. In the urban communities, patients have preferences for specialists. Hospitals are run like businesses. And with reason. After all, in order for the healthcare industry to survive, continue to employ allied health care professionals and improve on its services, it needs to be run wisely (at times insensitively) with a clear business sense. Bleeding hearts and charity cases are pointed in the direction of government hospitals. The burden of care is after all, the government’s concern. (Unfortunately, that’s the reality of our healthcare system.)

Hospitals are also unsympathetic when it comes to professional fees of doctors. Sometimes (oftentimes?), when the final bill of the patient is released (particularly for patients that needed intensive care your resources will definitely be usurped within a week or two). Many (if not all of the hospital finance departments) will ask the patient or their family to settle the hospital bill, then settle the professional fees with the doctor’s separately (or ask the doctor for a larger discount on the bill). Promissory notes are then flung left and right.  The hospitals will always require a guarantee and can send a legal team to demand payment later on.  The doctor is left to collect on his own.  More often than not, it’s left as a promise. End of story.

I write this not because I’m encouraging every physician to squeeze every little centavo out of our patients who are at the end of their resources to pay the professional fees. The profession should bat for government remedies in the form where unsettled professional fees can be claimed as part of losses in income for the year when we pay our taxes.  After all, like any legitimate business, unpaid promissory notes are tantamount to unpaid debts and should be dealt with fairly when declaring our income tax returns.  It’s the least the government can do to assist the profession in declaring tax returns properly. In the same vein that the patient is required to fill up a form that the professional fee was waived (and have it notarised), those that are unable to settle professional fees should be made to fill out a form and have it notarised and that it can be used to adjust our annual tax returns.

We can’t just have every foregone promissory note settled as two words “God Bless“. And while I’m flattered with the thousands of blessings profusely pronounced, we accept cash in installment or postdated checks as well.

For those that are the end of wits end on how to settle those promissory notes, we’ll take God’s blessing anytime.

There’s an interesting read about friends (and relatives) who go around “borrowing” money for various reasons.  Anywhere from an actual necessity (and there’s some sympathy in that), to simply borrowing to fulfill their wants (like borrowing to buy a new iPhone).  Many friendships (and families) have been destroyed because of “borrowing” and “lending” money.

On Facebook, there was an amusing (and irritating at the same time) thread of two former classmates identified as “Fhem Garcia” who was attempting to borrow money from someone named “Mhay“.  The exchange of text messages on messenger went viral with Fhem not gaining a bit of sympathy from the readers in the end.  What started as a supposedly friendly message from Fhem initially, revealed her true intentions as to why she got in touch with Mhay.  Fhem was borrowing money from Mhay.  And Fhem was angry when Mhay did not want to lend her the amount Fhem wanted.  It ended with Fhem cursing Mhay and calling her names, just because, Mhay refused to lend Fhem money.

Which lead to this blog post.

Should you lend people money?

The answer is an obvious NO.

I’m sure that my readers will have a variety of opinions on this matter.

I just don’t like lending people money.  Period.

If and when I do lend money, I don’t expect to get paid back.  Anytime.  At all.

I’ve always believed that borrowing money from friends is abusing one’s friendship.  Especially when one is borrowing for WANT rather than for NEED.

The problem with people is that many are unable to discern the difference between NEED from WANT.  Need is essential for survival – food, shelter, health.  Death is inevitable if our needs are not meant. Want is something we desire, which we may or may not be able to obtain or attain.

When people borrow money because of something they WANT, it’s a no brainer not to lend them.

Borrowing for need on the other hand falls on a case to case basis.  People who borrow for need should exhaust everything – to the smallest possession they have – before they should even borrow money.  It’s infuriating that someone is borrowing money from you because they NEED to pay for hospital bills or buy medicines, but they just purchased a new car.  As a general rule:

Lend only money when the person borrowing from you has absolutely no material possession left to hock or sell AND the need for that borrowed amount is for the purpose of survival (or will result in a morbid outcome if the means are not met).

For some who are willing to part with their hard earned resources,

If you do decide to lend money, remember the cardinal rule – only lend out what you can. The amount you will lend out should be tantamount to NOT BEING ABLE TO GET IT BACK ANYMORE.  Don’t expect to get paid back any time soon.  Since you were charitable enough from the get go, think of it as a donation.

I have relatives who have “borrowed” money from me in the past.  As a “moral” obligation, I did lend them money. But not in the amount they wanted, but in the amount I could part with.  After all, it was alms to me.  I never saw the money back, even though they have passed on to the other side of the world.  But I have no regrets. Think of it as “for a good cause”.

Then there are those lowlife people who borrow money for WANTS.

I will apologise for looking down upon them. But there is one cardinal rule I have.

Never lend people money for wants.  You’ll end up depressed, angry, frustrated and a schizophrenic in no time at all.

I’ve always believed that WANTS are goals that we have in life.  We want to go on a vacation.  We want to own a new car.  We want to have a new house.  We want a condominium.  We want a diamond ring.  We want a Hermés belt. We want an iPhone XS.  We want a Prada bag.  What we want, we need to work for.  That’s why WANTS are bucket lists! We plan, we dream, we earn – for what we WANT!  If that want is not achieved, then it’s a dream.  But a want is a personal journey in our life.  What we want, does not mean we necessarily get!

If you don’t have money for what you want, you need to wait until you have before you even buy it.  It is regrettable that there are thick-faced people who borrow money for their wants and even doubly disappointing that they have the temerity to be angry when you remind (and eventually demand) them for payment.

The final cardinal rule is

I find it stupid that you lend people money for their wants.  If and when you do, don’t expect to get paid back.  He/she is probably enjoying your moolah in some paradise somewhere in lala land laughing at how pathetically stupid you were at lending him/her money for the massage he/she is getting.

I read somewhere someone posting to “Live a healthy lifestyle choose drinks with minimal amounts of sugar”. And instead go for alcohol because they are “low in carbs”.

The irony of that post is that people thought it was right!

Wrong!

I’m not quite sure where people get this misinformation and just because something isn’t “sweet”, will help those who want to lose weight (or not gain weight for that matter). Alcohol is not a substitute for a healthy lifestyle.  While I understand that it was done in jest (or humour), it sends the wrong take home message.

There are calls by health advocates to increase the tax on alcohol drinks.  And I couldn’t agree more with this proposal.  The topic on the downside of alcohol is a given.  There is no justification for binging on alcohol.  Like its addicting counterpart, nicotine, alcohol serves NO MEDICAL PURPOSE.  It is, a recreational substance.

The overall evidence is unclear AND no rigorous clinical evidence is present to justify the medical intake of alcohol.  People will always try to rationalise that there are benefits to ANY recreational substance to justify their habits.

The definition of mild, moderate and heavy drinking is clearly a rationale at justifying alcohol intake.  It’s like smoking.  There are the social, regular and heavy smokers. If we slap heavy taxes on smoking, then we must slap heavy taxes on drinking as well.

The Mayo Clinic points out clearly that the latest dietary guidelines make it clear that no one should begin drinking alcohol or drink more on the basis of “potential health benefits. Indeed, for some people the avoiding alcohol is the best course – the possible benefits don’t outweigh the risks.”

The operative words used are POTENTIAL and POSSIBLE.  Meaning – the science isn’t there to back these claims.  The evidence about the health benefits of alcohol is UNCERTAIN.  Any potential benefits of alcohol are relatively small.  And may not apply to all individuals.

We have all read about drinking a glass or wine or two in order to lower cholesterol and being healthy and good for the heart.  No study has ever been able to prove these claims without an iota of a doubt.  There were claims that could reduce death rates from heart diseases, “possible” reduction of ischemic strokes, and “possibly” reducing the risk of diabetes.

These possibilities are most probably also wrong.  And the fact that it’s ONLY POSSIBLE, points to the evidence that it most likely doesn’t work. AT ALL.

There are, after all, more cons than pros in alcohol binging.  The definition of how much is too much alcohol intake has no verdict yet. Nevertheless, what science does underscore is the fact that alcohol increases the risk of serious health problems including:

• cancer (breast cancer and cancers of the mouth, throat, oesophagus and liver)
• pancreatitits
• sudden death especially in patients with underlying cardiac diseases
• heart muscle damage (alcoholic cardiomyopathy leading to heart failure)
• stroke
• hypertension
• liver diseases
• suicide
• accidental serious injury or death
• brain damage or other problems in an unborn child (in women who consume alcohol during pregnancy – fetal alcohol syndrome)
• alcohol withdrawal syndrome

Even the medical community is unsettled in their recommendations for alcohol.  Most (if not all) the doctors I have surveyed will always tell you that if you don’t drink, don’t start because of POTENTIAL health benefits.  But if you do drink and you’re healthy, “you can probably drink as long as you do it responsibly“.  And that is what the alcohol industry capitalises on.  RESPONSIBLE DRINKING!!!! They’re even allowed to advertise this using women in scanty clothes or macho men who show off their “strengths” with the end segment that DRINKING SHOULD BE DONE RESPONSIBLY.  Duh?!?!

I will hit a nerve among the lawmakers and business community, when I say that the alcohol industry should be censured like the tobacco industry.  What makes one treat the alcohol industry with a kids glove while throwing the tobacco industry to the sewer?  They both don’t offer any form of benefit at all.  Let’s call a spade a spade. While tobacco has caused the death of many individuals from respiratory and cardiovascular complications, majority of them are self inflicted. On the other hand, there have been more deaths from accidents and drunken behaviour from people inebriated with alcohol, yet we allow commercials to proliferate with the “responsibly” clause.  The double standard JUST ISN’T RIGHT.

Then there is the justification that alcohol intake is much better than sugary drinks because it is low in carbohydrate content.  Only an idiot who has no knowledge about the physiological function of the body will claim that.

Consuming too much alcohol (regardless of carbohydrate content) will slow down your weight loss. And if you plan to lose weight because you’re already on a low carb diet (and you’re drinking), think again.  Alcohol is burned before anything else in the body.  Hence, slowing down fat loss.

While there are alcohol substances that have no carbohydrates, ALL have caloric values. A typical glass of champagne contains 1Gm of carbohydrate. But contains 95 calories per flute glass (on the average).  A glass of wine (red or white) has an average of 2Gm of carbohydrate but contains about 85 calories per glass (on the average).  Sweeter wines like Moscato and Reisling have larger amount of calories and carbohydrates.  Remember – alcohol is made from sugar or starch.  That is why there are calories consumed as well.  But the calories from alcohol are empty calories, meaning they have NO NUTRITIONAL VALUE.  The verdict is clear – beer has the largest amount of carbohydrate and caloric content.  One bottle of beer has around 13-15Gm of carbohydrates and is 316 calories for a 330mL bottle.

If you’re even thinking of going on a diet and drinking alcohol at the same time, think again.  You need to take less alcohol when you’re on a low carbohydrate diet because you get intoxicated quicker.  It’s probably because the liver is busy producing ketones or glucose, and thus has less capacity to spare for burning alcohol, slowing down the process.

And that’s why I strongly feel that we need to tax alcohol the same way we tax cigarettes.  We need to prohibit the advertisement of alcohol and any form of alcoholic beverage because there is no such thing as “responsible drinking” (otherwise there should also be a term for “responsible smoking”).

Both alcohol and nicotine are recreational substances of abuse.  There is no science that says otherwise.

Patients will always expect that doctors treat them with dignity. That’s a given. After all, most of us in the health profession have the best interest in the care for our patients. I always tell people to lower some of their expectations with their physicians.  After all, we are not God. Nothing miraculous comes out of our healing. There is an art, a science, and yes, a heart full of compassion and understanding, underlying our passion to heal.

But, every physician-doctor relationship is a two way street. It’s literally a “blood compact”. Which is why there are expectations to be met. So it’s a given that we talk about doctors not coming to their clinic on time.  Or making sure that the patient is examined thoroughly.  That the diagnostic work-ups are done considering whether the patient needs them or not.  And that medications are prescribed because they are needed so he recovers. Our relationship is, uhmmm….complicated.

The other side of the coin is the patient.  As doctors, we expect patients to be understanding instead of being abusive.  And I say this because there are expectations that are left unsaid.  Here’s what we expect from you, my dear patients:

1. When you hear the doctor shouting at the top of his voice “NC yan“, it means NO CHARGE.  You’re free from the professional fee!! But that doesn’t mean that you abuse the kindness.  I have patients that actually ask me to be the godfather of their child thinking that all professional charges are waived.  (Really!!) If I waive your fees, you should be (a) grateful and (b) not expect any gift during the birthdays and holidays for my “godchild”.  My seeing him/her, for free, is enough.  That is why I decline ALL invites to be the godfather of a patient, unless I know the patient personally. For the other patients who are “pro bono” out of friendship, please remember, it’s being done out of being friends and not tit for tat.
2. Don’t abuse the kindness.  Just because you have access to the mobile number or email address of your physician does not mean you have to be “mental” about each and every concern.  I have patients that ask me the craziest and weirdest questions like “I think my son’s ear smells funny.  What do you think it is?” or wake you up at 3AM to ask you “my child has had fever for the last month, what do you think it could be since I’ve gone to see 3 other doctors?”. (Seriously??!?!?!?! fever for a month and you didn’t bring your kid to me and decide to wake me up at 3AM because he’s not better?!?!?!) or send an email with a picture of the kid’s butt and asks you to give a provisional diagnosis of the rash (Like, yeah right, Alex Trebeck is this the Tournament of Champions on Jeopardy?!?!?! Uhmmmm….what is….). Remember, I am a doctor – not a psychic!
3. I know you have concerns.  Especially when there’s a disparity in issues and the advent of spreading of bad or wrong information. The internet, while providing us with a wealth of information is also the main provider of a web of lies.  Just because you’ve read it in the news does not make it right.  There are a lot of facts that are not taken into consideration.  And all that news or political storm is not part of our practice to heal.  Medicine is not an exact science.  We deal with odds, risks, benefits, ratios, outcomes.  Medicine is a dynamic field. What is good for the goose may not necessarily be good for the gander.  One man’s medicine may be another man’s poison.  For example, Thalidomide was originally developed in 1954 in Germany as a sedative to treat “morning sickness” among pregnant women.  It was  licensed in 1958 in the UK and made available in the US in 1959. The thalidomide tragedy tells of the story of the side effect of this medicine.  Phocomelia (no limbs) among the babies born, was its number one adverse reaction.  Over 10,000 babies were affected and more than half died within a few months.  Based on data in 2014, there are only less than five hundred victims alive.  This drug was taken out of the market three (3) years after it was launched in the UK and the US.  While we know more or less what this drug does, it has been resurrected because it’s a beautiful medicine for the treatment of Erythema Nodosum Leprosum (a form of Leprosy).  You see, there’s a story to everything. But if you are ignorant and it is not your field of expertise, then I believe some enlightenment is due.
4. We are not a hard profession to please.  It is not all about the income. While we have families to feed, and that this profession is a form of financial remuneration for services rendered, please remember that we are all kind people. We have many cases where we don’t charge a cent for our consultation (and procedures). Regardless of financial status of the patient, we treat patients not because of the money.  But because we know we can make you better.  Treat your illness.  Make you live longer. If you encounter some physicians who extract you for every little penny, I’m sorry. But we’re not all made that way. Incidentally, just because you pay us our professional fee, does not mean that I will prescribe anything you want under the sun.
5. For those that are not familiar, everything has an overhead cost.  Things just don’t drop from an airplane and we end up with full supplies.  We need to purchase that. And the includes the smallest cotton to the most expensive vaccine.  Or from the disposable gloves to the portable ultrasound instrument in the clinic.  Then there’s the rent, the water bill, the electricity…oh and did I tell you that my secretaries have to feed their children? Yes my dear.  I need to pay them.  All.  Which is why private practice is not really lucrative unless you have a very good practice.  There are days when you’re just dead tired from having to see patients from 9 to 5. The travel time from point A to point B to point C to point D then back to point A alone is deadly.  But we do it because there are patients that need us at those pitstops.  The first and final pitstop will always be home.
6. We have a life.  I always tell my medical students and those in training, that the most important thing in this world is not about helping others alone.  Martyrdom are for heroes and saints.  Ordinary mortals like us need to escape from the humdrum and pain of seeing the sick, the lost, the dying, the forgotten, the depressed, the confused.  We cannot listen to the heavy burden of the sick and the needy and not escape from the madness once in a while.  The burnout rate is humongous.  Those little breaks we take is called recharging.  Sometimes we make an effort to relearn so that we can better our craft.  When we are not around, don’t take it against us.  We are human like you.  And we’d like to enjoy our lives as well.
7. I know it’s a techie world out there and out of habit, we usually consult google ahead of our health care provider. Which leads to the point that it’s really not nice coming to your doctor brandishing a whole bunch of documents you downloaded from the internet to ask me what I think “Google said!” I don’t mind you reading up on your disease or symptoms. It’s fine with me if you’re a hypochondriac. But whatever you read are information that you can remember so that you know more of less what to discuss with when you see your doctor for a visit. Don’t attempt to treat yourself with what Google says. You may end up a more complicated case, and by the time the doctor gets to see you, will need to spend much more in work-ups and treatment because you decided to check with Google and follow its advice first.

In the same vein that the patient is free to seek a second, third, and even fourth or fifth opinion and disengage relations with the doctor, the doctor too is free from disengaging at anytime from the patient.  Despite the disengagement of one or both parties, data privacy is a legal binding rule. No information can be shared without the consent of the patient.  Patients are free to ask for their personal medical records, close their engagement with you, and transfer to their doctor of choice.

The next time you get sick and have to see your doctor, make sure you tick all the boxes.  You are seeing your health care provider.  Not God.