Oh promise me…

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.


Wants vs. Needs – To lend or not to lend?

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.

Misconceptions of a “drink”

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!


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.

The other side of the coin

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.

Let’s talk about fentanyl…

The other week, I wrote about how wrong the president was when he said that fentanyl is “just a painkiller”.

From that blog post, we learned that it’s not just a painkiller. Because it is part of a group of drugs called opioids, this class of drug interacts with opioid receptors in the brain and elicit a wide range of responses in the body – from a feeling of relief from pain to relaxation, pleasure and contentment.

We talked about it’s licit (approved and proper) use for medicinal purposes. It’s approved indication include: managing acute and chronic pain particularly that due to cancer, nerve damage, back injury, major trauma and surgery. The caveat here is to use this only when all other lesser potent and addicting analgesics (narcotic or non-narcotic) fail.

It’s illicit (illegal) use is multiple and dangerous. Drug addicts get hold of the patch and extract the fentanyl from the patch and inject it. More commonly, however, is “diverting” method.

Diversion occurs when a medication that is prescribed by a medical professional, is not used appropriately, or is given or sold to a third party. (Alcohol and Drug Foundation, Australia)

Prescribed fentanyl can be “diverted” when:

  • individuals obtain medication inappropriately through their profession (e.g. doctors prescribe for themselves or among their peers)
  • individuals use their own prescribed medication recreationally for a non-medically intended purpose (e.g., to get euphoric effects or use it for sleep problems and not as a pain reliever)
  • individuals use medication prescribed to another person

There is NO safe level of drug use and what may be good for the goose, may not be good for the gander.  This means that its effect varies within and among different persons using the drug.

The most common side effects or “experiences” are:

  • nausea, vomiting
  • constipation and/or diarrhea
  • reduced appetite
  • wind, indigestion, cramps
  • drowsiness, confusion
  • weakness or fatigue
  • dizziness
  • euphoria
  • headache
  • incoherent or slurred or impaired speech and thought process
  • impaired balance
  • slow pulse (bradycardia) and hypotension (lowering of blood pressure)
  • rash (especially inflammation, itching, swelling at the patch site for those on the transdermal preparation

Since we know what fentanyl does and what its side effects are, let’s talk about withdrawing from this drug.

Withdrawing after using it for a long time is very challenging.  That’s because the body has gotten used to having opiates work at the receptor sites and withdrawing will mean that the body has to get used to functioning without it.  That’s what addiction is.  Whether you are a nicotine, alcohol, caffeine or drug dependent, the physiological function and response of your body has been altered to adapt to these.  Your body craves and longs for it.  Anything that changes your physiological function by craving for a substance that has made your body adapt to the pharmacologic effects of the regulated products.

The problem with fentanyl is that the withdrawal symptoms start as early as 8-12 hours after the last dose.  Withdrawal symptoms include:

  • goose bumps
  • bouts of chills alternating with bouts of flushing and excessive sweating
  • irritability
  • insomnia
  • loss of appetite
  • yawning and sneezing
  • watery eyes and runny nose
  • vomiting and nausea
  • diarrhea
  • increased heart rate and blood pressure
  • pains in the bones and muscle
  • general weakness
  • depression alternating with bouts of anger and confusion

Fentanyl is NOT JUST a pain killer.  It’s use and abuse are dangerous if not used properly (I heard that someone doesn’t really like following his doctors and takes an extra pop of the drug if he feels like it).

I am writing this to educate people that quitting after being on addicting agents is challenging and difficult to do.  That the side effects are sometimes difficult to differentiate from the actual disease (example is pain in bones and muscle during withdrawal versus using the drug for treatment of pain).  That when we are addicted to a substance, we will always rationalise why and how it is used.

Age doesn’t matter…

When former First Lady Imelda Romualdez Marcos was found guilty for graft on 7 counts last week, many people felt that despite half a century since committing the crime (three decades of the case in court), justice wasn’t blind.

Or isn’t it?

Police Chief Oscar Albayalde went on the record on the air to say that “considering her age” the Philippine National Police shall not handcuff nor arrest her hurriedly. Minority house speaker Danilo Suarez didn’t feel that the crime Imelda did was a “big deal” and we ought to just poopah and “forgive and move on.”

For these two to provide these statements, it meant that they acknowledged her guilt. BUT, insinuate that we need to show kindness and compassion because she is 89 years old.

No rational moral thinking human being would even have thought the way Albayalde or Suarez thought. Clearly, people like these have biases and it’s just hard to pick the right words to describe their vapid line of thinking.

The bottom line is – the Sandiganbayan finds the accused, Imelda Romualdez Marcos – guilty in the 7 counts of graft. For all the suffering of the Filipinos because of the crimes of this family, I don’t understand how some people get the temerity to brush aside the guilt? How easy is it to tilt the balance of justice just because the accused are political friends with benefits with the incumbent rulers?

When these elderlies are still eligible, willing and able to run for public office, by golly, they should also be answerable and accountable to the office they occupy. In short, if there is graft and corruption committed by them during their term in office, they must pay for that crime! It is unjust that we look the other way just because of age. You cannot be willing to do one thing but not be accountable to answer for the misgovernance or corruption you committed.

The Philippine judicial system is slow enough that these people would have died before they got convicted. There is no moving on as long as the suffering and crimes are not reconciled. There is no forgiveness unless there are apologies.

Let’s call a spade a spade.

Justice cannot be selective. Justice must be tantamount to the crime committed. Regardless of people, power or personality.

Majority of our countrymen have limited funds for a decent meal, clothes to wear, shoes or slippers to walk kilometers to go to school, or a decent roof over their heads. When politicians deprive our countrymen of basic needs or even the sheer decency to live and survive day to day because they engage in shenanigans for personal gains, it is enraging that they are treated with kids gloves when they are found guilty of criminal acts.

If we stand for nothing, we fall for anything.

Remember: For fools to fall for the folly of the elderly, we deserve the injustice we get.

You are wrong!

Screen Shot 2018-11-12 at 2.17.03 PM

When news like this circulates, it is mandatory that the medical community should react.

Whatever the president insists, he is totally wrong on this matter.

Fentanyl is a potent synthetic opioid.

It is 100 times more potent than morphine as an analgesic. (Yes, Mr. President.  It is a painkiller.  A very very very strong pain killer.)

Its pharmacologic effects are – analgesia, sedation, nausea, vomiting, itching and respiratory depression. Compared to other opioids, fentanyl causes more muscle rigidity.

It’s approved medical uses (licit) are:

  • management of cancer pain in patients already receiving opioid medication for their underlying persistent pain  (for the sublingual tablet formulations)
  • management of chronic pain in patients who require continuous opioid analgesia (for the transdermal preparation)
  • analgesia and anaesthesia in surgery (as citrate for injections given intravenously, intramuscularly, spinally or epidurally)

It is abused (illicit) for the following effects:

  • euphoria
  • substitute for heroin in opioid dependent individuals

Whether it is used licitly or illicitly, fentanyl use is addicting. Drugs that cause dependence are classified as habit forming and categorised as dangerous drugs. Under the DEA (drug enforcement agency of the United States), Fentanyl is controlled under Schedule II of the Controlled Substances Act.

A drug under Schedule II of the Controlled Substances Act means that:

  • The drug has a high potential for abuse.
  • The drug has a currently accepted medical use in treatment in the US or a currently accepted medical use with severe restrictions.
  • Abuse of the drug may lead to severe psychological or physical dependence.

In the Philippines, the Dangerous Drug Board and Philippines Drug Enforcement Agency have rules on prescribing narcotics and regulated substances.  The schedule in the Philippines is similar to the United States. Fentanyl is classified under Level II (previously called Schedule II). While it carries the same classifying definition as the US DEA, in addition:

  • Only doctors with S2 licences can prescribe them.  (Not all doctors have a S2 license.)
  • There is a separate yellow prescription form (that can only be purchased through the selected hospitals by S2 licensed physicians) that needs to be accomplished.  Fentanyl falls under that category.

Fentanyl is a controlled substance. In any part of the world. And yes. Even in China and Russia.

It is not JUST a pain killer.

It is addicting. It is regulated. Controlled substances are classified as with medical evidence or without. Either ways, it has abuse potentials. Only schedule or level II drugs are “legally” allowed to be prescribed. But it does not mean that just because it is prescribed it is not addicting.

I really don’t care if you’re using this for the various pains you claim to have. I’m really not concerned whether you’re really sick or not, or how sick you are. I just don’t like the fact that you go around having to rationalize what medicines you use to the point of changing the science of medicine, pharmacology and regulatory science.

Just because you are president, you do not get to change the fact that fentanyl is an opiate.


Focusing on the red herring

Whenever I make teaching rounds with my medical students, I always tell them to look out for a “red herring”.

Red herrings are clues that are intended to be distracting or misleading. Let’s take the case of a 4 year-old patient with 14 days fever and macular rashes is seen at your clinic. He tests negative in routine dengue test kits except for IgG dengue. A complete blood count with platelet shows a white count of 3,000 (90% lymphocytes) and a platelet of 25,000. Many will be tempted to make a diagnosis of dengue. The red herring is the neutropenia and thrombocytopenia.

Many diseases will present with a low white count and low platelet. This patient was seen by two different doctors in the 2 weeks interval. The final diagnosis in this case was acute leukemia.

I talk about red herrings today to emphasize that there will always be misleading clues that will make one make the wrong conclusion.

The idiom “red herring” was thought to have emanated from using this fish’s smell to train dogs to track scents. The modern meaning of “red herring” as a false trail, was thought to be popularized by English journalist William Cobbett. Whatever the origins are, red herring is something that misleads or distracts us from a relevant or important issue.

Red herrings, while taught in medical science, are seen in contemporary society. Politics is an example of how to use distractions in order to bring to fore an agenda. The real situation of an economy or justice or national security of any country can be fended off through fake news and bad policies and decisions by creating background noise and news. This makes the masses confused with the real current pressing and potential issues surrounding a nation.

Red herrings sow confusion. Confusion results in a lack of focus on what the real problem is. In medical science, this ends up with health care providers working up patients with more unnecessary tests, increasing hospitalization days, instituting unnecessary treatments, placing them at higher risks of complications, and shifting the burden of cost to an insurmountable amount.

It is a fallacy that an argument is correct but does not address the subject being discussed. It is an attempt to change the subject.

In this highly digital age of technology, social media is used to sow confusion and distract us from what is true. It is like medical science where instead on focusing what is the real evidence, we are distracted with the diagnosis because there were too much tests that gave ambiguous results.


In any situation, focusing on Red Herrings is a deadly distraction.

He speaks his mind…

Self opinionated or being straight to the point? Saying the truth or being upright?

Many people don’t like people who are contemptuous in speech, particularly when you’re expected to say things “nicely” and with “modesty”.

But being direct to the point can actually be insulting for some.  Others expect that whenever we speak, it is done properly and with tact.

I remember I once told someone that whenever we speak, we must practice how to be “politically correct” because not a lot of people understand why we say what we say.  Saying what one needs to say without being hurtful is an art.  Not everyone is able to get away with what one wants to or needs to say with the reason of “having to speak one’s mind“.

Speaking one’s mind is a reflection of one’s upbringing. It’s a cultural thing as well.  There are people who don’t like being directly called out for being wrong.  They mistake being told off as a sign of being rude.  But being honest about situations makes a healthy relationship.  It’s also a cultural thing to shrug off  opinionated people and regard them as being offensive or having inconsiderate behaviour.  After all, there’s a thin line between speaking out for justice and truth, and speaking out of hate.

There are two reminders I will share…

When anger rises, think of the consequences.

– Confucius

During fits of emotional distress, it is best that we get out of the room or try to avoid your mobile phone or laptop, so you can avoid the impulse of letting go awful and mean things (no matter how accurate) to say to others.  You can’t get that back when you’ve let it go.

Before you say something, think how you’d feel if someone said it to you.

Then there’s the other situation where we need to have a voice.

Many people, especially ignorant people, want to punish you for speaking the truth, for being correct, for being you.

Never apologise for being correct, or for being years ahead of your time.

If you’re right and you know it, speak your mind.  Even if you are a minority of one, the truth is still the truth.

– Gandhi

Calling and pointing out what is wrong, what is evil and what is not right should always be the right thing to do. But the circumstances on when to do it will require some degree of adroitness and sensitivity when dealing with difficult issues. Placing what is right in the right perspective is important for relationships in every sphere of life. Saying what is right without humiliating another is an art we all should try to learn.

There are situations where we just need to speak our mind.

The most important compass when we speak our mind is to “never worry about who will be offended if you speak the TRUTH.  Worry about who will be misled, deceived and destroyed if you don’t“.

The stories of our life

Everyone has a story.

There will always be drama and comedy, poignancy and fairytales, love and fantasy in each of our stories. After all, only we write them.

In life’s twist and turns, the outcomes may be in our favor and considerably be rewarding. Other times, life is unfair.

We are all bad stories in other people’s life. Some people won’t own up to reality and issues that they create. No matter how laid back and cool one is, there will always be that one person who doesn’t like you for no reason.

I write this to remind everyone that we should also have understanding and empathy and sympathy with our fellow men. After all, we are all actors in this life. And each of us have a version of life’s story.

In the local mini series Maalaala Mo Kaya (Can you Remember), the stories of our lives are weaved, remembered and recreated. This mini series is a beautiful reminder that we make our own stories in our lives.

Appreciate where you are in your journey even if it’s not where you want to be. Every season serves a purpose.

In the end, only three things matter: how much you loved, how gently you lived, how gracefully you let go of things not meant for you.

Let’s make sure we write it well. Edit often. And celebrate it!