DR. Gatbonton is Editor-in-chief of the Manila Times Publication, HealthNews. She is a board certified internist and endocrinologist, and a past president of the Philippine Society of Endocrinology and Metabolism.
I knew I wanted to be a doctor when I was 7 years old.
The noblest of professions, being a doctor comes with a certain prestige in society for many reasons: the long years of study requiring intelligence and diligence; the devotion to a life of caring for the sick and easing suffering; belonging to a profession that perpetuates its own mysterious language, ‘doctor speak’ which widens the gap between medicine and the general population; the degree of respect the title “doctor” brings, and rightly or wrongly, the perception that he is doing well financially.
So, thanks to my father (who paid and still continues to indulge me), I found myself more than 15 years after I went to college, finally starting a practice. With a newly minted diplomate in endocrinology under my cap, I thought I would just “Hang up my karatola, “and get on with it.
I didn’t realize how difficult it was going to be. First, getting all the necessary papers: PRC license renewal, PhilHealth membership, applying for SSS and TIN numbers, registering as a business, getting receipts printed, ordering prescription pads and business cards, and all the requisite paraphernalia to start a clinic.
Second, establishing ground rules for yourself: Number of hours (What you earn is directly proportional to how many patients you see, but also not always, more later.) Four to Six. Days of practice? Monday to Saturday. What hospitals to apply too? Don’t want to beg dad for more money for shares, so home base and teaching institution. How much time am I willing to spend in a day to make what I need to be comfortable? Not more than half a day. How much time am I willing to spend in traffic? Don’t want to travel more than 10 kilometers from home.
Third: How much do I charge for service? (What is prevailing rate in my area of practice? New patient versus old?) Who do you charge and not charge? Professional ethics extends the no-charge policy to fellow physicians and their immediate families. Many doctor friends, by choice, do not charge the religious, employees of the hospital, a family friend and sometimes extend this courtesy to a friend of a friend of a friend. (Otherwise known as an extension in UP-PGH lingo. Extensionitis is a patient you do not expect to charge). Of ten patients in the waiting room, half would be card-toting & HMO-paying, two would be religious, and only three will pay the consultation fee. Not much to show for a hard morning’s work.
So you hang up your karatola and get on with it. And I have had my own small, private practice running out of a small, private hospital for the last 15 years. I see 10-12 patients a day, by choice, because that’s all I can manage. A new patient takes up on average 45 minutes of my time. A follow up consult, depending on whether diabetes (longer) or thyroid (shorter) can take from 20-30 minutes. I take the patient’s vital signs myself. I do a physical exam, note labs, discuss patient issues and fill the prescription. More patients mean more income, but also less time to do things properly.
I can honestly say that the usual complaints, the disenchantment with the medical profession itself that has driven many physicians abroad: the paltry HMO-driven consultation fees, the long wait for checks, the looming threat of compulsory malpractice insurance, the persecution and paper chase by the Bureau of Internal Revenue (BIR) has yet to bother me.
Until now. As a self-employed professional, I pay a monthly 3 percent tax, a quarterly tax, have ten percent of any income automatically withheld, and pay my annual income tax in two instalments. My little practice, with my accountant’s help, has been paying unto Caesar, what is due Caesar.
To my shock, in the middle of a patient’s visit three weeks ago, I get a frantic knock on the door, from my secretary saying, “The BIR is here and they want to speak to you.”
A team of four charges in with a very official looking Mission Order, which states they have been ordered to stake out my clinic for TWO months, starting immediately. And from that moment, they have not left me or my patients alone. Every person who comes in and out (whether patient or companion or a med-rep) is automatically asked for a receipt. Even if they are still waiting for me and just need to get something to eat or go to the toilet. They list the names and if an HMO, also get their card numbers to verify that they are really HMO patients. They demanded a receipt for two cloistered nuns from St. Claire’s. My secretary said, “Doctor has never charged the religious,” and gestured to their offering on the bench. How do you issue a receipt for 5 dozen eggs?
The first week was horrific. Even if you know you have not done anything wrong, I could not sleep for worrying. (People have told me, if they are fishing, then they will find something.) I felt horribly violated, our collective privacy invaded. One patient asked me, “Doctor, am I obliged to give them my name and contact details?” I told her, “I don’t think so; they are investigating me, not you.” And I teared up in front of her. What must they think; my doctor is doing something wrong because the BIR are outside.
Some of my long standing patients have taken up the cudgels for me, lambasting the BIR people sitting outside my door, inveighing against their intrusion into my life and the inconvenience to theirs as well. A lawyer patient has kindly volunteered his services. I hope I will not need them.
This is how it feels to be raped. They have not charged me with anything; my accountant has submitted to RDO 32 all the books they require. But why are they making me feel like a criminal? I have to grit my teeth and ride this out; I cannot make them go away. When I went out of town for a weekend course, they showed up and asked my secretary to initial their time records. The biggest irony is that my taxes go toward paying their salaries. As a Filipino citizen, I am paying for them to do their job. My only respite from them is Sunday and this long Undas weekend.
One in-patient they have been monitoring did not pay me and left a promissory note which my secretary is holding. And they will probably have to wait forever for her to show up, as will I.
The patient may leave the hospital as long as he has paid his bill, but there is no holding him back, even if he does not pay his doctor a single centavo.
Patients who do pay, automatically assume a doctor is overcharging. Socialized fee for service is the general practice. For most in-patients, physicians charge depending on the room rate. We honor the senior citizen discount. Do we ask the person who cuts and colors our hair for a break?
How many times have my clinic mates and I lamented, “Mayaman ako sa promissory notes.” If I could collect all the money owed me through the years now that would be a sizeable amount to tax. But I do not run after patients who do not pay. The Patient’s Bill of Rights notwithstanding, what about the physician’s right to be paid for services rendered? We tell ourselves: We’re not in this for the money. But the reality is, we cannot eat promissory notes for dinner, nor will it put gas in my car or pay for our children’s education. By experience, less than 1 in 10 will come back and settle the balance. The rest we chalk up to heaven, experience and good karma, trusting that what goes around, comes around.
So in spite of this service and goodwill we doctors extend to our Filipino kababayans, this is how our BIR treats us. In yesterday’s Philippine Star headline, the BIR boasted that they had filed charges against 75 tax evaders to date, and trumpeted the name of a colleague of mine who did not issue a receipt to a poseur patient and has now been charged as a criminal at the DOJ. What did they have to do that for? Why isn’t there a first offense, second offense policy? Why not spare the physician the humiliation?
Down with the BIR harassment of Filipino physicians treating Filipino patients faithfully, selflessly and well!
Not too many people can wake up and say they love the work they do. The beauty of the medical profession is that it brings rewards that money cannot buy: A unique sense of purpose and fulfilment. It is something other people don’t or can’t have. Although money is necessary to sustain a comfortable life, it mustn’t stain our hearts, morals and principles. Nor must it entirely drive our career decisions. It certainly does not drive mine.
There is a joy in healing those who come to you for help. I was happy to go to work every day. Before October 5, 2011. The BIR exacts a pound of my flesh very regularly, making good Ben Franklin’s truism, “But in the world nothing can be said to be certain except death and taxes.” But this time, the BIR has inflicted a deep hurt in my heart, and taken from me something bigger: my joy.
Knowing they are out there, watching me, waiting for me to slip up, has spoiled my day even before it has begun. And they will continue to do so until December 5, 2011. The end of that day can’t come soon enough.
