Why appointment systems aren’t a simple fix for Philippine clinics

To begin with, I think most doctors agree that no one likes waiting and that most of us will do our best to see patients on time.

Notwithstanding the tongue-in-cheek joke about how patients should be, uh, patient, there really is no good reason to waste anyone’s time. Especially the time of people who are sick and should be resting instead of waiting for hours in a room also full of sick people.

Let’s first dispel the idea that the system abroad is so much better. When I was training as an internal medicine resident in the United States (US), we had patients booked in advance into slots in the clinic. Once those slots were used up, that was it for that calendar day. If someone needed to be seen earlier, they could go to urgent care or the emergency room (ER), which would end up costing a lot more out of pocket. You also couldn’t go straight to a subspecialist. You had to go through your primary care doctor, usually an internist or family practitioner, before you could be referred to a specialist.

Most primary care doctors in the US are booked for weeks to months at a time. Yes, you would be given an appointment, and the doctor will see you at the correct time, but it would usually be far into the future. In addition, each patient visit has strictly limited time. If you go beyond the allotted 15 minutes, you will have to schedule another appointment if you have other concerns.

I remember one time, my wife had symptoms of a UTI and the earliest slot she could get for her primary care doctor was two weeks from the date we called. I was able to get one of our colleagues to write her a prescription because the alternative was going to the ER or becoming so sick that she would have to be hospitalized.

These delays in care are why there is a growing trend of “concierge” doctors in developed countries. These are doctors who are paid a retainer fee to be available by phone at any time for their selected group of clients. As you can imagine, these are very expensive and you would have to pay whether or not you used the service for the agreed upon period.

Even rich countries like Singapore, the United Kingdom, and Finland, all of which have universal healthcare, are seeing the rise of concierge and private practice providers because the government system is so backed up and overwhelmed. Unfortunately, it all boils down to money and availability of enough physicians willing to accept a reduced payment from the government or a set salary.

Unlike abroad where primary care is the gateway into the healthcare system, you can see specialists and subspecialists directly in the Philippines in private care without a referral. The co-pay (or participation fee), with good medical insurance coverage in the US for a regular clinic visit is about $20 to $50. This is, in fact, more expensive than the entire professional fee for a clinic visit for most private doctors in the Philippines. Of course, you can sign up for the free universal healthcare primary care providers locally, but that could mean even longer waiting times than private providers.

I don’t know if the original poster was talking about seeing a government doctor, a health maintenance organization (HMO) doctor, or a private physician in a clinic. Government clinics are perpetually overbooked and because they are free, many patients line up as early as 4 a.m. just to get in. There is a cutoff and even then, the residents and fellows are overworked.

Many doctors take HMOs early in their practice because it provides a steady stream of patients despite the lower professional fee, and these can get really backed up. However, many stop taking HMOs after they are more established because they can make more money by seeing fewer patients.

Lines at private doctors’ offices are a mixed bag. For very popular doctors, the lines can still be very long because they are in demand even if they charge a lot. Many will do a mixed practice—some days are appointment only while other days are first-come, first served. For some subspecialties like infectious diseases, most of our patient load is in patients admitted to the hospital and so our private clinics aren’t super busy. However, some subspecialties also do primary care concurrently and so lines can get pretty long.

For specialties with procedures like surgery, cardiology, and gastroenterology, they have to spend time in the operating room, and this further lessens the time for face-to-face patient care. Not to mention the patients that have to be seen on inpatient rounds in the hospital.

My private clinic waiting times for patients are much more reasonable since I don’t take HMO patients, but I do have to delay or cancel the clinic when I have meetings or travel coming up. While some meetings and travel are scheduled, a lot of times I only get short notice, and I am either late or forced to cancel at the last minute. This is why I prefer a first-come, first-served arrangement because I see patients as they come and as many as I can when the clinic does push through.

My wife, a gastroenterologist/hepatologist who teaches at the UP College of Medicine and the Philippine General Hospital, has it much worse. Aside from her teaching load, she also does research work, does procedures, and sees many more clinic patients than I do.

She still takes HMO patients even if she has more than enough private patients because she feels that access to skilled subspecialty care is a right for everyone. Unfortunately, this causes the lines in her clinic to be long, and while she does try to manage the amount of time she spends with each patient, some demand up to one hour per visit. She gets home much later than I do and she is exhausted. She has already reduced the number of HMO patients substantially for her own health, but her hours remain long.

At the end of the day, the reason for the long lines is quite simple. There are not enough doctors to go around, and the ones we have are stretched thin. Many richer countries are in the same boat. The only solution is to produce more doctors, and to pay them well enough to stay in the profession. Otherwise, the waiting will continue, and we will all have to be patient. — Dr. Edsel Salvana