Medicine in my ‘mother’s land’

My mother of Filipino descent left the security of her upper-class home outside Manila at the young age of 18 to venture out to the United States.  She met my father of American Jewish descent in New York City after bouncing around for a few years. Shortly after their courtship, I was born.

I am a physician of mixed descent—half-Filipino and half-Caucasian—but none of this is evident from my appearance alone.

My diverse background has aided in developing my empathy. I have built a multicultural identity for myself.  However, as a physician and more specifically a radiologist, I have tended to shy away from direct patient contact toward playing an overall larger indirect role in patient care. This move comes at the expense of compassion and a loss of individualization. As a medical society, we have moved away from clinical and interactive diagnosis to more costly, advanced, image-based diagnosis, for better or for worse.

After spending time in the Philippines, working in medicine in rural towns with limited resources and even fewer doctors, I have come to realize that health is improved by more direct patient interaction with greater individualized care rather than more specialized care.  Most of the medicine I saw in the rural parts of the Philippines was paid for out of the patient’s pocket. Very few in these regions have the national insurance plan PhilHealth, and most imaging can be very costly to the patient.  As a consequence, the burden of responsibility shifts and utilization becomes more selective.

At the small community hospital where I spent the majority of my time, CT scans were performed only if all other avenues of diagnosis were exhausted. This financial burden weighed heavily on patients, so local physicians paid closer attention to whether a patient could actually afford the examination. More stock was placed in the clinical history and physical examination.  It was also common practice to understand the patients’ full situation and follow them throughout their lifetime. This all leads to more individualized care and more selective medical practices.

The medical culture in the Philippines differs in ways that reflect its traditions and attributes.  Compassion takes a strong role in healthcare, especially with the elderly.  Although resources are scarce in many regions, palliation is accepted, not rejected.  Their healthcare providers have a more personal relationship with their patients and can often spend more time with them on each visit.  There is less standardization, no real issues of overutilization.

Some of these principles may be getting lost in the American healthcare culture, and it may be time to revisit them as the healthcare system shifts in the United States.  The current US fee for service model may be replaced with accountable care organizations or bundled payments in the near future, and these providers do not necessarily conceptualize the costs to the patient.  More is not always better.

Hopefully, we can take away some principles from how medicine is practiced in those regions where resources are scarce and revive the compassion, comprehensive and personalized care that the patient truly deserves.

Andrew Kesselman, MD, is chief resident in diagnostic radiology at Suny Downstate Medical Center in Brooklyn, New York. He received his medical training at New York Medical College.