Last week, doctors and medical societies were up in arms when a retired media practitioner publicly shamed a doctor for what he felt was an unreasonable professional fee that was charged to the mother of his friend. The doctor, a renowned wound-care specialist and cardio-thoracic surgeon, had supposedly charged an exorbitant professional fee for taking care of a woman who had transferred from another hospital to the Philippine Heart Center, a government hospital that also caters to private patients.

With all the acrimony that has been thrown around on social media, it is difficult to separate fact from fiction at this point. The uproar, however, does highlight a frequently misunderstood aspect of a physician’s practice: the professional fee.

Doctors all swear to uphold the Hippocratic Oath, which sets out the ethical standards for the practice of medicine. Since we take care of our fellow human beings, medicine is naturally an altruistic profession. However, doctors, just like everyone else, need to make a living. In medical school, we are taught that the professional fee is incidental to healing people, and we should never let the capacity to pay affect our efforts in treating a patient. This doesn’t mean that we shouldn’t charge a fair amount for our services. The cost of training as a doctor is tremendous, and we have all sacrificed our time, blood, sweat, and tears to acquire the skills that we have. Most doctors start practicing well into their 30s, and those specialties that rely on manual dexterity, such as surgery, have a limited amount of time in which they can continue practicing before they develop arthritis or their skills become outdated because of newer techniques.

The practice of medicine in the Philippines takes several forms. Medical students, upon graduating and doing a year of general internship (with the exception of the University of the Philippines College of Medicine, where we graduate after completing internship), are able to practice medicine upon passing the Physician Licensure Examination. This type of doctor is known as a general practitioner (GP). GPs can see all types of patients. The professional fees that GPs charge, however, are typically lower than those of specialists or subspecialists since there is a limit to the procedures they can perform. Many hospitals don’t accept GPs for admitting privileges because a higher level of skill is required for taking care of sick inpatients. GPs mostly do outpatient care. There are some highly skilled GPs in the provinces where there are no specialty doctors available, and they have had to step up to do almost everything. Some can deliver babies and even do major surgeries. Though it is rare to see GPs in urban centers, since they tend to get crowded out by people with more advanced training. Some GPs can make a good living with private practice, especially in the provinces, but it can be challenging to practice in more developed areas of the Philippines. Some GPs end up not practicing at all and instead take on corporate jobs or administrative roles in hospitals and the health department.

Among those who decide to pursue further specialty and subspecialty training, a lot of time and sacrifice are needed. Specialization in medicine entails going through residency training, which can take two or more years. Internal medicine residency, for instance, takes an additional three years after graduating from medical school. Subspecialty training, known as a fellowship, can take one or more years after residency. We also end up taking exams for specialties and subspecialties. In addition, continuing medical education is required for the renewal of our license every three years. This means going to medical conferences or attending lectures, which cost a lot of money. By the time someone is done with residency and fellowship, they will be in their mid-thirties. Women who put off having children to finish medical training are at higher risk for difficult pregnancies and chromosomal abnormalities in their babies.

While most specialists and subspecialists end up doing some form of private practice, others join government hospitals to work as specialists and subspecialists. These physicians are given government items which range from about ₱40,000/month for part-time positions up to almost ₱100,000/month for full-time specialists. These medical specialists take care of charity patients and some also teach students, residents, and fellows. The salaries they receive are nowhere near what private practice doctors make, and so many of these doctors also do private practice on the side. To attract medical specialists to government hospitals, some beds are set aside for private patients, and government specialists are given admitting privileges. In the extreme, like at the Philippine General Hospitals (PGH), a subset of doctors called WoCs (short for without compensation) are expected to see charity patients with trainees without regular pay, but are allowed to admit patients as a form of compensation. Doctors who do private practice in public hospitals tend to charge PFs that are a lot less than what their private counterparts bill. For instance, I typically charge half of what I would bill for a patient in the Philippine General Hospitals versus what I would bill in the private hospitals where I practice. Medicines and laboratory exams in government hospitals are also minimally marked up, and the hospital bill of the patient is usually substantially less than what it would be in a private hospital.

Admittedly, there are physicians who charge more than the average PF, and some are downright exorbitant. Usually, these physicians are highly skilled with strong clinical reputations, and so it is kind of like paying for a branded product. Interestingly, some of these physicians can also be found practicing in government hospitals like PGH, where they may charge just a fraction of what their PF is in private hospitals. Perhaps it is a way to make their skills accessible to those who would otherwise be unable to afford them.

From what I have heard of the case that caused the social media uproar, the doctor involved is a prominent surgeon who teaches and donates his time to government hospitals like the Philippine Heart Center. The professional fee was more than reasonable for his level of expertise, and the patient supposedly wanted to pay with a guarantee letter, which, in my own experience, is anything but guaranteed. I believe guarantee letters for private care are a misuse of government aid because they are meant for indigents without resources. Since we already have Universal Healthcare as well as charity care, Filipino taxpayers should not be made to pay for anyone’s private care, regardless of whatever connections they have. Guarantee letters also promote a patronage and mendicant culture and should be phased out, with the budget for these going to Universal Healthcare instead.

In the end, this case should be a good teaching point for the general public about how doctors make a living and what to expect when contracting private care. HMOs are an altogether different issue, and we can discuss those at a later date. The bottom line is that doctors are entitled to fair remuneration for their private medical services, while the government should ensure that adequate social safety nets are in place for those who cannot afford private care.