Doctors work abroad as nurses

Special Report in The Manila Times

Doctors work abroad as nurses

By Patricia B. Gatbonton, MD
Posted on Monday, February 09, 2004

The exodus of doctors from the Philippines has been continuing. But this is hardly news anymore.

Over the past few years, however, the exodus has taken a new twist: Filipino doctors are moving abroad to look for jobs not as physicians but as nurses. And the country’s health care system may collapse if society does nothing to stop the hemorrhage.

Aging baby boomers are straining the healthcare system in developed countries, causing an acute shortage of nurses. In the US, the shortage is estimated to be 600,000 by 2010; in Japan, the nurse deficit will be 1.2 million. A BBC report says that over 17,000 Filipino nurses—the largest minority group—migrated last year to work in Britain.

The Philippine Nurses Association estimates that some 2,000 doctors have enrolled in nursing schools throughout the country. The National Institute of Health Policy Development pegs the number closer to 3,000—double the number of licensed medical practitioners produced each year. One hundred physicians took the nursing boards in June 2002.


Disenchantment with the profession:


Nearly every physician I know speaks of at least one colleague who has taken up nursing. There are as many reasons as there are profession shifters.

Disenchantment with the medical profession itself: 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. As self-employed professionals, doctors pay income tax quarterly, have 10 percent of any income automatically withheld, and pay an additional 2-percent monthly tax. On top of this, any physician who grosses over P500,000 a year in professional fees has to register as VAT and pay the additional 10 percent. Do the math.

To practice in a hospital, on top of needing certification credentials, the applying physician may need to buy stocks, rights to practice, and clinic and parking space, ranging from P800,000 to P1.5 million. In addition, if the doctor is lucky enough to beg, inherit, or borrow the money, there is no guarantee he will get a return on his investment. Patients balk at having to pay an outpatient consultation fee of P350 to P500 in a medical center. Socialized fee for service is the general practice. For most in-patients, physicians charge depending on the room rate. But admissions and out-patient consults are seasonal, and go up and down, depending on whether it is tuition fee time or summer vacation, Christmas is another lean season. Most doctors earn between US$300 to $1,000 a month. Although doctors figure in the BIR’s top 100 taxpayers, these are long established specialists in their field.

The unkindest cut of all is when patients and their relatives automatically assume a doctor is overcharging. Do we ask the person who cuts and colors our hair for a discount? 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.

That is not to say physicians are not capable of charity. Doctors are charitable with both time and knowledge in the medical school wards with doctors in training and their patients. 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 know as an extension in UP-PGH lingo. Extentionitis is a patient you do not expect to charge). Of 10 patients in the waiting room, half would be card-paying, two would be religious and only three will pay the consultation fee. Not much to show for a hard morning’s work.

Charity should be a personal choice—although frankly, sometimes there is no choice. How many times have my clinic mates and I lamented, “Mayaman ako sa promissory notes.” 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, only 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.

Other push-me-pull-me-away-from-my-homeland factors include the state of the nation’s peace and order, the current and future political climate, “If FPJ wins, I’m out of here,” is a phrase I hear nearly every day, the free-floating anxiety triggered by the free-falling peso, the escalating cost of living, the enticement of the almighty dollar, the greener (currently snow-white) pastures in the US, London, Canada and Ireland. Filipino doctor-nurses are among the top human resources the Philippines currently exports.

At an October meeting of the Philippine College of Physicians internal medicine residency training institutions, participants wryly acknowledged that fielding a full plantilla of trainees, even in medical university affiliated teaching hospitals, was more difficult than usual. The palpable reduction in the number and quality of applicants is a shared experience. In years past, competition was fierce for a limited number of slots. The inevitable conclusion: Everyone’s taking up nursing.

A byproduct of hard times

The doctor who is also a nurse is a rapidly growing phenomenon, an evolutionary byproduct of hard times. The game of life is all about survival of the fittest—those that survive are the most ready and willing to double-task and start over. Evidently many of my colleagues are. Anesthesiologists, general and specialist surgeons, obstetricians, general and subspecialist internists, general and subspecialist pediatricians, dermatologists, radiologists—you name it—there is no exception, physicians are jumping on the nursing bandwagon.

As with any trend, there are positive and negative repercussions. Nursing schools are sprouting everywhere. The latest tally at the Commission on Higher Education (CHED) of the Department of Education, Culture and Sports (DECS) is there are 233 nursing schools throughout the country; CHED accredited 32 new schools in 2002. On the other hand, enrolments in medical school have dropped.

The initial special curriculum for doctors and other allied medical professionals required a licensed doctor to undergo one year of classroom and practical training before receiving a nursing diploma. The premise being, after four years of medical school, one year of internship, plus an additional three to five years of residency and an optional two to three years of fellowship, the physician needs only one year to acquire additional nursing skills. Contrast this with a regular four-year college-nursing course.

This is the mind-boggling paradigm shift: medicine is now a pre-nursing course. Is nursing an upgrade or downgrade of medicine? Talk about evolution in reverse (or vice-versa).

Beginning in 2004, the course will now take two years and is a heavier investment in both time and money. This has got the goat of both the doctor nurses-in-training and nursing students.

Reality bites

Doctors complain about the additional time requirement (How long will it take to learn how to mix intravenous fluids and drugs?) And even if the clinical instructor (CI) addresses you as “doctor” in the classroom, going on duty as a nurse in the wards is a tough reality check. You might frontline patient care, but have to strait jacket every impulse to do more. Like order laboratories or medicine in the chart. Talk to the family about the patient’s diagnosis. Make decisions that affect life and death. Something a doctor does all the time. Something that is second nature. How does one turn “being a doctor” off?

A friend (whom is migrating because his licensed-dentist wife is an American citizen practicing in California) tells me of the day a group of doctor-students sheepishly stood around a hospital bed, learning how to change the bedding layers, rubber sheet and linen, with a patient still in bed (Easy-peasy you say? Its a lot harder than you think.) A competent and compassionate internist, the patient’s condition set off his clinical radar and he automatically went into doctor-mode, interviewing the patient’s relative. His CI gently chided him, “Doctor, your assignment is to change the bed sheets. That’s all.” Reality bit him hard that day.

Unfair competition?

Nursing students, on the other hand, claim the nursing board exam degree of difficulty has gone up—because doctors are topping the exam. (Although another friend says its not as easy as she thought, she would often answer the question on the mock boards and find she got it wrong, because she was thinking like a doctor, and not like a nurse.)

A nursing student I know (whose sister is a nurse in Michigan, and will help him apply to a position at the same institution) says that doctor/nurses are bad news. Obviously, a doctor/nurse is formidable competition, with years of clinical experience and the medical degree behind him. Hospital recruiters would prefer the doctor/nurse to the wet-behind-the-ears new nursing graduate like him. He is counting on the family connection to help him land a job.

The nursing board results in December this year, just released, had a 43-percent-passing rate. Three thousand three hundred and eleven new nurses will shortly receive their licenses. Scanning the pass list quickly, I recognize many familiar names, and am frankly shocked and saddened, at seeing one or two. Many physicians will not openly admit to having enrolled in nursing, and rumors abound in the medical community grapevine.

The reality is that nurses can make an average of US$50 an hour. Working eight hours a shift three times a week, a doctor can make in one month five times what he will make in the Philippines if he is lucky. Hospital recruiters understandably hire doctor-nurses in the Emergency Room and Intensive Care Unit settings—where they command up to US$80 per hour.

One anecdote making the rounds is a story of a long practicing anesthesiologist, now a licensed nurse in California. On ICU duty one night, with a second-year medical resident, he came upon a patient needing to have a breathing tube put down his throat. The inexperienced resident found it difficult, the patient was in bad shape, and there was no one else to help. The doctor-nurse suggested that he insert the tube himself, and both the patient and the resident benefited from his skill. Had that got out though, legally, the doctor-nurse could have been liable. His license to practice in California is as a nurse, not as a doctor.

Honor in our calling

Many doctors who are sticking it out in the country are looking at other alternative sources of income. Teaching pays peanuts, even in the best medical schools, so those full time academicians teach for sheer love of the job. I know, I taught for three years before I wised up. Many doctors sell nutriceuticals and other supplements, real estate and insurance. Many go into business on the side. One neurosurgeon friend supplies bangus from his fishpond to hotels in Manila.

That we have to go into business to subsidize our profession saddens me. As much as I kid around that I will quit my “day job” and work as editor of HealthNews full time, the reality is that being a doctor is 24/7. I can’t give it up. Once a doctor, always a doctor, licensed to practice or not. Doctoring is in our blood, a part of who we are. Away from the hospital, when people find out you are a doctor, they will come up to you for the opinion, the prescription, the ambush consult. It goes with the territory.

So we do what we need to do to stay as doctors. I empathize with my friends and colleagues who feel the only way to improve their lots is to leave the country. I don’t question their reasons, idealism or nationalism, because I can’t be a hundred percent sure that I won’t go down that road myself one day.

As a very low maintenance singleton with no family pressure and indulgent parents, I can’t really identify with the mortgage, the tuition, the car payments, the bleak future.

Not too many people can wake up and say they love the work they do. That a doctor’s life and work rewards with a sense of purpose and fulfillment may be unique to the health care profession. It is something other people don’t or can’t have. Although money is necessary to sustain a comfortable life, we mustn’t let it stain our hearts, morals and principles. Nor must it entirely drive our career decisions.

It is not hard to explain or reconcile the doctor-nurse phenomenon, for if you cannot, by force of circumstances, stay a doctor, nursing is the next best thing. Nursing is as much about caring for a patient’s well being, lessening pain or suffering, and bringing comfort as doctoring is. And if it happens to pay well, there is nothing wrong with that. There is honor and calling in both professions, at home or abroad.

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