For the #Frontliners

To my dear Medicine Residents and Fellows,

A passage from one my favorite books, written by Tolkien, goes like this:

“Frodo: I can’t do this, Sam.

Sam: I know. It’s all wrong. By rights we shouldn’t even be here. But we are. It’s like in the great stories, Mr. Frodo. The ones that really mattered. Full of darkness, and danger, they were. And sometimes you didn’t want to know the end, because how could the end be happy? How could the world go back to the way it was when so much bad had happened? But in the end, it’s only a passing thing, this shadow. Even darkness must pass. A new day will come. And when the sun shines, it’ll shine out the clearer. Those were the stories that stayed with you. That meant something. Even if you were too small to understand why. But I think, Mr. Frodo, I do understand. I know now. Folk in those stories had lots of chances of turning back – only they didn’t. They kept going. Because they were holding on to something.

Frodo: What are we holding on to, Sam?

Sam: That there’s some good in this world, Mr. Frodo…and it’s worth fighting for.”

By now, you’re probably feeling the same, facing a scourge you can’t see — an illness that does not yet have a cure. You fear coming home, because you might be bringing back something deadly. Your family might be calling you, asking (or begging) you to come home. You had lots of chances to do that, but courageously, you kept on returning because you have grit, you have perseverance, and what you do is noble and holy… and your friends are counting on you.

“You can trust us to stick to you through thick and thin – to the bitter end. And you can trust us to keep any secret of yours – closer than you yourself keep it. But you cannot trust us to let you face trouble alone and go off without a word. We are your friends, Frodo. Anyway: there it is.

We know most of what Gandalf has told you. We know a good deal about the ring. We are horribly afraid–but we are coming with you; or following you like hounds.”

We are also ready, preparing to step in, drawing up our plans and failsafe, making sure you have your PPEs, are eating well, and that you do not feel alone and abandoned. We are inspired by your dedication – all of you… and we are so proud of you.

Always keep the faith.


Process Flow for #RTOC

Assume in this scenario that the clinic is physically CLOSED but virtually OPEN. Your secretary has the clinic phone. Your patients usually call the clinic phone to set appointments, or just to find out if you are holding clinic.

In this post, we will try to mimic a doctor-patient interaction in an online consultation.

  1. Patient calls secretary for appointment
    1. Secretary notes patient’s name, mobile phone number, and email
      1. I ask for the email because this is where I usually send the laboratory request or prescription
      2. Alternatively, you may opt to send these documents via viber (whatever is convenient for you and your patient). Recommend that you use another phone for this (not your personal phone) as patients will then get your phone number, allowing them to call you anytime.
    2. Secretary does a quick TRIAGE on the consult (Quick question: Is your secretary capable of triaging?).
      1. Is the patient’s condition an emergency?
        1. Provide a list of symptoms specific to your specialty that your secretary would know to indicate an emergency
        2. For example, in gastroenterology, the alarm bells should ring when patient says
          1. Intractable vomiting
          2. Increasing abdominal pain
          3. Increasing size of the abdomen
          4. Passage (either vomit or pooping) of blood
          5. High-grade fever (above 39C)
        3. Should the patient mention ANY of the above symptoms, the instruction is to PROCEED to the EMERGENCY ROOM right away
      2. Is the condition urgent?
        1. Schedule a consultation via Zoom or Viber right NOW
      3. Is the condition NOT an emergency or NOT urgent?
        1.  Schedule a consultation via Zoom or Viber following your usual methods
  2. The doctor sets up the CONSULTATION Room (see previous post on how this is done)
  3. The doctor starts the consultation proper
    1. Your disclaimer
      1. This does not replace our face-to-face interaction in the clinic
      2. The doctor is just limited to suggesting a diagnostic exam, or providing a verbal or written prescription
      3. Improvement is expected within (usual time frame), but if symptoms persist OR deterioration occurs, please notify your doctor thru (mobile phone) ASAP
      4. Agree that if a physical exam is absolutely necessary, we will schedule at a date and time in the clinic or hospital for this.
    2. There may or may not be a FEE for this consultation –> your personal CHOICE.
  4. End your consultation
    1. Send your laboratory request (via email or viber)
    2. Send your prescription (via email or viber)
    3. Send your billing statement (via PayMaya, GCash, or bank transfer).

Then go see your next patient.



Rapid Transition to Online Consultations #RTOC

NOTE: Majority of the information in this blog was created by the Doctors and Information Technologists under the guidance of the Medical Services Department of the Makati Medical Center. To them, I owe much.

One of the most heart-rending stories I hear are the cries of patients, unaffected by COVID-19, but still needing care for their conditions (the diabetics, the hypertensives, the fatty liver, the acid reflux…). The clinics have CLOSED. The community is under quarantine. They CANNOT get in touch with their doctors.

Doctors NEED to go online. NOW. This is your patient’s lifeline. Let me show you one way to get it done, and get it done FAST.

You need:

  1. Laptop – check that the camera and microphone works
  2. Phone with Data or Wifi access
  3. Reliable internet access
  4. Paymaya (download on appstore or playstore)
  5. Zoom for cloud meetings (download on PC/Mac/appstore/playstore)

Paymaya and Zoom were chosen because these are free to download while offering the  services that are sufficient for our purpose. I have NO disclosures or interests in these apps/companies. There are other options out there (i.e. GCash, BPI QR, BDO fund transfer, among others). Explore them and compare. The more payment options you are aware of and are available to you, the easier it is for patients to pay your consultation fee.

What is Telemedicine?

Telemedicine is the remote delivery of healthcare services, such as health assessments or consultations, over the telecommunications infrastructure. It allows healthcare providers to evaluate, diagnose, and treat patients using common technology, such as video conferencing and smartphones, without the need for an in-person visit.

What is Teleconsultation?

Teleconsultation is a subset of telemedicine which focus on providing remote consultation services without the need for specialized assessment and diagnostic equipment.

Qualifications for Teleconsultation

My hospital leaves to the doctors the discretion to decide whether their patients are qualified for teleconsultations, but here are some of the recommendations:

  1. The doctor should have existing doctor-patient relationship and that they have seen the patient in person prior to the teleconsultation
  2. The patient’s condition is not an emergency nor requires urgent medical intervention or procedure
  3. The patient does not require any assessment and/or diagnostic procedures which can only be performed by the physician at the point-of-care
  4. The patient can communicate effectively through the communication medium chosen by the physician (Viber, Skype, Zoom, etc.)

Setting up Zoom for Cloud Meetings

Download and sign up for a free (basic) Zoom account. If you have an active google account, signing up is as easy as clicking “join using google account.”

The following steps detail setting up a Zoom meeting on a phone. The laptop version is similar and I enjoin you to explore its features (and differences) from the phone app.

Scheduling a Consultation

Select the Schedule button and set the Date, Time, and Duration of your meeting (hereafter, we will call it a consultation). The time zone should be the same as the meeting host (hereafter, referred to as doctor). Attendees (hereafter, referred to as patients) join time will vary by time zone. Duration allows for easy time-blocking on calendars and does not limit your actual consultation time. We usually set a duration of 30 minutes.

Deselect the Personal Meeting ID (PMI). We don’t want the next patient to enter the “room” while a consultation is ongoing (just like in real-life).

In the meeting field, enter “Consultation: Patient Name”

Some options to consider:

  1. Video – Choose if you want the doctor’s or the patients’ webcams on or off when joining the consultation. I suggest you choose ‘off’ for the doctor and patient. The doctor and patient will have the option to start their video in the meeting
  2. Audio – We prefer to select ‘Both’ to allow patients to use any computer devices or telephone to listen and talk on the meeting.  Most of your consultations would use the computer device.
  3. Enable join before host (doctor)– Allow patients to join the consultation
    without you or before you join.
  4. Mute participants upon entry – This will mute the patient as they join the consultation. The patient will have the option to un-mute their microphone in the consultation. 
  5. NO NEED to enable waiting room

The scheduled calls will appear in the “Meetings” tab.

Invite Your Patients

Select a scheduled meeting from your list. 

Click on “Add Invitees”

Click on “Messages”

Alternatively, you can paste this invitation as a message sent to your patient’s email, messenger, or copy to clipboard and paste in viber.

As the consultation time approaches, click “Start” to begin your interaction.

(((( Your consultation proper starts here ))))

To end the consultation, click “End” or “Leave”.

Setting up Paymaya

Start by downloading the Paymaya and creating an account. The steps are:

  1. Download the PayMaya app from the App Store (Apple) or Play Store (Android)
  2. Fill out the online form. Once done, tap the Continue button.
  3. Read the Data Privacy Policy page and tap the Agree button. PayMaya will send you a verification number via SMS. Enter that number in the app and tap “Verify.”
  4. Tap the View Card button.
  5. Enter your address and birthday.
  6. Enter the required information under the Online Payment Card Number page.
  7. You’ll receive a confirmation of your PayMaya account activation.

Next, upgrade your account by following these steps:

  1. Log in to your PayMaya account. Once in the app, access the menu then select UPGRADE YOUR ACCOUNT.
  2. Fill out the required information and make sure you have at least one [1] valid primary ID. Please ensure that the Name and Birthday you entered in the Upgrade Application form matches the Name and Birthday reflected in the Valid ID that you will be uploading.
  3. Record and submit a 4 to 5-second video selfie
    1. When taking the video selfie, you must follow the instructions onscreen and take note of the required gestures.
    2. Make sure not to cover any part of your face and remember to position your head / face properly in the video capture frame.
  4. After recording your video selfie, review your application and click on SUBMIT.
  5. You may monitor the status of your application by clicking on CHECK MY UPGRADE STATUS in the app menu.
  6. Once your upgrade application is approved, you will receive an SMS confirmation within 24 hours and can then start enjoying the features of your upgraded PayMaya account.

NOTE: Upgrading your Paymaya at this time is OPTIONAL, but would be necessary later on if you decide to transfer funds to and from your bank account.

Getting Paid

After your consultation is finished, let’s talk about getting paid.

  1. Open your PayMaya app and click on “Request Money” option.
  2. Click on the “Send Request Money Link”

Patients will receive an SMS notification about the payment request indicating the amount, the name of the doctor, and instructions to click on a link to proceed with the money transfer.

Once payment has been made, the doctor will receive an SMS notification that the amount was received through PayMaya.

If your patient does NOT have PayMaya installed, refer to the instructions above and teach them.

Data Privacy

Telemedicine must strictly adhere to the data privacy act. Zoom has its privacy policy here. The importance of adhering to good data privacy practices cannot be overemphasized.

Patients must acknowledge that an online medical consultation is not an adequate substitute for a regular or face-to-face consultation at the out-patient clinic due to its inherent limitations, like inadequacy of physical examinations, and/or lack of access to medical tools, among others.

Patients must also acknowledge that the initial management may be limited to a verbal and/or written advisory and medical prescription. It is incumbent upon the patient to keep his/her follow-up appointments. Further, the patient must acknowledge that he/she must immediately inform the doctor via an agreed upon method of communication if symptoms are not relieved as expected, or if deterioration occurs.

In such events, patients would also need to make the necessary arrangements to be seen in the clinic and/or hospital.


There are times even before this COVID-19 crisis that I don’t charge patients. The money has always been secondary to the service. This solution gives the patient and physician the chance or option to avoid having money contaminate the relationship. If you don’t want or need to get paid (or maybe you want to set a lower or higher fee), that’s your CHOICE.

Setting up FREE consultations sound nice and noble. A few issues become apparent here.

One, doctors (and their families) will eventually need to eat too. Since majority of your consultations would involve OLD patients who usually pay for their consultations, why should online consultations be treated differently?

Two, the doctor-patient relationship exists once you engage your patient. It cannot unilaterally be terminated by the doctor (abandonment), but a patient may choose to drop you at any time. If during the course of your consultation and the patient experiences an adverse outcome, you can be liable. You didn’t get paid, you’re still liable! Get paid because you will need this for your liabilities in the future.

Three, have you ever had patients refuse to consult you again because you didn’t charge them at all? They’re upset because you gave something of yourself and they have no opportunity to reciprocate. So they give a chicken, or eggs, or even a whole cow. You eventually learn that they had to go out of their way to give something to you. Nothing is completely free (except our unconditional love to the ones we love).

My personal experience is that if you have a good relationship with your patient, they will find a way to pay you. It may not always be with money.

I still have emails from patients saying that they wish the clinics would open soon (That’s ok, it’s my wish too). Overall, you get the sense that what they really need is CONNECTION – a way to communicate. Most people are built that way.

This online thing is our NEW normal, we must go to where our OLD patients are, whether we like it or not… whether we are ready or not. Go, or go the way of the dinosaur.

Us doctors NEED to be ready.

Living Patients

Intensive Care

It started as a tightness in the chest while I was on the way to work in the hospital. It felt like a metal band preventing me from taking a deep breath. It was a new and uncomfortable feeling.

I hopped off the car, told my wife to go ahead, while I headed towards the emergency room. Blood pressure, I thought. I’ll get this sorted out and do my hospital rounds after. I sent a message to my cardiologist friend, who I knew would be in the hospital at that time. We often bump into each other during rounds.

“Are you in the hospital?” I asked.

“Yup,” she answered.

“Am having chest tightness and feel bad,” I continued. “I don’t know what’s going on, but headed to the ER now.”

“Get an ECG right away,” she replied. “I will see you there. Is this a recent chest tightness?”

“Yes,” I said.

I walked in to a full emergency room, but glad to see a familiar face, I asked a doctor friend if he would be able to get my blood pressure.

“160/100,” he said. “Please take off your shoes and lie down here.”

He called an ECG tech, gathered a tracing of my heart, and, except for a slight slowing, the tracing looked generally normal.

The band of tightness around my chest continued to bother me. It felt like you were in water (or under water), with the pressure preventing you from taking a breath. It felt like a slow suffocation or a drowning of sorts.

By that time my friend walked into the emergency room. She had bumped into my wife who was on the way to the office, and brought her to me. My wife was oblivious to the events unfolding at the ER. Not her fault, but mine. I didn’t want her to worry.

The laboratory tech came and drew blood.

Then another wave of tightness came. My cardiologist friend appropriated the portable ultrasound and began an echocardiogram. No abnormal chamber movement, she said.

The room began to dim, and I felt like sleeping would be the best thing to do at that moment.

The next few moments were a haze, or a dim memory. I heard my friend let out a panicked cry. She shouted my name. My wife was whispering something in my ear. And I felt like responding, but could not understand why my mouth would not cooperate.

The next few minutes were a blur of activity. I was unaware of the flurry over the difficulty securing an IV line. Or the continued drop of my blood pressure, undetectable by the machine, and a heart rate of 26 per minute.

I began to wake up, wondering how I had gotten to the critical unit of the emergency room, as the effects of the injected atropine began to work.

“Can I start my rounds now?” I asked my wife, who was beside me all that time.

TO be continued.


The Unsung Hero in the Video

Much has been posted about the incident involving a student (a black belt martial artist) and his peers. There are those quick to condemn the child, the parents, and the school.

I saw the videos before the school memo came out. The acts in the video made my blood boil too.

Reading through the hate, the uproar, and the anger, it is so easy to get carried away. To share, to post, to get as many people on board – the beginnings of a swelling MOB. I felt the anger of many towards the actions and taunts of the bully. Some actually wanted to hurt the bully – an eye for an eye, to feel the full fury of social media. I felt the burning shame of the family of this child. I felt the helplessness of the school teachers and administrators – how could they have missed this? I felt the overwhelming rage of a parent seeing that it was his son forced to kneel on the floor, or nursing a bloody nose. I felt the despairing fear of my co-parents, was my son involved in this? Will my son face this problem as he goes to school? Does this happen to my son now?

There is an unseen hero in this maelstrom of events.

Notice the second video in what appears to be the school park. Notice the Child in the pink and blue shirt.

The Child was being accused of some thing or other. It was unclear what the problem was. The taunts of “Fight me! Fight me!” were, however, very clear. This Boy was itching for a fight, a boy who knows with confidence that even if he was small, he has been trained well.

“I know I have wronged you,” the other Child said. “But I will not fight you.”

He received multiple punches and kicks, yet his hands remained neutral and defensive. He walks back, calm and composed. He calls out his tormentor’s name.

I have wronged you, but I will not fight you.

The video cuts to the third fight, which is another story.

I don’t know if this fight continued as the first video did, with bloodied noses and hurt all around. I don’t know if this Child knew some secret martial art, that the video was cut because the Boy received a beating in return.

I am very proud of this Child who kept his head and his heart, even as the blows and kicks fell. I would like to get to know the parents of this Child – how they managed to bring up a Child who showed strength by NOT joining the fight.

Isn’t this strength worth noticing and sharing with our children?