Archive for April, 2015

Having “Urgent” but not “Emergency” Surgery in the Philippines, Part 2

by on Wednesday, April 15th, 2015


Dr. Ramos with a nurse in Bob's room

Dr. Angliongto-Ramos, head of plastic surgery, with a nurse in Bob’s room

My friend Bob interrupted his one-year trip through Southeast Asia in order to have to have a large carcinoma removed at The Medical City in Manila. This interview took place at my home in Quezon City. The story of the decision-making and the successful outcome appears in Part 1. Part 2 deals with post-surgery care and the conflict with his US insurance company. In an email to me, Dr. Angliongto-Ramos writes,The blog has been making the rounds in the hospital and Bob’s concerns are being looked into. I am pleased with how Bob’s surgery turned out. I hope it was an overall good experience.”  Yes, indeed, Bob found his experience at Medical City overwhelmingly positive.

It will be interesting to see what effect cases like Bob’s have in the future as Americans choose to have surgery overseas. I’m predicting that US insurance, healthcare and malpractice industries will close ranks to protect themselves from foreign competition at one-tenth the cost–how bizarrely, I can only guess. A couple of years ago I attended meetings with Filipino-Americans campaigning to have Medicare available to US citizens living in the Philippines. But then someone speaking as an expert said, “Not only is this a long shot, but the doctors would have to have malpractice insurance.” That did it for me.

Bob’s story

Across the road to McDonald's

Across the road to McDonald’s

After the surgery I was very careful. When you’re 65 years old and paying for surgery yourself, you don’t want to screw it up. Dr. Angliongto-Ramos practices at three hospitals, so she’s got a lot of experience, and she’s very conscientious about avoiding infection. Because she’d done a flap operation and not a skin graft, I only had to stay in the hospital for four days. On the second day I was allowed to get up to go to the bathroom. On the third I could go across the open courtyard to Starbucks. Instead I broke the rules and crossed the road to McDonald’s because the WiFi was better.

My defection led to an international incident with the security guard who saw my hospital ID bracelet and tried to block my path. I was having none of it. He followed me. While I was inside McDonald’s on Facebook, the first guard and his boss were outside on their walkie-talkies. Another guard monitored me through the plate glass. They were trying to figure out a strategy because I was not going to be taken alive. All of these guys were impeccably dressed and ready for the most demanding of inspections. The supervisor was a big bruiser who assessed the situation and finally came in. We shook hands, and I invited him to sit down. He asked to see my ID, and I asked to see his, which he wasn’t prepared for.

He said, “Why are you here?”

Medical City tower as seen from a table outside McDonald's

Medical City tower as seen from a table outside McDonald’s

“Because the Internet at Starbucks sucks.”

“We have Internet at the hospital,”

“That’s even worse.”

He understood. “Are you going farther than this?’

“No, this is as far as I go. I promise you. I can see my room from here.” I pointed out the tower. “I will go no further. And I am coming right back. I am not trying to escape.”


We shook hands. He patted me on the shoulder and gave me a big smile. I apologized through the glass to the first guy. Everything was fine. I did worry a bit that Dr. Angliongto-Ramos was going to hear about it because she was responsible for injecting this foreigner into the system. So I did what I could–I apologized to the people of the Philippines on Facebook, and I tried to be a better person thereafter.

Bob wearing bandages and drainage tube

Bob wearing bandages and drainage tube

The total bill was a shock. It was $5,700, still a huge bargain by comparison with the US, but it took me a bit of processing to get over the difference from the $4,300, the lower of the  initial estimates. Before I was discharged, I had a meeting with the surgeon and more testing. She signed my release and met with the desk staff who were preparing my bill. Then I met with the finance department and with the cashier. I paid and got a receipt to submit to the charge nurse on the floor,  who released me. That system is certainly efficient and keeps collection costs down. I was fortunate in having the money available on my Bank of America Travel Rewards Card, which contains an internationally recognized computer security chip.  To my relief the charge went through immediately.

The additional costs came from the many extra biopsies and tests which had to be done because squamos cancer cells–much more serious–were found among the basal cancer cells. Also, the operating room was used two or three hours longer than planned. Imagine all the surgeons and technicians in the operating theater standing around, the patient waiting in the anteroom and finally the anesthesiology team strolling in forty minutes late. When they finally wheeled me into the OR and the anesthesiologist entered, none of us looked at her. We were all silent but polite. I certainly didn’t want to piss off the person putting me to sleep. The extra charges included the longer use of the OR, the extra tests and I suspect the extra nursing care from the staff. Had I understood the Filipino system, I would have had a companion with me instead of making many demands for assistance. Once they understood my situation, the nurses and assistants really went out of their way to help me.

My conflict with Blue Cross Blue Shield HMO Blue was over a common sense issue, not a legal one.  BCBS’s bureaucracy is so entrenched that in order to satisfy their definitions of coverage–definitions which disagree both with my US doctor and within BCBS itself–it sacrificed huge savings both to the company and to me.  It was a word game: “emergency” versus “urgent.” Despite the enormous savings, urgently needed surgery was not covered if done overseas. They chose to focus not on my large, bleeding, bursting carcinoma but on what part of the hospital admitted me and where the biopsies and surgery recommendations were coming from.  When surgery became necessary, we’d lined up Dr. Angliongto-Ramos. Then I saw what a bargain the surgery would be and asked my wife, her company’s BCBS liaison, to contact BCBS HMO Blue to see if they would authorize overseas surgery at a leading hospital in the Philippines. Keep in mind that BCBS is a major insurer in the Philippines, so the local staff could easily have verified that the hospital was excellent and the surgeon very highly qualified. Instead BCBS looked at the computerized decision tree that insurance companies train their staff to use in order to pay the minimum number of claims at the lowest cost. Any variation from the standard falls on the patient. This network of prepared questions is designed to take claimants where the company wants them to go.

The insurance representatives had charts. They knew what the surgery would likely cost in the US and in the Philippines, they had the dimensions of the carcinoma, they had photos, they had all the information they needed to make an informed decision. Instead of factoring in the cost, they kept saying, “Come back to the US for the surgery, and we’ll cover it.” The ridiculous thing was that for me the BCBS deductibles and the cost of going back to the States far exceeded the total cost of the surgery in the Philippines. My family doctor, in a very long conversation with them, was also unable to persuade them to accept the surgery as an emergency and cover it. In order to satisfy a processing clerk in the US, I was advised to instruct this leading Filipino hospital to play silly, unprofessional games like writing “emergency” into every service order. My surgeon in Manila should conspire with the emergency department to admit me on an emergency basis, to have biopsies done in the ER and to have me checked into the hospital from the ER. At every turn it should be classified emergency, emergency, emergency. Even then coverage was not guaranteed. None of this smelled right from the beginning.

The scar and draining tube

The scar and draining tube

Dr. Angliongto-Ramos was so generous with her time. Her office hours don’t start until four p.m. because she’s done six to eight hours of surgery before that. She didn’t take a vacation last year. And BCBS said she should plan out this whole ruse? It was just absurd. I did run it by her. She listened, but I could tell she was going into a slow burn herself. She’s had previous experience with American insurance companies and with their attitudes, the ignorant assumption that everything in the Philippines is like jungle surgery, with doctors eating greasy pork with the fingers of one hand and operating with the other. It’s humiliating. She’s a leading plastic surgeon, practicing in three hospitals. Now she’s supposed to call a junior functionary at BCBS from from her home at night—there’s a thirteen-hour time difference—to create this artificial construct, then write up reports that only an idiot, certainly not a medical school graduate, would believe? So the insurance people in the US would have a good laugh over the stupidity of these people in the Philippines, writing something up as an emergency that doesn’t fit? I was embarrassed for having asked her. I’m really glad she took offense and absolutely refused.

I’ve heard estimates from the high $20,000’s to low $100,000’s for this surgery and hospitalization in the US. With all the tests I had done, I can see it’s far north of $29,000 and maybe not too far south of $100.000 that I saved BCBS. They’re getting excellent premiums for insuring my body, not the location at which I have something done. They can’t get out of their own way. If I don’t deal with them again in my life I’ll be only too happy—and that is what I feel about the entire medical system in the United States.  I would have all my surgeries for the rest of my life at Medical City if I could.

How to apply the bandages

How to apply the bandages

Someone who’s never lived overseas might be taken aback by the cultural differences in care and communication. Here there might be information you don’t get which the doctor doesn’t think it’s necessary to tell you and other information which seems far too technical for a patient to absorb.  There are also systems which are routine in the Philippines which are different from US routines that they don’t think to mention.   The systems of floor doctors and assigned doctors are different. I don’t think one is better or worse than the other.  I was surprised to learn that there are routine procedures, such as dealing with catheters or dispensing medication that only doctors are allowed to perform at Medical City, but I will tell you that my surgeon saw me three times before the surgery, every single day in the hospital, in the late afternoon or at seven at night. I don’t know where she got her energy. On the discharge day she spent quite a bit of time with me and with the staff getting me cleared for dismissal. And she saw me for times in the ensuing five weeks at no additional charge.

I’d thought in two weeks I’d be on my way, but she knew from the beginning that the first three weeks would be very delicate and require strict germ control and antiseptic procedures and that it would be a minimum of six weeks before I could resume full activities. I had very thorough visits with her. She did a lot of care herself, like inspecting, de-scabbing and re-sterilizing the area, reapplying the bandages and changing the types of bandages and elastic pressure bandages. She taught me how to apply them and Carol how to do the things I couldn’t see, mostly applying disinfectant and things like that. She didn’t charge me for follow-up visit or for medical supplies that aren’t cheap anywhere. Her whole share of the $5700 fee was $1000. The anesthesiology team’s fee was only $500.

As I said, the biopsies revealed a second type of cancer cell. The tests for those took fourteen days. Then I found out that on top of that one-millimeter basal cell carcinoma I had a squamous cell carcinoma–on top, but not reaching in. Squamos is a still treatable but much more serious form of cancer that does metastasize, although it’s far more treatable than a metastasized melanoma. Dr. Angliongto-Ramos was constantly testing my lymph system. Metastasizing cancers go first to the lymph nodes, then to the lungs, to the liver and kidneys and other vital organs and then to the bone. So if you have a squamous cell that’s metastasized, you’re likely to become a stage-four cancer patient. Fifteen percent of people diagnosed with stage four-cancer are still alive a year after diagnosis and one percent are still alive five years later. I’ve had two friends diagnosed with stage-four cancer, and they were both dead within months. So I’d been flirting with a possible death sentence and didn’t know it.

The pressure bandage

The pressure bandages

Fortunately, all the pre-screening and post-screening tests were exactly the right ones to rule out any metastasizing squamous cells in my body after the surgery. Migrated cells would have shown up on the chest x-rays. Anyway, it was enough to throw a scare into me. I’m not the doctor I think I am. I get too blasé about things. I have no patience with ill health. I really believe that staying mentally positive has given me a great quality of life. I don’t go running to the doctor for an antibiotic every time I sniffle or get a hacking cough.

If I were to have surgery again I would probably have it done in Korea. Nearly 100% of Korean doctors went to medical school in the US. Their reports use the same formats, so I can read the results of a blood test by looking at the US heading. Plus, Korea was my second home for over ten years. In order of preference I’d put Korea first and certainly the Philippines second. Singapore would be too expensive. Then probably India, where some modern hospitals are dedicated to medical tourism, which I would highly recommend. The savings are phenomenal.

I should add that Korean doctors hate to be questioned by anybody. Confucian society holds that you don’t question educated people at all. Everything they say is true and they possess profound knowledge that mere mortals don’t. Historically, doctors in the Confucian countries–China, Korea, Japan–were trained to protect you from yourself, not to tell you when you were dying of cancer, not to discuss what was wrong with you, only to tell you what treatment plan to follow, and sometimes not even to tell your family. The doctor knows best.

Once I stopped by a Korean hospital to get some antibiotic salve. The young, American-trained doctor asked how I knew what salve to request.  I said, “Well, it’s only pink eye. It’s not the end of the world.”

He snapped, “Where did you get your medical degree?”

I snapped right back, “Do you think that doctors own all the medical information in the world? Do you think that people should not be allowed to have the medical information they need and pay for? It’s out there. Live with it.”

He was furious. But things are changing. As Koreans travel and return to Korea, they have a different expectation of the doctor. As doctors are trained in the US, they understand that there’s a different way of doing things which involve making a patient a partner in their own recovery.  Many are starting do take that on board.

A big part of the savings in getting healthcare outside the US is that the doctors are not paying hundreds of thousands of dollars every year for medical malpractice insurance.  Dr. Angliongto-Ramos pays no malpractice insurance. She doesn’t need it. Even if a plaintiff won an award, the award wouldn’t be significant. Here people have to accept responsibility for their own decisions and behavior—spilling hot coffee on themselves at McDonald’s, for example. The medical malpractice industry in the US has become absurd and it places a huge cost burden on the healthcare industry. It’s layered and appears in every aspect. The Band-Aid you get in the hospital is $20 because the manufacturer is being covered against claims for failure to maintain an antiseptic environment. The hospital is being covered against claims of improper storage and handling. We need national health insurance. Then all this malpractice insurance scamming and greedy patients going for the malpractice lottery grand prize will disappear. It’s the golden rule: he who has the gold gets to make the rules. If you’ve got one entity, the US government, paying for healthcare, then the laws would quickly contour to fit. You can’t sue over a free lunch that you didn’t enjoy.

So that’s my ten cents worth on the subject!

Links to copy and paste on your navigation bar:

Here’s my (Carol’s) post on eye surgery after the first one or two. I’ve had sixteen in total, all at the expert and caring hands of Dr. Milagros Arroyo, who is also connected with Medical City.  “The Eye Thing,” Three-fourths of all cost connected with my macular degeneration was paid without argument by Pacific Cross, which is associated with Blue Cross Blue Shield. Years earlier I had a $2,000 gall-bladder operation in Seoul. Korean National Health Insurance paid half, and Pacific Cross paid the other half.

For a completely different surgery-in-Asia experience, check out “Robert’s Appendix,” which happened in a small town Chinese hospital thirty years ago.

A Medical City doctor writes:

Yes I read it and enjoyed it very much also. Had a funny moment when Bob, in response to the guard who followed him at McDonald’s said the internet in the hospital was even worse! Oh he speaks the truth. Anyway, what a folly the Health Insurance is indeed. I do hope it gets better so that it can also be availed off with less hassle here.
I doubt seriously that insurance private insurance will improve in the US. The companies have too many lawmakers in their pockets, and state control of the industry means only piecemeal reform. As I said in the intro to that piece, I suspect the insurance industry will put up more barriers against medical tourism when they get threatened. That’s why we need comprehensive reform in the US with a single-payers system of the type you find in Europe, Canada, Australia, New Zealand…
A reader writes:

I live in Taiwan. On April 16 I went to the emergency room at Xinwu Clinic and immediately saw a physician. I’d made two previous visits to the clinic and received 36 pills and four containers of cream for cellulitis. On this visit I was told I had an abscess. I was given super antibiotics and pain pills that proved too strong. Three days later I had a 30-minute incision and drainage procedure in the ER and was handed four bags of meds. Five hours after that, I had the bandage changed there. The total bill for the clinic visits and surgery was 600 Taiwan New Dollars or $18 US dollars. In contrast, in the ER at Desert Springs Hospital in Las Vegas, Nevada, I was wrongly diagnosed with cellulitis of the eye, treated and billed $2,000. This was later negotiated down to $800 after the county hospital UMC advised that the condition was in fact pink eye.

A reader writes:

Interesting, but I did think your friend Bob played a little fast and loose with his health.


Having “Urgent” but not “Emergency” Surgery in the Philippines, Part 1

by on Wednesday, April 1st, 2015

Open foyer between the towers at Medical City

Open foyer between the towers at Medical City

This year my friend Bob is making a one-year trip to Southeast Asia and cashing in the huge stockpile of Korean Air frequent flyer miles he built up over his decades as a merchant banker in Asia. The trip had to be interrupted for surgery. Based on my personal experience, I recommended The Medical City in Metro Manila, one of the leading hospitals in the Philippines. Although It is not the most expensive hospital in Manila, Medical City costs three times as much as the national hospitals. Excellent physicians also practice at public hospitals for humanitarian reasons, so the care is the same for the patients of equally qualified doctors, whether at private or national hospital. Of course any hospital is beyond the reach of many of the poor, who have no choice but to go back to the provinces and die.

For those of us with some knowledge of healthcare in Asia and health insurance in the US, the end of Bob’s story is highly predictable. I wonder what defensive tactics we’ll see from US insurance companies as they feel more and more threatened by medical tourism.

Bob and I spoke at my house in Quezon City. Thanks to Bob for some of the photos.

Bob’s story

Bob at lunch

Bob at lunch

In 2006 I developed a basal cell carcinoma on my face. It looked like a pimple, but it wouldn’t heal, and it got larger and larger. When I had my executive physical in Korea, I was referred to a dermatologist who did a biopsy and told me it was a basal cell carcinoma. It would never metastasize, never enter my lymph system or my blood stream, never travel to my lungs, my vital organs or my bones. It wasn’t dangerous, but it wouldn’t heal. He told me he could remove it on my Korean National Health Insurance. It was getting pretty ugly. The removal was just a two-hour procedure done under local anesthetic. All during the surgery the doctor and I had a pleasant conversation about living and working in the US and Korea. I did notice that the carcinoma was a less than dime-sized lesion, but the doctor had to tunnel under the skin on my cheek almost over to my ear and almost up to my eye and almost down to my chin. He kept taking biopsies and sending them out for results in order to determine that there were no cancer cells left in my face. I had a four-inch scar on my face which within two years wasn’t even noticeable.

Probably about 2012, I got a spot on my back to the left of my right shoulder blade. It felt similar to the earlier one. Remembering how slow-growing that was I just told myself I’d get around to having it removed eventually. Two years later when I was getting ready for my one-year travel adventure throughout Southeast Asia, I decided I should probably have it removed. My primary care physician referred me to a dermatologist and surgeon, Dr. Patel, an ethnic Indian physician in his seventies who’d been practicing in Massachusetts for forty years.

He said, “It looks like a basal cell carcinoma to me, but it’s so large that it’s going to need a skin transplant. When are you going to Asia?”

The scar from the first carcinoma

The scar from the first carcinoma

“September 17. I’ve already got tickets.”

“We don’t have time now because a skin graft is a delicate operation. You have to have the area immobilized for some time after to make sure that it takes. You’re grafting your own skin, but it has to establish a connection with the nerves and blood vessels. Really, you have no time. You should probably reschedule your trip.”

“Well, I had great experience with surgery in Korea. Maybe I’ll get it done there, maybe in Thailand or the Philippines.” I was still thinking it would be a simple procedure.

That led to a discussion about overseas surgery. He seemed very enthusiastic and proud of India’s growing reputation for medical tourism.

I said, “Since these things are slow-growing and never fatal, I might come back a year from now.”

“It’s going to be about 30% bigger, but you do have that option,” he said.

When I left on my trip the carcinoma had gotten larger and more ugly, but it never bothered me. If I took a hot shower or I rubbed it against the sheets, the scab on top would occasionally come off, and it would bleed a little.

Three months into my trip, it suddenly started getting much bigger, bursting and bleeding every couple of days. I was staying in different hotels every day. I bought two bath towels to place over the hotel sheets so that I wouldn’t bleed on the sheets. Some Asian countries can get very fussy about stains or a cigarette burn on their linen. I had an argument with the Hotel Stella in Cebu, Philippines, which wanted to fine me $17 because I hadn’t had time to wash blood from a towel before I left.

About four or five months into the trip I was in the Chulalongkorn Hospital, the finest teaching hospital in Bangkok. I got in line and went through a screening, and the doctor told me I had to get it done right away, I should come back and he’d schedule surgery. In the hotel I was filling out the hospital forms when I came to the section which said, “You must have 60 days remaining on your entry visa or we will not perform any surgery.” Thai immigration regulations are very cumbersome and very rigid, giving you a fixed number of days you can be in Thailand over various periods of time. I’d already used up a lot of time. So I went to Vietnam for a couple of weeks and tracked the number of days I’d been in Thailand during the last ninety days, and I saw that surgery in Thailand was out of the question. In the meantime the carcinoma had become a bloody mess, seeping and weeping and smelling.

I contacted my friend Carol Dussere about coming to visit earlier than we’d planned. She’d had fantastic experience with surgery in the Philippines—and eye surgery at that. I arrived in Manila on February 19. Carol had made an appointment at a beautiful medical facility, The Medical City in Ortigas. There are twin towers surrounded by a couple of other medical buildings and a really fully equipped, state-of-the-art hospital, very well staffed, covering every discipline available in medicine. It’s one of the leading hospitals in the country.

Dr. Lourdes Ramos

Dr. Lourdes Angliongto-Ramos

I saw Dr. Lourdes Angliongto-Ramos, the head of plastic surgery. Like Dr. Patel in the US, she was concerned that the carcinoma was so big she might have to do a skin graft, but she also thought there was a 30% chance she could just do a flap operation. During the flap procedure they remove the carcinoma in concentric circles leading out from the lesion, and do lots and lots of biopsies, stopping only where there is no cancer in the entire circle. The surgeon moves live skin and fat cells, tunneling under the skin and leaving a large area detached from the flesh, then filling up the hole made after the carcinoma was removed, in this case about a four-inch by seven-inch section. After that the skin and flesh are dragged forward and up and over from the different sides and attached where the carcinoma was. The advantages are that there’s usually not a problem with skin rejection or infection, and the hole is filled to a great extent with your own fat, whereas if you take tissue from your thigh and transplant it to your back, you’re got two very different kinds and colors of tissue and textures with no fat tissue for filler. Dr. Angliongto-Ramos said it would be very noticeable on my back, and I’d have a rectangular scar on my thigh where the skin came from. That was why she strongly favored the flap operation, but wouldn’t know until the surgery whether it was possible. Off the top of her head, Dr.  Angliongto-Ramos listed everything I would need from the surgery and recovery and hospital stay and said the bill would be between $4300 and $4700. This included seven days in one of the best hospitals in the country, food, nursing and everything. The following week I’d have surgery.

The pre-surgical preparation and testing was impressive. Dr. Angliongto-Ramos wrote what looked like prescriptions for blood work, pulmonary and cardiological work and chest x-rays. Then she sent me downstairs to an outpatient clinic in the next tower, where I took a number. Filipinos are both very kind and respectful to senior citizens, and there were senior priority queues throughout the hospital, so I didn’t have to wait very long for any procedure. I’d get in line, take a number and check my number on the video screen to see what to do next. I’d go to the cashier to pay, wait until I was called and have the test. I did probably three or five tests the first afternoon, went home, returned and found I had an appointment wiFth the cardiologist who was in charge of my pre-surgery screening. He sent me out for a couple of other tests. After a couple of day’s break, I learned that I’d just screwed up the system because the electrocardiograph would take so long. But the technicians moved heaven and earth and finally gave the cardiologist an unsigned, unofficial reading which he used for my clearance, knowing that the final report would be in before the surgery.

Then I met with an anesthesiologist. We reviewed my allergies, my history with anesthesia and my family history with anesthesia. He explained what would likely be used and gave me a couple of skin-prick tests. That was very good because my aunt had nearly died from anesthesia thirty years before during a very simple procedure at the hospital in Berverly, Massachusetts. Every time my mother had surgery her blood pressure dropped dangerously low, and that had happened with me too. Not only was the preparation incredibly thorough, these tests—it was pay as you go—were so inexpensive. A series of chest x-rays, including the scans and reports in English, cost me 500 pesos or $12.50. Other tests were five dollars here, four dollars there. If I’d been buying candy, I’d have bought a truckload. The most expensive test was the very involved electrocardiography done on a very expensive machine and with well-trained technicians reading these results, and that whole procedure was only $100.

I’m not used to going to doctors. I went for thirty years without going to a doctor. The only surgery I’d had prior to the first carcinoma was an appendectomy in 1967. I stay healthy, which is so much a state of mind in my opinion. The strongest thing I’d taken in the last forty years was aspirin, which is an amazing painkiller. I insisted to the anesthesiologist that I be given the absolute minimum of pain medication and that I be able to stop getting it at any time. He agreed. Later I got into discussions with nurses and floor doctors who just couldn’t believe I wanted to avoid pain medication. I got it stopped as soon as I got out of the operating room. I figure pain is your body’s way of telling you something. If you move and it’s painful, don’t move. I healed very quickly and wasn’t constipated from the narcotics. It was a great experience.

The day before the surgery I checked in. The room looked just like Beverly Hospital where I’d brought my mother many times, truly a state-of-the-art facility, but there were subtle differences that I hadn’t really thought about and wasn’t prepared for. As in other Asian countries, in the Philippines a hospital patient has a “companion” staying with them twenty-four hours a day—a domestic helper, a relative or even someone who’s been hired for the occasion—so the nurses are not tied up doing things that a layperson can do, like emptying a bedpan or getting a glass of water or picking up something. They staff accordingly. There aren’t as many floor nurses or aides as there are in the States. I think there was little bristling on the part of the desk staff because in their opinion it was not their job to dump my urine bottle or get me a knife and fork from across the room. It wasn’t their job to do many of the things I couldn’t do for myself the first few days. But several of the staff went out of their way to help me and make me comfortable and make me not feel guilty about it. It was obvious that I hadn’t planned that part.

The nurses' desk

The nurses’ desk

When I was brought out of surgery and returned to my room, the urinary catheter came halfway out. As soon as I came to I was in agony. I was using my nurse call button, but the call didn’t get a quick response because everybody assumed my companion would come to the desk for anything important. The other thing I didn’t know was that the communication systems are different. Everything goes through your surgeon, who has doctors who are assigned to cover her patients when she’s in surgery or at home. With the slightest movement came intense pain. I kept pressing the button. Responses were mixed. A nurse would come in, and of course in the Philippines for most people English is not their first language, although it’s a strong second language. Between an American English speaker and a Filipino English speaker there can be communication problems regardless of education level.

So there was confusion. The surgeon had ordered the catheter to stay in for three days. No one was authorized to remove it. Only a doctor could touch it, not even a nurse. On my fourth call the nurse came in, and I explained that I was looking up on the internet how to remove a frigging catheter myself. That’s how bad the pain was. I knew I needed a ten-milliliter syringe to put in the tube and remove the sterile water in the balloon in order to pull the catheter out, but of course I didn’t have access to the syringe. Finally they contacted the doctor who was assigned to fill in for my surgeon. However, her primary purpose in life was to avoid disturbing the surgeon at home. She was playing pain chart games with the nurse. “Well, find out is the pain a four or a six or ten.”

So the nurse was going back and forth. At this point she was convinced that there was something wrong. “Yes, he’s in great pain, and he really needs to see you.”

Bob after surgery

Bob after surgery

She refused to come and look at it. Finally, I went on a bit of a rampage. With the nurse’s full support, we upped my pain estimate to eight. According to hospital guidelines, at seven or over the doctor had to come and see me. She came, but she obviously still didn’t want to disturb Dr. Angliongto-Ramos. I’m the last one to bother the doctor at home, but it was agony. Finally she was persuaded to call, and Dr. Angliongto-Ramos authorized removal of the catheter provided that I promise not to try to get out of bed. They removed the catheter and gave me a urine bottle, which was a great relief.

The care was fantastic overall, and the sanitation was great. The food was amazing. I didn’t get a choice of food, but it didn’t matter. Later I found out the dietician had decided I was overweight so I should be on a low-carbohydrate diet, but I hadn’t noticed. There were lots of great soups, pork soups or chicken soups that you spoon over rice, and lots of vegetables. They fed you five times a day, three meals plus a mid-morning snack and a mid-afternoon snack. I couldn’t get over it. I don’t like fish so there were a couple of dishes I didn’t eat, but it was not a problem. After a couple of days I learned you could order room service twenty-four hours a day.

A readers writes:

Hi. I happened to awaken early this morning and so had time to read Bob’s story. Also, of interest due to my medical past and the issues with healthcare. Fascinating the differences between the cultures.What remains the same in both, however, is the godlike status of the surgeon who cannot be disturbed post surgery for anything less than an 8 on the pain chart. At least his pain didn’t cost him thousands upon thousands of dollars! I hope that Bob is recovering nicely.


In my experience, the attitude of the junior doctor in question is very, very much in the minority, actually if you discount punctuality the only one I’ve heard of among lots of helpful, caring, humble people, whereas in my experience in the States the godlike attitude seems to affect even medical students, including one of my former roommates. Bob is doing well.

A reader writes:
Forwarding to my husband and a few others who work at Medical City. Thanks, Carol. Hope your friend is well.
Bob’s doing well and following doctor’s orders to the letter.
A Medical City doctor writes:
First of all, congratulations on that detailed experience by your friend Bob. Nice to read a story which absolutely hides nothing. Experience wonderful or not is always valuable more so medical as this provides help to others as they too in the future may need it, and don’t we all in one time or another? I do agree that there is a chain of command in the medical hierarchy and this will continue to do so with good reason, but one thing is certain and that is cultures do differ. Having written that I can say that the care given here usually is more compassionate. Nice to know that Bob is doing great.


Thank you. I agree. Yesterday I had a reaction to the sugar shock test at Megaclinic. The staff immediately had me in a wheelchair and on a bed, took my blood pressure, gave me a electrocardiogram and sent in a doctor . In a short time I went back to the lab for the second blood extraction. When I thanked the technician for her kindness, she said, “We love you.” The doctor saw me again. Then I had my badly needed coffee and breakfast. That’s the kind of treatment I’ve had here. At home on the Internet, I found that passing out–which I came close to–is a common reaction to the sugar shock test, which would be why the staff wouldn’t let me leave the lab area.

A reader writes:

Good to know local medical facilities and health care specialists and teams are appreciated One should realize, though that the cost of less than US$5k, including taking lab tests for the cost candy, is still outside the reach of the regular working man in Manila. That amount is still over 200k Philippine Peso, more than half of our annual wages. How I wish we all could just afford ‘urgent care’. May I share this post with my friends who work in TMC?


I understand. That’s why I inserted that bit into the introduction about national hospitals and people who can’t afford them either. If I need any long-term care myself it will be in a national hospital where one of my Medical City doctors practices. Please share the post with as many people as you like. Perhaps they might do a pamphlet for foreign patients who don’t understand the Filipino companion system or the doctor system.