The doctor will see you now… on screen

“What can I help you with?” (Photo by National Cancer Institute on Unsplash)

Bonjour, and welcome to Very Online, issue #10.

It’s been two weeks since I received my second COVID-19 vaccine booster shot. I registered online, waited two days for confirmation and other details via SMS, then drove to the SIVC/NPF Mega Vaccination Center in Parañaque City the next day. There, I waited for an hour to enter the vax center premises, but the time from entry and QR code check to jab and waiting period was less than 30 minutes. I was in my car the whole time and got my shot while sitting in the driver’s seat, much like how you’d go for McDonald’s drive-thru.

“Can I have a Moderna booster to go?”

The only adverse effects I experienced with this (Moderna) booster were a sore injection site – consistent across four vaccine shots – and a large and painful lump in my left armpit (well, that’s a first), plus some fatigue. I’m thankful these three were it for me; I’ve heard of others who had it worse.

And I’m doubly thankful I still haven’t contracted COVID-19. But with all the subvariants and mutations popping up worldwide, my luck will run out soon and I’ll need all the protection I can get. I belong to the A3 priority category of the Philippine population – the group that lives with existing comorbidities. I run the huge risk of having a severe case if/when I do get COVID-19.

Obviously, I’m not gonna play stupid games to win stupid prizes.

BTW, the SIVC/NPF drive-thru site will be open only until July 31. If you’re A3 like me and super tired of waiting for the Department of Health to give us clearance for second boosters, register and go there now!

I’ve also been told that SIVC/NPF has a history of offering primary and booster shots to at-risk groups with or without DOH clearance, and ramping up their approvals during case surges, so…


Before getting my second booster shot, I used SIVC/NPF’s healthcare partner Zuellig Pharma‘s services – via its eZConsult app – to consult with a doctor. I was concerned about whether it was a good idea to mix Sinovac (primary), Pfizer (first booster), and Moderna (second booster) vaccines; and what the overall effect would be given the medications I’m taking now (for hypertension and SSCD-related vertigo). Then I did another telemedicine consult via the AIDE app for a second opinion.

The two doctors I consulted with (an internist, and a general physician) said that if I already had the option to take a second booster, I’d do well to take it. My drug interactions are at an acceptable level, but the Philippines’ COVID-19 infection and vaccination situations are becoming more unwieldy by the day. Government and private vaccination sites nationwide are closing, only 15.7 million of the 71.4 million fully vaccinated Filipinos received booster shots, we as a nation are so brand-conscious that it’s ridiculous at times (give me Pfizer or Moderna or give me nothing!), testing is going down, cases here are going up, and no one does social distancing and proper masking anymore. Things will get worse before they get better, and everyone’s already tired.

And thanks to my chatty internist, I now have a better idea of what’s going on where he is (Pampanga, in Central Luzon). While we down south in Metro Manila are fretting about second boosters, most Filipinos are still on their first boosters with not much takeup. That, and it’s a struggle to get people to take even the primary vaccine shots – the Dengvaxia controversy is still pretty fresh on people’s minds, and they now think all vaccines are bad.

More than that broader situational view, my audio-only consult with the internist ran an hour long instead of the usual 15-30 minutes. That was because we got along fairly well, but also because he did his due diligence. He noted my cardiovascular and hearing/balance history, all my current medications, and the lab tests I should do once the COVID cases ease up again. He listened to everything I said, and did not wave away or dismiss my concerns and opinions like older (male) doctors would. After our call, I had updated prescriptions and lab-test orders, and a tailored game plan for both my second booster shot and afterward.

That’s in stark contrast to my second-opinion consult, done via in-app text chat. We were done in 15 minutes because the general physician took only a brief medical history, and supplied only short answers to my questions.

Don’t get me wrong – I’m not blaming the physician in any way. I might have had better results if I had a video or audio call with her instead of just text chat. Or maybe not.

Either way, we really roll the dice with telemedicine.

Pros and cons

“Well,” you may ask, “why didn’t you see your actual cardiologist and ENT for clearance?”

“Because that will take more time than I have, and I have to make a decision now,” I’d say.

For me, that’s the biggest advantage of telemedicine: it goes much faster, and I’m waiting in the comfort of my own home. Pre-pandemic, I would have to call or text my doctors’ secretaries to set up an appointment a few days or a week down the line. Then I’d arrive on time but end up waiting for hours for my turn, only to be rushed because there are more people coming in after me.

(My longest waiting time was five hours, for my OB-GYN. FIVE HOURS. Imagine what you can do in five hours.)

Compare that to telemedicine, where I can schedule an appointment on an app for the same day, then wait for only a few hours for my turn. That’s impressive – and I say this as an eternally impatient person.

And then there are the problems related to choice.

I first used AIDE in mid-2020 to consult with a neurologist to rule out a stroke after a particularly nasty bout of vertigo, vomiting, and cranial and inner-ear pressure. Then I learned of other platforms like NowServing (which my cardiologist uses), the aforementioned eZConsult, KonsultaMD, Lifeline, Medgate, Zennya, and other DOH-approved third-party providers.

Government programs like Bayanihan e-Konsulta (then with the Office of the Vice President under Leni Robredo from April 2021-May 2022; now with her Angat Buhay Foundation) went with Facebook and Messenger to accept messages and assistance requests, then these cases were diagnosed and given prescriptions online. COVID-19 Care Package Kits were also sent out to COVID-positive patients, and volunteers monitored their cases all the way to recovery.

By the end of Robredo’s term as Vice President:

…a total of 2,741 volunteers were engaged in the program, processing over 56,262 requests from all over the Philippines.

p. 115, “End of Term Report of the Office of the Vice President, 2016-2022

(FYI: Bayanihan e-Konsulta’s back on, folks. 1,100 volunteers “in less than 20 minutes“? Sweet.)

For its part, the Philippine Department of Health had >100,000 patients consult with it in Q1 2021 via Cisco Webex. Cisco Philippines also noted that the government agency had “17,400 sessions over Webex in 2020, equivalent to more than 2.3 million minutes of meetings and teleconsultations.”

Major Metro Manila hospitals also adapted by quickly cobbling their own systems. Makati Medical Center, St. Luke’s Medical Center (Quezon City and Bonifacio Global City), The Medical City, Asian Hospital, Cardinal Santos Medical Center, and the Ospital ng Makati all went for a mix of online landing pages + landline calls + consults via Zoom or Microsoft Teams + payments via virtual wallets. These systems aren’t as cohesive as the healthcare apps above, which cover booking and prescriptions and fill-outs all the way down to payments. But they’re better than having nothing.

In a free market, everyone can make and maintain their own telemedicine apps and systems, with medical services paid for or not. That means both healthcare professionals and their patients have plenty of choices – but also plenty of UIs and procedures to learn, and quirks to put up with.

For example, some apps would close while I’m using them. I would have to reopen then and sometimes, do everything all over again. And for some apps, I would try to download a prescription or lab-test request, but my phone won’t tell me where it saved them.

Some doctors and clinics also – unwittingly or intentionally – brought their bad habits to telemedicine. The older/senior-citizen doctors have no time or patience anymore to learn new technologies, so they would insist on communicating only via Viber. I heard of a few who simply gave up and retired, closing their clinics when patients (and their staff) needed them the most.

Before the pandemic, my cardiologist’s waiting times were so bad, his secretary had to hand out those buzzer devices used in restaurants’ queuing systems.

Of course, my friends immediately asked if I got free coffee or bread for my three-hour wait. 😉

It took me months to get ahold of him mid-pandemic, which meant I was ‘consulting’ with my father’s cardiologist for an emergency case (again, via Viber) in the meantime – without him ever having even met me. Then I couldn’t just straight up ask my actual doctor for a telemedicine consult. I had to go through his new secretary, who insists on using goddamn Viber for appointment-setting on NowServing.

The kicker was I showed up on time online – and my doctor talked to me two full hours later, and that was after I told his secretary to just cancel my appointment because I was ailing and now fucking mad. And then I paid my hefty ₱1,000 consult bill through bank transfer.

Clearly, telemedicine favors younger and relatively optimistic doctors (and their patients). They thankfully haven’t acquired these bad behaviors yet, and they are digital natives who can easily and quickly learn new platforms/UIs and skills.

I referred my aforementioned neurologist to a close friend, and she said the doctor did good work on her too, and was pleasant and meticulous all throughout. The Pampanga internist charged only ₱300 for our audio chat, showed up on time, and had a great bedside manner. And while both the neurologist and internist do hospital rounds and have their own clinics, they do telemedicine from home (including the digital paperwork) – which brings down their costs, which then means there’s less of that passed down to me.

Compare that to them keeping hospital hours + clinic rental, maintenance, and utility fees + specialty equipment + secretaries’ salaries, and telemedicine obviously wins. For patients like me, the old method would have me pay ₱500 to ₱1,500 per in-clinic consult, depending on the doctor’s years of experience and place in the hospital hierarchy. Then tack on a few thousand more for medications and tests and follow-up tests, and two to three more digits for parking fees.

If telemedicine wins in efficiency, costs, and access to doctors outside my city of residence, what’s the verdict for the actual practice of medicine (expert examination, diagnosis and follow-ups backed by decades of study and clinical practice)?

As uncomfortable as it can be, nothing compares to physically being in a doctor’s office and consulting face-to-face. It feels more personal, more involved, and more informed. The doctor is right there, you can describe and/or show them what’s bothering you and they’ll see what you see, and there is little room for misunderstandings. It’s also easier to proceed to lab tests and other procedures straight from your doctor’s clinic.

The telemedicine boom in the Philippines happened mainly because the pandemic ensured we didn’t have any other option. Our hospitals were overrun with COVID-19 cases; and the healthcare professionals who bravely stayed in the country were truly at high risk, overworked, and underpaid. ‘Back then’, everything was a risk.

So for those like me whose conditions were not related to COVID-19, all in-hospital checkups, tests, and procedures were postponed indefinitely. If you can’t postpone it, you’re stuck with telemedicine, such that on KonsultaMD, online consults with doctors went up a whopping 450% by July 2020.

And if you really had to go to a hospital designated as a pandemic hub (as I had to do eventually, for CAT scans, MRIs, and hearing/coordination tests), you had to fill out clearance forms in advance every time – and you must accept that you may contract COVID while you’re there. Damned if you do, damned if you don’t.

Other concerns

Once again, I am aware that I am speaking of telemedicine in the Philippines as a person of privilege. But I also know that the demographic and sector telemedicine is supposed to help first – those in rural areas, the marginalized, and the underemployed – urgently need improved access and tailored tools for it.

This March 2022 story on BusinessWorld scratches the surface of telemedicine and its shortcomings. It raises SMS telemedicine and 24/7 voice-call hotlines as equally viable options for access, especially for Filipinos who rely on Facebook’s Free Basics. In a country like ours with shitty and expensive internet, text and landline calls would always be more reliable and cost-effective.

The questions of gadget access and digital literacy were also raised in that article and in this November 2021 article in the Frontiers in Pharmacology journal. Think about it: how can the underprivileged do telemedicine if they don’t have a cellphone to begin with, or the needed knowledge and adaptability for new tech?

The Philippines is also highly dependent on exporting people to survive, and has been for decades. That includes healthcare workers: doctors, nurses, therapists, and caregivers. Remember when the government banned these workers from leaving the country in April 2020? Yeah, that happened. Basically, we have too many patients needing healthcare that few professionals can provide, or are willing to stay to do so:

…the shortage of doctors is also a problem, according to Jay Fajardo, chief executive officer and co-founder of telehealth platform provider Medifi.

The capital region has 10 doctors for 10,000 patients, but in the countryside, the ratio is down to fewer than three doctors, he told an online forum last year. “That needs to be addressed.”

Arjay L. Balinbin, “Telehealth offers Filipinos a lifeline amid pandemic“, BusinessWorld, March 3, 2022

Frontiers in Pharmacology also named the Philippines’ lack of legal frameworks for telemedicine (with app-makers and third parties taking the initiative instead) as a barrier, and the need for telemedicine to be included in medical programs and residencies. Both will take a long while to sort out and have them bear fruit. But it looks like telemedicine is here to stay, even after COVID-19 ends… Assuming COVID-19 ends.

Punyeta, this pandemic better end. With me (and you) still alive. Until then, take care, and maybe have a video call with your doctor(s) to keep your records and status updated. And always ask them how they’re doing. The situation’s been pretty fucked up for them, too.

Heyyy 👋

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