The Cost of Integrity

 A few nights ago, I had a conversation with a very good friend I rarely see these days. He recently resigned from his corporate post after decades of working for the company. I guess those in sales, especially those who are pulled away from their families because of their jobs, suffer burnout the most. Anyway, after resigning from this huge company, he became the chief of staff of our congressman, who is also his close friend from way back their college years.   So from corporate, my good friend changed into a completely different path: that of politics. 

He just started his job in the congress last July 1. He then had firsthand experience of the systemic rot that pervades the hallowed halls of government, especially congress. He saw how contractors literally bring bags of cash into congressmen's homes and offices, how for every project, various politicians earn a percentage of the total project fee (1% of 1 billion is a huge amount, mind you), how the construction companies already know the projects that are up for bidding way before the budget gets approved. Corruption is already so ingrained and commonplace that even the staff of these congressmen get their own share as well.   For every meeting, they get an envelope with a wad of cash. And yes, the pressure from the higher-ups is high. If you oppose the current administration, your district does not get budget allocation for your projects, no matter how noble, urgent, and necessary those projects might be. And yes, they are required to list flood control as their priority projects. Tsk, tsk.

My good friend, idealistic, kind, and patriotic as I have always known him, could not stomach it all. He tendered his resignation and will step down from his post once August ends. He only managed to stay for two months. Because that’s what a rotten system does to good people: it drives them away. Because if they stay, tiny cracks form in their walls of integrity until they eventually collapse. And they, too, become part of the very system they once swore to fight.

I am very proud of my friend. In a place where power tempts and money blinds, he chose to walk away. And that, I think, is the cost of integrity: you have to know when to walk away. As for me, I am just happy that my friend is back home, where we can climb mountains and dream about change again.

Divine Justice

 Today, I want to believe in divine justice. I want to believe that the universe keeps a quiet ledger, that the good we put into the world comes back to us, and that evil eventually devours itself. I want to believe that those who toil under the sun, breaking their backs and sacrificing their dreams, will one day reap what they have sown.

But lately, that belief has been difficult to hold.

I have been watching old Kara David documentaries that leave me gutted. Children smashing glass bottles so they can sell the shards and take home fifty pesos a day. Agta kids diving into freezing waters in the middle of the night for pugita, splitting four hundred pesos among nine of them. The children of sakadas laboring under the heat of the noontime sun, earning thirty pesos to buy rice for the family. It is poverty so stark it has no poetry, no silver lining, no redemption. Just survival.

And then, in the same breath, the news parades the “success stories” of people now embroiled in billion-peso infrastructure scandals. Ghost projects. Substandard flood walls. Billions siphoned away from funds meant to protect the most vulnerable. These same people are filmed stepping out of luxury cars (which they bought because they like the umbrella or the wine glass), displaying their bags, their watches, their lives of excess. And they call it wit. Strategy. Business acumen. Media even sells it as something aspirational, an inspiring “rags to riches” tale for Filipinos who have been working honestly, grinding quietly, and still barely making it to the next day.

It is devastating, this betrayal.

I want to believe that there is a cosmic reckoning. That the ones who steal from the poorest among us will suffer, that they will taste despair so sharp they will wish for death. I want hell to exist, and for it to start early for those who profit from the hunger and broken dreams of others.

I want divine justice to be real. I want the universe to intervene, to hurl its thunderbolts and demand penance from those who rob us blind. And yet, I also know that divine justice, if it exists, is slow. Sometimes it never comes.

Which means the weight falls on us. If heaven does not intervene, then perhaps it is our responsibility here on earth to choose better, demand better, be better. 

Because corruption does not begin with billion-peso scandals. It starts small, quiet, almost invisible. It is the little unethical acts we normalize until they snowball into systemic decay. A pharmaceutical grant in exchange for prescriptions. A shortcut offered for a favor. A “gift” accepted because “wala namang mawawala.” These things seem harmless, but each one chips away at our collective integrity until we wake up in a country where stolen billions barely shock us anymore. Corruption does not exist only in government. It exists in our own lives, and thrives wherever we allow convenience to trump conscience. 

Corruption pervades every layer of society because we allow it to. And if we keep excusing it saying “wala namang masama,” “normal na ’yan,” “lahat naman gumagawa niyan”, then we are part of the same machinery that breaks this country apart.

Divine justice will come someday, I am sure of this. But we don't have the luxury of time to wait. The reckoning must begin with us. We need to examine our own lives.  We must examine our own ranks, whatever profession we belong to, whatever job we hold. We need to stop normalizing small acts of dishonesty, to stop glorifying ill-gotten wealth, and to teach our children that success without integrity is hollow. Because if we don’t, the cycle continues. Our people continue to suffer, while the corrupt build their kingdoms above our silence.

And finally, we need to demand accountability. We need to seek transparency. We need to remind our government officials who they are supposed to serve. We need to show them that those who are corrupt suffer the consequences. It doesn’t take divine justice. It only takes a people who refuse to stop watching, who refuse to forget, and who refuse to forgive.

The Case For Asking

 

If we are shopping for a new phone, we ask first, "Magkano po ito?" If we are hiring someone to build our dream house, we ask, "Magkano kaya ang aabutin nito?" If we ask a lawyer to represent us in court, we ask, "Magkano ang PF mo, Attorney?" Even when we buy mangoes at the palengke, we ask the price before we negotiate.

So why is it so uncommon, almost taboo for patients to ask doctors, “Doc, how much do you usually charge for your services?”

Doctors don’t have standard rates across the board. Our fees are shaped by a mix of factors: complexity of the case, urgency and risks, type of institution, location of practice, years of expertise, scope of services, and even personal values and principles. And ahh yes, included in that list is the difficulty and attitude of the patient and the family members (I'm smiling, but not joking).

Some of us deliberately charge below the norm because we believe that healthcare should be accessible. Others match industry standards to ensure long-term sustainability: for themselves, their staff, and their families. And yes, some charge higher, and may have very good reasons for doing so. These could include the rarity of their specialization, the intensity of their training, or simply the number of hours they spend at work and in continued learning.

Over the years, various medical societies have attempted to standardize professional fees, releasing guidelines and tariff schedules to help physicians navigate the complex landscape of pricing. But our profession is unlike others, it is both a science and an art, a business and a calling. The truth is, in these offical society statements, the disclaimers are often longer than the prescribed rates. “Depends on the case,” “Depends on the hospital,” “Depends on the procedure”, "Case-to-case basic", "Upon the discretion of the physician". We’ve all said those lines before. Because pricing in medicine is never one-size-fits-all.

Every doctor is different, and so is every patient. Which is why transparency is key. And the best way to begin is to simply ask.

So my proposal to this perennial professional fee issue is simple: wouldn’t it be better if we normalized the question, “Doc, may I ask how much your PF is for this kind of case?”

It is not offensive; it is practical. It empowers the patient. It opens the door to a respectful conversation where the doctor can explain the range, the rationale, and any possible caveats, such as added procedures, complications, or extended care. It also avoids later awkwardness, or worse, assumptions of greed.

Surgeons and anesthesiologists can do this. Why can't internists?

Patients deserve transparency. But transparency is a two-way street. If a patient is expected to trust a doctor with their body, health, and sometimes even their life, then trust must also extend to finances. And when that happens, when patients ask before doctors render their services, and when doctors answer with honesty and fairness, we meet each other with dignity. There’s no guilt. No awkwardness. No insult. Just mutual respect.

It is true that the physician-patient relationship is a fiduciary one. It is built on trust, shaped by the ethical imperative that doctors always act in the best interest of the patient. And whether we like it or not, this relationship is inherently unequal. The physician holds the medical knowledge, the tools for diagnosis and healing, and often, the authority within the room. The patient, by contrast, is vulnerable: physically, emotionally, and sometimes financially.

This is precisely why transparency matters.

Even with this asymmetry, or in my opinion, perhaps because of it, we must strive to bridge the gap in all the ways we can. And one of the most accessible and respectful ways to do that is to talk about money: clearly, kindly, and early.

To empower patients is not to deny that the relationship is unequal; it is to acknowledge it, and then to offer clarity as a form of care. When patients feel informed about their treatment and about the costs involved, they feel safer, respected, and more in control. And when physicians are asked respectfully, not second-guessed or assumed to be greedy, we are reminded that trust can be mutual.

And once the patient and the family are informed, they can now be empowered to negotiate. To me, and I am not speaking for the entire profession, it is never wrong to ask if something can be made more affordable. But context matters. Timing matters. Tone matters. And assumptions, especially the ones made without knowledge, can bruise even the most compassionate hearts.

So if you’re a patient, ask first. I hope that while you trust us with your health and with your lives, you also trust that we are not doing what we do to enrich ourselves. 

As for me, I can promise that when you ask, I will answer clearly and with care. And I will listen to your negotiation with compassion and justice. 

A Healer, Not a Haggler

The truth is, I charge way below standard professional fees. Many times, I don’t even collect, and often, my patients happily carry a stash of medicine samples from my clinic, which cost more than my professional fee. I’ve had patients walk out of the clinic saying, “Hala, tun lang PF ni Doc?” Relieved, surprised, and maybe a little guilty. Some of the colleagues I have worked with have even asked the nurses, "Mabubuhay kaya si Jean jan sa PF nya?"  I take that as a compliment.

I chose this profession because I wanted to help people. And yes, because UP has "brainwashed" me into making serving the underserved my ultimate goal, I take that goal seriously.

So when someone assumes, let me emphasize the word "assumes",  that I must be charging too much, it stings. Not because of the money, but because of what it implies: that I need to be bargained with. That this profession I have loved deeply, trained for with both discipline and delight, can be haggled down like produce in a palengke. That something rooted in compassion and science, something I’ve poured decades of curiosity and care into, needs to justify itself before it is paid for.

Let me be clear: I understand that times are hard. I understand what it’s like to count coins for a consultation. I have waived my PFs many times, without being asked. In fact, I price my fees in such a way that patients can retain their dignity without needing to beg. Because if people are sick, and made poor because they are sick, then the least they deserve is to keep their pride. I feel sad when they have to set their pride aside to ask for discounts. So I have always made sure that my PFs are fair and lower than standard rates, rooted in the principles of justice, compassion, and kindness.

But what I struggle with is the assumption that I must be overpriced. That I must be earning too much because I am charging too much. That I must be made to prove I’m not greedy before I even open my mouth. 

This week, the internet lit up with a commentary from Ramon Tulfo, who called out a doctor at the Philippine Heart Center for allegedly “overcharging.” Many were quick to judge. Few paused to ask what the full story was. Medical groups stood by the physician, stating that the professional fee was fair, compassionate, and reasonable. That the doctor had, in fact, already lowered it.

We do this all the time. Quietly. Out of compassion. But that compassion is neither limitless nor owed.

Doctors are people, too. We have bills to pay, families to raise, and dreams to chase. What we do is a vocation, but that doesn’t mean we should be asked to live off vocation alone. We cannot keep patching a broken healthcare system with our own self-sacrifice. Compassion should not require self-erasure.

And when the system fails, as it often does, it is not just the patients who suffer. As my UP-NTTCHP professor, Dr. Nemuel Fajutagana, so powerfully put it: "If we truly value life, we cannot keep patching a broken system with the sacrifices of those who hold it together. The dignity of patients matters, and so does the dignity of those who care for them. If we want a healthier Philippines, we must fix the system, , not break the people who sustain it."

If someone took the time to ask, “Doc, how much is your PF usually?” And then, after hearing the fee, said, “Would it be possible to lower it a bit?” Now, that’s a negotiation. That is honest communication. And I appreciate patients and their families when they do that.

But asking for a discount without even knowing the price? That is so disheartening. And when it happens after the first or second visit, after trust has supposedly been built, it is even more infuriating. Because that’s like handing me a message that says, “I trust you enough to save my life, but not enough to pay you fairly.”

Worse, it feeds into a painful, misguided narrative that medicine is now just business, that those who took an oath to heal have turned it into a profit-making, self-serving machinery. That the profession I love, the one many of us have dedicated our lives to with sincerity and sacrifice, has somehow gone to the dogs and that we physicians have turned into the devil himself. It is unfair. It is untrue. And it breaks my heart.

So please. Ask first before assuming I’m too expensive. Don’t haggle before hearing me out. Respect my work the way I respect your pain. Stop assuming the worst of the people who are trying their best.

I am a healer, not a haggler. And I believe we can meet each other where kindness and respect live.

This is Not Where I Belong

 

Sometimes, I wonder if I am at fault.

I was raised -- academically, intellectually, emotionally -- by the University of the Philippines. And in UP, we are taught to speak up when something feels wrong. We are taught to question systems, to challenge the status quo, to hold authority accountable, not with disrespect, but with reason, with courage. We call our deans “Sir” or “Ma’am,” yes, but we speak to them not with fear, but with mutual respect. They teach us, and we teach in return. That is the heart of the university: a place where knowledge is shared, not hoarded behind titles and rank.

That was the culture that formed me. That’s where I found my voice. But here, in this current institution, things are… different.

Here, you are expected to stay quiet. To say yes. To go along. Because you are just a “lowly” faculty member. Because questioning makes you a target. Because the system values hierarchy above dialogue. The higher the title, the less accessible the person becomes. The farther away they sit, figuratively and literally, from the people who do the actual teaching.

The other day, I attended a meeting at the main General Santos campus. The architecture and ambiance reminded me so much of UP Diliman. But the feeling was not the same. There was no familiar thrum of shared purpose. No sense of being in a place where ideas are free to roam. For me, there was no pride, no love. And when the chancellor walked in, he was flanked by bodyguards, assistants, an entourage more fitting for a celebrity than an academic leader.

And I just knew: I do not belong here.

And yet, paradoxically, I do love this university. I love my students, fiercely and completely. I love the hope they carry, the questions they ask, the fire in their eyes. I love what this institution stands for: unity in diversity, peace and progress in Mindanao, respect for indigenous cultures. Those values matter to me. They are what keep me here, still trying.

What I do not love is the system. The worship of hierarchy. The silencing of dissent. The bureaucracy that mistakes fear for order. And the slow erosion of passion in those who simply want to teach and grow.

I don’t know how long I will stay. But I do know this: I will never apologize for expecting more. For believing that respect should not be earned through silence, but through truth. For knowing what it feels like to walk into a campus and feel love for it in your chest.

And for now, I carry that love elsewhere: with my students, in the classroom, and in the quiet work that I still choose to do well. To me, that's what matters the most. Perhaps for now, I do not have to belong. I only have to do the work that I signed up for, to the best of my ability, maneuvering away from the system that I feel is suffocating. I need to focus my attention on my purpose and my students. 

Then perhaps, soon, I will find a new home. 

The One Percent

 

As physicians, we have always been taught to follow guidelines. Weigh the risks against the benefits. Always be evidence-based. We are told that the complication rate is low. One percent. Sometimes even lower. It’s the kind of number that helps us sleep at night. We tell ourselves, “Most patients do fine. Most bounce back.” And they usually do.

Until one of them doesn’t.

And suddenly, that 1% stops being a statistic. It becomes a person. A patient whose name you remember. A woman who was stable, pain-free, and smiling when you last saw her. A patient you had tried to prepare for a procedure meant to help her, not take her away from this world forever. 

She had an NSTEMI five days ago. Her troponin shot up from 500 to over 40,000. Her ECG showed dynamic changes. We stabilized her. Started guideline-directed therapy. She improved. We recommended PCI early on, but consent took time. So did logistics. And money. The usual constraints. She was finally sent to the cath lab yesterday. The interventional cardiologist's hands were competent and steady and I know I can trust her with even my own life.

Her coronary angiogram showed three-vessel disease. Diffuse atherosclerosis, with eight separate lesions that looked amenable to stenting. CABG would have been ideal, but the patient had made it very clear from the start: no open-heart surgery. It wasn’t an option she would ever consider. So when the family saw the angiogram, they agreed to proceed with PCI.

But even before the first balloon could be inflated, she suddenly went into ventricular tachycardia. It rapidly degenerated to asystole. They tried to revive her. They couldn’t bring her back.

I wasn’t there when it happened. I was in clinic, seeing other patients. So when the resident called me that she arrested and they were currently in the middle of ACLS that has extended for almost an hour already, I was stunned. What did I do wrong? I followed the guidelines. Why did she die instead?

That’s the thought that keeps looping in my head. She was stable. Pain-free. Talking. Breathing better. Eating. She asked when she could go home.

You think of all the things you could have done differently, even when you know, clinically, you did the right thing. You followed the guidelines. You prepared her as best as you could. You didn’t delay, although the system did. But it doesn’t stop the ache.

Because we live in probabilities, but we grieve in absolutes. And no matter how rare the complication is, 1%, 0.1%, 0.01%, someone still ends up being that one. And this time, it was her.

Right after clinic, I went straight to her family. What I saw broke my heart. Her two granddaughters were sprawled on the hospital floor, crying like children in the middle of a tantrum. One of them was pounding her fists. The other couldn’t catch her breath. Her son just sat there, staring into space, stunned, unmoving.The first word he asked me was: “Why?”

And I told him, as honestly as I could: “I’m so sorry. I thought she would be fine too.” I stood there quietly. Sometimes answering their questions. But mostly, just quietly. Because sometimes there are no explanations, no right words. Just presence. Just grief, shared in silence.

Sometimes I wonder if God picks His 1% with care. Not randomly, not to punish, but for a reason we won’t understand just yet. I have to believe that. Otherwise, this would all feel unbearable.

Because here’s what no one really prepares you for: Medicine will teach you guidelines and protocols. But it will also confront you with mystery, with things you can’t predict, can’t control, can’t fix. And somewhere in that tension, between evidence and surrender, we do our best to carry on.

We do what we can. We show up. We care. We remember their names.

And we try again the next day, knowing full well we’ll never know who the next 1% will be.

Doctors are not gods. And while I do my very best for every patient, I know I have a God who knows better than I do. Whose plans I may not always understand, but whose grace I choose to trust anyway.