"Orienting a health system towards primary care can enhance the continuity and coordination of care, thus reducing the inappropriate use of specialty services and improving a population's health. One of the features of primary care-based health systems is the requirement to visit a generalist – acting as gatekeeper and coordinator of care – prior to accessing further specialty care."
Velasco Garrido M, Zentner A, Busse R. The effects of gatekeeping: a systematic review of the literature. Scand J Prim Health Care. 2011;29(1):28-38. doi:10.3109/02813432.2010.537015
The concept and title captivated me while I was inside the lecture hall of the top floor of my medical school. In my mind, I was bound for specialized care as a Pediatrician, Endocrinologist or as an Emergency Physician - that was first year of Med. Most of which have been influenced by personal experiences, fascination from Biology classes, and a few seasons of Grey's Anatomy. In between all the med school grind and clerkship hospital rotations, the notion barely crossed my mind as I was deep into tertiary level of care, or at least at the tertiary care set-up. It was only towards the end of the 4th year (clerkship year) that I got reintroduced to the idea.
If you had to make a gamble with your career at its infancy, that was how the entire medical internship for me was like. Half of my internship was designed in such a way that I spent 5-6 months in a community center, serving as a health center doctor-in-training under the guidance of a Family Medicine-IDS practitioner (who served as the City/Baranggay Health Officer), and around 20 faculty specialists (FCHM, Surgery, Internal Medicine, OB-Gyn, Pediatrics, ENT, Ophtha, Derma, Radiology and Psychiatry). This what was known as the Community Enhanced Internship Program of ASMPH, the country's first and a pilot project of the school, hence the risk I mentioned.
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| Co-interns in our specialty clinic with our faculty-consultants |
It was during the morning hustle and bustle, in and outside of the clinic, that we played the vital role of triaging for the health system (at least the biggest baranggay of District 1). Does the patient need to be seen by a physician of a deeper specialty, or another center that of higher care? For some of the ordinary folks within the baranggay, that seemed to be a usual and logical question prior to and during the consultations. However, for those individuals who are used to the access of care they get from hospitals and specialty clinics, it's a matter of when and where and they'll just go (i.e. people who drive straight to the hospital for care). Most of the patients that we saw in the 'specialty clinics' came from the morning health center encounters, or the out-of-the-clinic outreach activities, while very few were walk-in.
These acts of providing appropriate care and deciding when to refer were further emphasized when I took my first airplane ride to the islands of Batan and Sabtang. I observed the struggle and success of a Doctors to the Barrios physician, who not only served as the primary care physician but more apt with the title of "medical portkeeper", since the nearest hospital was a 30 minute boat-ride away.
So let's go to the question of 'What do I do for work?' I hold the door and gatekeep. By the way, I'm a physician employed by a private clinic network. At the time of this revision, I am no longer employed in said clinic.
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| A basic healthcare team would consist of a physician, nurse, pharmacist, radiation technologists, medical technologists and clinic assistants. This is supported by a managerial team who also work behind the lines. |
In theory it sounds logical and proper: that for all medical concerns you are seen in the primary care level (not really by a general practitioner, but anyone practicing how this level of care can be given), and for the times where the provider cannot handle your condition anymore, that's when you get referred up with your health travel pass. That is where you meet your specialists or diagnostic technicians who would do more in-depth studies or provide more meticulous care for you. Sometimes, I may even give the signal that a patient needs to be admitted or be seen immediately by the Emergency Room.
Evidence may still not be that convincing or comprehensive, especially in the context of the Philippines, but the approach aims to lessen the burden of the top tiers in the health system. It also aims to reduce the expenses that the patient or their health insurance may incur during the course of the illness. A comprehensive and comparative analysis of existing health systems with gatekeeping function needs to be done to determine the concept's impact on health outcomes (morbidity, mortality, waiting time, expenses, and a whole lot more parameters of success). It also aims to provide a seamless transition of care, what we commonly coin as continuity of care. I see you in the clinic, but I want your current condition to be seen by a Cardiologist. The cardiologist, once done with his care, should redirect you back to me for an uninterrupted delivery of service.
What does it mean to be a keeper of the light? I have to be on my toes every single day because I may never know the profile and concern of the walk-in patients. "Kapag nagpractice ka naman, hindi mo naman mahuhulaan o masasabi na ganitong pasyente lang ang makikita mo". It might be a simple cough and colds (not simple anymore in the time of the pandemic), a child with the mysterious rash or discomforting bowel movements, a young female for her first pregnancy, a patient with minor trauma of either the skin, bone, or eyes. I have to be abreast with the clinical approaches and updates so I provide the freshest and best level of care for my patient, family and the community as a whole. I have to be competenent and learned enough that my patient's won't lose hope in this structure. "Dapat dumeretso na ako sa specialista, sinayang ng doktor na yun oras ko, di naman pala alam gagawin. I have to be responsible enough to avoid future imagined scenarios of specialists saying "Did this doctor really refer this simple case to me?!?". If I am knowledgeable, I am brave enough. I have my training to thank for this, and my subconscious for yanking me to study every now and then.
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| Taken during internship year I remember prescribing and titrating insulin for a diabetic patient which entailed a lengthy instruction sheet |
It further necessitates that I have to be a navigator, knowing what direction and avenue they should proceed in the referral network of the local or regional health jungle. It's a mess out there, and became worse because of the limitations. I have to be aware of the patient's financial and logistic capability, and not play favorites on certain institutions and healthcare providers. Sometimes, I transfer the care to a public physician to mitigate the cost even though the quality of care may not be the same.
I have laid down my job as a gatekeeper for now, with the hopes of coming back.
For a brighter Philippines.
