Challenges and Experiences of Young Medical Specialists in Establishing Private Clinical Practice

Introduction

Rapid development in the medical field and the health care system at present pose unique challenges to young physicians starting their medical careers. The patterns of practice are different from the olden days where doctors treat all types of patients. In the urban setting, there is also scarcity of the old-fashioned doctor who will sit and chat leisurely with patients, get to know their whole family, and make house calls. Health care in the 21st century is strongly influenced by technology, social media, sub-specialization, and evidence-based medicine. [1] 

 

In the present healthcare setting, change is notable in the following areas: a) patterns of practice; b) business of medicine; c) shift in demographics and generation of the healthcare workforce; d) emergence of sub-specialization; and e) advances in research and technology.[1] With regards to patterns of practice, in the past, physicians were largely self-employed or part of small practice, however, today’s physicians are employed by large healthcare organizations, as well as integrated delivery systems.[2] 

 

A newly graduate physician needs to choose from the different models of practice. The traditional medical practice, also known as a solo practice, is a practice without partners or employment affiliations with other practice organizations. Group practice is typically divided into single-specialty or multispecialty practice where doctors have legal partnership in managing patients, income, and expenses. And lastly, employed physician practice is where one is hired by a health system, government agency, or other business without the opportunity to become a partner. [2] . Aside from the type of practice, deciding on the location and setting of practice is another challenge. Previous studies stated the following factors considered by physicians in choosing between rural and urban settings: a) family, especially spousal support, b) access to continuing professional education opportunities; and c) ability to connect with other specialists and modern facilities. [3] In our setting, a study by Carandang and colleagues showed that experiential and non experiential factors such as personal preference for certain status, lifestyles, geographical areas, and work and leisure characteristics seemed to have the most influence on the choice of medical practice.[4] 

 

The business of medicine has changed how physicians are paid. As there is continuous shift in the demographics and generation of the healthcare workforce, more and more will seek adequate professional fees or salaried positions with benefits and working conditions that permit a work-life balance. The present is also the age of sub-sub specialization, wherein there is a specialist in just about any body part. Barondness et al. have raised concern about the splintering effects of advanced sub-specialization and its potential to increase the cost of healthcare delivery.[5] There is little doubt that the trend in medical education and training is towards refinement of subspecialty and will be the  mainstay of medicine and surgery practice. The fuel to the above changes, is the tremendous advancement in research and technology in the 21st century. Despite all these changes, the goals of establishing a clinical practice remain the same. Joson pointed out two goals of establishing a private practice in the Philippines—to earn a living in the Philippines, and to contribute to the health development of a community in the Philippines. Furthermore, the medical practitioner should be satisfied, happy, and healthy, earning enough to be a healthy person and to enjoy and sustain a comfortable living with a frugal lifestyle in the Philippines. He should be earning enough and contributing to the health development in a community in the Philippines and is healthy in terms of sustaining physical, mental, and social well-being for as long as possible or at least up to the average lifespan of a Filipino living in the Philippines.[6] Achieving the above-mentioned goals may prove to be difficult and may require tremendous resources, including effort, time, and capital, especially for a physician starting a private practice because the resources come solely from the physician himself. 

 

Internal medicine is a broad field with several subspecialties to choose from, a young physician who graduates with more than ten years of study and training would be eager to go out of the real world. Unfortunately, during formal medical education or training, physicians receive little to no instructions on how to set up and manage a medical practice, making the process of starting a medical practice a daunting task. There are also very few publications that discuss the challenges dealt with by physicians starting their practice and there are no guidelines as to how to go about it. At present, this area of study is very dynamic in terms of knowledge and discoveries, and is exponentially growing. The young internist then is faced with this unique dynamism and the aforementioned changes in health care. These interactions with his working environment, his support system, and the practice logistics, in turn affects the way he establishes his clinical practice, and therefore, the challenges and issues he encounters along the way. 

 

This study aims to determine the challenges and experiences of young physicians who graduated from Internal medicine training from 2013-2018 with regards to establishing their private clinical practice in the urban or mixed setting. It also aims to determine the capital and recurrent costs of establishing private practice. 

 

Conceptual Framework

A physician’s medical practice is influenced by three overlapping main factors such as: 

1. Support system, composed of: 

  1. Family 
  2. Friends 
  3. Peers 
  4. Mentors 

2. Working environment, composed of: 

  1. Specialization 
  2. Nature of practice (private/government/ mixed) 
  3. Availability of HMOs/healthcare insurance 
  4. Place of practice (urban/suburban) 

3. Logistics of setting up a medical practice, composed of: 

  1. Distance of residence to work 
  2. Capital availability (space, finances, equipment, manpower) with the ultimate goal of a satisfying career and a comfortable lifestyle. 

 

 

Operational Definition of terms 

  1. Young physicians - Internists who graduated from training within 2013 to 2018 
  2. Medical or Clinical practice - occupation that involves interaction with patients in a clinic with the goal of diagnosis and treatment 
  3. Urban setting – clinical practice within Metro Manila or National Capital region (NCR) 
  4. Mixed setting - medical practice in Metro Manila or NCR and nearby provinces 

 

Methodology

Study Design 

This is a qualitative research, a case study type. The participants were junior internal medicine consultants with or without subspecialty and the setting was the University and Training Hospital. 

 

Sample/Case Selection 

Participants were selected by convenience sampling from the junior consultants who graduated from 2013-2018 from the Department of Medicine of a university training hospital. After initial invitation to 15 medical doctors (MD), only 10 junior internal medicine subspecialty consultants gave consent and participated in our study. Data saturation was achieved with 10 MD interviews hence further recruitment was not done. 

 

Data Collection 

Two sources of information were utilized. The primary data collection method was participant interview. We conducted an individual, semi-structured, recorded, and transcribed interview with each participant. All interviews were arranged to accommodate the participants’ schedules and were conducted in locations conducive and convenient for the participant. The researchers used a digital phone recorder with adequate memory and clear reception. Each interview was saved in a digital folder in two locations providing duplicate sources of original material in case a back-up was needed. 

 

The second source of information was an interview protocol or interview guide which was designed and created by the researchers in accordance with the objectives of the study. This form was preliminarily distributed to the participants which they answered prior to the interview. Its purpose was to give an itemized question on their experience in setting up a medical practice and also to give them a background on the study and basic flow of the interview. It also includes demographic data in the first part of the questionnaire. 

 

Data Analysis 

Transcripts from the recorded in-depth semi-structured interviews were employed as the main focus of the data analysis. The interview centered on twelve questions about establishing their clinical practice. 

 

The participants were given ample time to recall the details of their experiences in establishing their clinical practice by providing the preliminary questionnaire weeks ahead of their actual interview. They brought the questionnaire to the interview and used their preliminary answers as their guide. This established the trustworthiness and credibility of the data gathered.

 

Participant’s names for this qualitative case study were coded and replaced. Data for this study were analyzed manually through categorical aggregation. The audio-recorded interviews were transcribed by the researchers. The transcriptions were read and re-read several times. Notes were written and important phrases were highlighted. The researchers then started the process of coding by aggregating text with the same thought process and then classifying them into categories and themes. 

 

Ethical Considerations 

This study was reviewed and approved by the institution’s Research Ethics Committee (REC) prior to its commencement. The name and identity of subjects were kept confidential. Informed consent forms were signed by each participant prior to the conduct of the study. The researchers financed the study. 

 

Results

The physicians were 35 to 40 years old; 6 (60%) females and 4 (40%) males, who recently started private practice, seeing both general Internal Medicine cases and their subspecialty cases, with at least two clinics for two to five years at the time of interview. Three (3) were rheumatologists; 3 cardiologists; 2 Hematologists/Oncologists; 1 endocrinologist, and 1 nephrologist (Table 1). The first year of practice was generally described as the most difficult because it was a time of adjustment in schedule and responsibilities from a trainee who works in a team to a private practitioner. 



 

Table 1: Participants’ Characteristics

Age

Sex

Specialty or Subspecialty

Type of Practice

(Private & Gov’t)

Place of Practice

37

M

IM-Rheuma

Private & Gov’t

NCR

39

F

IM-Rheuma

Private

NCR

39

F

IM-Rheuma

Private

NCR/Bulacan

35

F

IM-Cardio

Private & Gov’t

NCR

37

F

IM-Endo

Private

NCR

37

M

IM-Cardio

Private & Gov’t

NCR

40

M

IM-Cardio

Private

NCR

36

F

IM-HO

Private & Gov’t

NCR

36

M

IM-HO

Private

NCR

37

F

IM-Nephro

Private & Gov’t

NCR

Legend: IM, Internal Medicine; Rheuma, Rheumatology; Cardio, Cardiology; HO, Hematologist/Oncologist; Gov’t, government; NCR, National Capital Region


 

The meta-themes identified during the interviews were 1) Tough Days; 2) Torn and Divided; 3) Tremendous Debt; 4) Difficult but Tolerable and 5) Dreams and To-dos. 

 

Tough Days

Period of figuring out the system 

The subjects’ application to hospitals was not as easy as they expected it to be. The long list of requirements was one difficulty, in which tax papers were included. One subject specifically mentioned that he had to look for a “good accountant” because he did not have enough knowledge of the country’s tax system and did not have the time to learn about it. Some of them had an immediate relative who is a physician who served as their guide. Majority of the participants did not have a family member who had first-hand experience of establishing a clinical practice, hence they needed to figure out everything on their own. 

 

Self-introduction 

By establishing their medical career in hospitals or areas where there were subspecialist internists practicing already, particularly in highly urbanized areas, the subjects felt that they were perceived as “competitors.” It was a challenge for them to practice in an area where they had to “share the hospital with those who came before them.” Most of the subjects had to seek the approval of senior consultants before they were allowed to hold clinic in a hospital. 

In areas where there were no or less subspecialist, promoting one’s self and the subspecialty is an important issue. “Selling your practice” to people who are not aware of what you are “selling” is awkward and embarrassing. 

 

Few subspecialty patients/cases 

The participants handled more Internal Medicine cases than their subspecialty cases, particularly in the first one to two years of their medical practice. It was estimated by the subjects as 75 to 90% Internal Medicine cases and 10% to 25% subspecialty cases. While seeing Internal Medicine cases is mandatory and inevitable in the provinces, being decked or given Internal Medicine cases in the city is considered a “blessing.” The subspecialty cases come as occasional referrals from friends and mentors practicing in the same and nearby hospitals, which gradually increased in number during the second and third year of practice. 

 

Feelings of frustration and depression 

The participants stated that they were eager to work but there were none or very few patients seeking consult. Sitting in their clinics with nothing to do but wait for patients was “frustrating.” There was a point in their work week when they thought of not reporting at the clinic for that day because they were not expecting patients to come anyway. Sometimes, friends or relatives visit their clinic for check-ups, however, they will not charge a professional fee for it and go home at the end of the day knowing that they “spent more than what they earned,” and that their secretaries and drivers earned more than they did, was depressing. 

 

Torn and Divided

Unpredictable work schedule and workload 

The participants took on several clinics during their first one to two years of practice, as well as several hospitals to visit, to cover as much area of practice as possible and to generate as much income as they can. This led to occasions when there were too many patients to take care of in a week, but there were mostly none in the other weeks. The Schedule was difficult to manage for the participants whose clinics are situated far away from each other, especially if one clinic is in the nearby province/s and the rest are in the city. And even if the clinics are all in the city, getting to and from one clinic to another takes so much time because traffic is often slow. One participant said, “Pag nag-overtime ako sa isang clinic, sigurado late ako sa kasunod.” (“When I work overtime at a clinic, I am sure I am late for the next one.”-P2) 

 

Lack of time for issues outside career 

Holding a clinic in some hospitals may require the physician to be involved in administrative and teaching tasks. This additional work further increases the time spent on clinical practice which will then decrease the time that can be spent being with family, taking care of children and parents, being with friends or colleagues, running the home, monitoring and improving the family business if not starting one, teaching in a university, or taking another degree. 

 

Tremendous Debt

Large startup cost

It was not enough to comply with the hospital requirements for the participants to be able to start their medical practice. They were required to pay stocks and/or “right to practice” in at least one of the hospitals they applied to, in the range of Php 500,000 to Php 1.2 Million, either as a one time payment or in installments after a 20 to 30% down payment. They also had to contribute to the construction expenses for the clinic, and paid around P50,000 prior to using the clinic (Table 2). Their savings at that time was minimal because they had minimal salaries during the residency and/or fellowship training that they just completed. There are hospitals that do not need stocks to start practice but usually they would require 1 to 5 years visiting status prior to approval of clinic. 

From another perspective, let us not forget the capital cost which includes the medical school expenses as well. All of our respondents were graduates of private medical schools, where tuition fees range from P100,000 to P200,000 per annum. 

 

Expensive maintenance 

Monthly bills were composed of monthly rent, salaries of secretaries and/or drivers, meals for drivers, transportation cost which includes fuel and fees, or commute fare, plus installments for the stocks and “right to practice.” Monthly expenses ranged from Php 20,000 to Php 50,000 (Table 2). The subjects also mentioned that the registration fees of conferences they are required to attend are “additional burden.” 

 

Table 2: Capital and Recurrent Costs (mean) of starting and Maintaining Clinical Practice

CAPITAL COST

Item/Description

Amount

Clinic 1 (private hospital with stocks)

Shares of Stocks

Php 500,000 to 1M

Clinic 1 interiors

Furnitures and fixtures

Php 250,000 to 750,000

Clinic 1

Lease for 25 years

Php 250,000

Clinic 2 (No stocks required)

Registration fee

Php 10,000

BIR 

Registration fee

Php 5,000

TOTAL 

 

Php 1 to 2 Million

 

RECURRENT COST

Item/Description

Amount

Clinic 1 

Monthly rental

Php 2,500 to 5,000

Clinic 2

Monthly rental

Php 2,500 to 5,000

Secretaries (2)

Monthly

Php 10,000

Clinic operations (2 clinics)

Monthly utilities

Php 3,000

Transportation allowance

Monthly

Php 10,000

Accountant

Monthly/quarterly

Php 2,000 to 5,000

TOTAL 

 

Php 25,000 to 30,000 per month



 

Difficult but Tolerable

The participants’ decisions regarding their clinical practice were made mostly by themselves, without consultation, but in careful consideration of their responsibilities to their respective families, particularly those who have children. Making these decisions was a challenge in itself, but was tolerable because of the support from friends and colleagues, mentors, and family. 

 

Going home to a family 

The support of a spouse and/or parents were fundamental in “surviving” the early years of their practice. Their family and goals for the family were major factors on their decision where to establish their clinics. Some of them emphasized that their schedule worked around their children’s schedules since they have toddlers and pre-school children. One went on saying, “Nakakawala ng pagod yung makita ko yung mga anak ko, kaya madalas nagmamadali akong umuwi para maabutan ko na gising pa sila.(“There is a feeling of relief to see my children, so I often hurry home to catch them awake.”-P3) Aside from moral and emotional support, additionally, the majority of the subjects were provided their start-up funds by their parents. 

 

Call-a-colleague 

Friends and colleagues were sources of patient referrals. Most of the time their residency batchmates became their network of referrals. They were also the go-to persons with regards to questions on how to go about the application process in hospitals, taxation, and other requirements. In times of difficult cases, at least one colleague is ready to help. Active networking and ease of referral to other subspecialties are advantages of working in subspecialty-focused institutions. 

 

Debt of gratitude to mentors 

According to all the participants, they had at least one mentor who was instrumental in paving the way for them to start in a reputable institution. Their recommendations were valuable and vital. Most of them also got their first patients from referrals of mentors. To be associated with a mentor is a blessing for them, because they would often “cover” and see their patients in their mentors’ absence. This would help them to be introduced in the circle of referral. It should be noted that most of our respondents are not a daughter or son of a doctor, so their mentor served as their second parent in guiding them in their medical careers. Mentors also served as role models to emulate their career path. 

 

Dreams and “To-Do’s”

After surviving the arduous first few years of clinical practice as a young medical specialist, the participants did not forget to bring up their aspirations. One would like to open one or two more clinics. Some would like to venture on non-medical business. While the other one would like to close one of her clinics with the prospect of taking graduate studies. Post-graduate or master’s studies were consistently mentioned in their future plans. Majority of them plan to start teaching in the medical school soon. 

 

Discussion

In this qualitative study, we have shown the experiences and challenges of starting a private practice in an urban setting. Clinical practice as defined by the Physician’s Act of 2020 can be divided into general medical practice and specialty medical practice.[7] Medical practice is also of different types namely: solo private practice, group practice, or being a part of a health maintenance organization (HMO) practice, and government practice. In the Philippines, a specialist can choose to combine these types as long as his or her time permits. Mixed practice was perceived to offer more opportunities in terms of patient care, both in quantity and quality, but entails more medical responsibility, more time spent in travel, and higher operating costs. Mixed practice may also broaden the geographic coverage of the subspecialty with limited manpower. 

 

Most of our participants described their experiences in establishing a solo private practice, which means the responsibility and full control of operation is theirs alone. There are certain advantages of solo private practice such as 1) being in control of everything; 2) decision-making is straightforward and fast; 3) lower start-up cost. While the drawbacks are as follows: 1) no work, no pay; 2) higher chances of exhaustion; 3) less control of work-life balance. [8-9] This is still the predominant type of medical practice in the country. Our participants’ main challenge in establishing solo private practice comes from the unfamiliarity of the sheltered-newly graduated medical specialist in the business of medicine. And this is not surprising, since their training was focused on the art and science of their specialty or subspecialty while lacking on the business aspect of medicine. A study was conducted with senior medical students regarding their interest and knowledge on business and financial literacy, and a pre-test and post-test questionnaire after completing an elective 20-hour business course was done. Results showed that students have a substantial interest in the course but very limited initial knowledge and competence. At course conclusion, there was a significant improvement in competence in financial management and fundamental knowledge of business aspect of medicine.[10] Most of our participants’ knowledge in business were informally passed down from their senior consultants and/or mentors. Admittedly, they had difficulty in figuring out the system and the process, especially taxation. This is not only seen in the medical profession but also in the other allied health programs including veterinary medicine and dentistry. [11-12] Whether or not it should be incorporated into the medical curriculum as a regular subject or elective rotation is something the medical educators should look into the future. 

 

Majority of our participants are subspecialists and practices in the National Capital Region, they described their experiences and challenges in practicing in a highly urbanized and subspecialty focused centers. Since most subspecialty training programs are located in the urban areas, a newly graduate subspecialists tend to start their practice in the city and/or in the nearby areas. According to the Philippine Statistics Authority, as of 2015, the local government in the country consists of 145 cities, of which 33 are highly urbanized cities, and five are independent component cities. These are where specialty training hospitals and medical centers are concentrated.[13] The scope of medical practice in rural areas is diverse. Family physicians in the US, and most likely subspecialists, may have more opportunities to treat patients beyond their specialty, have broader hospital privileges, and make house calls. They may also have more clinical independence in their practice. On the other hand, physicians practicing in urban areas may have more access to colleagues with different subspecialties, as well as sophisticated medical facilities.[14] Most cities have large conglomerate hospital systems with sites around the catchment area, which adds flexibility in terms of traveling from 1 area to another. The downside is possible compartmentalization of practice and tight competition as more subspecialists tend to cluster in urban areas. 

 

Limitations

This case study is limited only to one specialty (Internal Medicine) and its subspecialties. There is a limited application to the rural setting since we did not include physicians with exclusive rural practice. 

 

Conclusion

Learning the ways of the healthcare business, effectively promoting oneself to the community, dealing with the emotional turmoil of having few patients, coming up with a strategic schedule and area of practice, looking for funds and paying it back, and working on dreams outside of their clinical practice were the challenges and issues faced by young physicians as they establish their careers as specialists in the urban and/or rural setting.

 

Conflict of Interest 

The authors declare no conflict of interest.

 

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  10. Mizell J, Thrush C, Steelman S. The Business of Medi cine: A Course to Address the Deficit in Financial Knowledge of Fourth-Year Medical Students. The Journal of medical practice management: MPM [inter net]. 2019 May [cited 2022 Sep 22];34(6):344. Available from:https://www.researchgate.net/publication/338083232_The_Business_of_Medicine_A_ Course_to_Address_the_Deficit_in_Financial_Knowledge_ of_Fourth-Year_Medical_Students 
  11. Kieves NR, Roark AW, Sparks TK. Business education in veterinary schools: the potential role of the Veterinary Business Management Association. J Vet Med Educ [Inter net]. 2007 Winter;34(5):678–82. Available from: http:// dx.doi.org/10.3138/jvme.34.5.678 
  12. Dayrit MM, Lagrada LP, Picazo OF, Pons MC, Villaverde MC. The Philippines health system review. In: Health Systems in Transition. World Health Organization. Regional Office for South-East Asia; 2018. 
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Table 1. Participants’ Selected Interview Quotes

Themes

Quotes

TOUGH DAYS

 

Period of Figuring out the System

“Noong una hindi ko alam kung saan mag-uumpisa. Pagkatapos kong mag-graduate sa fellowship, officially unemployed. Nagtanong-tanong ako sa mga seniors at mga kaibigan kasi wala naman akong kamag-anak na doctor.” (“At first I didn't know where to start. After I graduated fellowship, I am officially unemployed. I kept asking seniors and doctor friends for advise because I don't have a relative who is a doctor.”) (P3)

 

“Since 3 of my hospitals did not have an established residency or fellowship training program, it took a while to adjust to a different system like answering calls from GPs or in-house physicians, answering in-patient referrals and communicating through the nurses, and ordering insulin drip/therapy which some nurses didn't fully understand how to do it.” (P5)

Self-introduction

“Sa isang hospital na inapplayan ko nahirapan ako magpakilala kasi very close knit ang mga doctors na doon nag-training. It’s awkward to start conversations and introduce myself every time.” (“In a hospital where I applied, it was difficult for me to introduce myself because the doctors who trained there were very close. It’s awkward to start conversations and introduce myself every time.”) (P6)

 

“It was a challenge at the start to make myself known to other doctors practicing in the same hospital in order to gain referrals. It took time to establish relationships, nag-aattend ako lagi ng meetings/conferences for them to know me.” (“It was a challenge at the start to make myself known to other doctors practicing in the same hospital in order to gain referrals. It took time to establish relationships, I always attend meetings/conferences for them to know me.”)(P9)

 

“Ok din na natanggap ako kung saan ako nagresidency/fellowship, at least kilala na pero nakaka-ilang kapag nirere-feran ka ng mga senior consultants. Nakakatuwa at nakaka-kaba,” (“It's also ok that I was accepted where I did residency/fellowship, at least I'm known but I get anxious and excited when senior consultants refer to me.”) (P8)

Few subspecialty patients/cases

“I started investing on a private hospital, shortly after it opened in April of the same year. As a newly opened hospital, there were few patients going to the outpatient clinics and being admitted or referred, tiyaga lang sa paghihintay.” (“I started investing on a private hospital, shortly after it opened in April of the same year. As a newly opened hospital, there were few patients going to the clinics or being admitted or referred, I  just patiently waited.”) (P5)

 

“Kahit may subspecialty ako, nag sign-up din ako na tumingin ng IM cases kasi confident naman ako mag-manage, buti na lang kasi yun ang pinaka-source of income ko sa simula.” ("Even though I have a subspecialty, I also signed up to look at IM cases because I'm confident to manage them, it's good decision because that's my main source of income in the beginning.") (P7)

Feelings of Frustration and depression

“Minsan nakakalungkot kasi ang layo ng byahe at traffic tapos wala palang dadating na pasyente. Nagdadala ako ng ibang gagawin para malibang ako.” (“Sometimes it's sad because the travel distance is far and traffic and then there are no patients coming. I bring other things to do to use my time wisely.”)  (P3)

 

“Kaya ako nagdesisyon magmasterals kasi nasasayangan ako sa oras na mag-hintay lang ng pasyente, kesa malungkot ako, inilaan ko na lang ang panahon ko sa ibang bagay. Ginawa ko munang by appointment or napapamessage ako sa secretary pag may pasyente.” (“So I decided to become masters so as not to waste my time just waiting for patients…I just devoted my time to other things. What I did first was by appointment or my secretary can message me when there is a patient.”) (P1)

TORN AND DIVIDED

 

Unpredictable work schedule and work load

“Marami akong inapplyan, I printed so many CVs and distributed them. Natanggap nman, kaya may days na busy talaga, meron nman walang pasyente!” (“I applied in a lot of hospitals/clinics/HMOs, I printed so many CVs and distributed them. I was accepted in most, so there are days that are really busy. There are days with none”) (P4)

 

“Syempre kapag bago ka, tanggap lang ng tanggap. Hindi pa ako marunong humindi noon. Minsan na-ooverwhelm na ako.” (“Of course when you're new, it's just accept everything they assigned to me. I didn't know how to say no before…sometimes Im overwhelmed.)” (P4)

Lack of time for issues outside of career

“Akala ko kapag consultant na marami ng time sa family, pero pag nagsisimula, di ka pa pwede masyado magbakasyon. Iniisip ko pag lagi kang nandyan, ikaw lagi ang tatawagin.” (“I thought when you become a consultant you will have a lot of time with your family, but when I started, I can't take much vacation. I think if you are always there, you will always be called for referrals.”)(P10)

TREMENDOUS DEBT

 

Large start-up cost

“I had to pay an expensive fee corresponding to the privilege to practice in two of my private hospitals.” ("I had to pay an expensive fee corresponding to the privilege to practice in two of my private hospitals.") (P2)

 

“My parents lent me the money to pay the so-called stocks which would give me the privilege to practice in the hospitals. They also helped me to renovate my clinic and until now they are still partially helping me as I establish my practice.” (P5)

DIFFICULT BUT TOLERABLE

 

Going home to a family

 

“I still stay with my family and my siblings with pamangkin. Important may solid emotional support lalo na pag may toxic patient or namatayan ng patient…they keep my sanity.” (“Because I am single, I still stay with my family and my siblings with nephews. It is important to have solid emotional support especially when there is a toxic patient or the patient dies… they keep my sanity.”) (P7)

Call-a-colleague

“One colleague of mine encouraged me to apply to a hospital where she was currently practicing because the said hospital still needed my expertise.” (P5)

Debt of gratitude to mentors

“Sobrang laking tulong ng mga mentors ko, they constantly supported me especially during the start of practice.” Malaking bagay yung magpapa-relieve sila. Kung may tanong ka lagi silang nandyan. ("My mentors were very helpful, they constantly supported me especially during the start of practice." It's a big thing that they will relieve. If you have a question they are always there.”) (P1)

 

“They recruited me at medical school. Sila ang ultimate role model ko. (“They recruited me at medical school. They are my ultimate role model.”)(P8)



 

 

 

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