Private Hospitals Part 2 - The Plot Thickens

( I think Raffles Hospital should've "clarified" from the very beginning, in their first Forum letter. )

Transcribed from Stomp Online:

It was right to send injured from Ferrari-taxi crash to TTSH , say specialists

STOMPers questioned the SCDF's decision to send the injured from the fatal Ferrari-taxi crash on May 12 to Tan Tock Seng Hospital and not the nearby Raffles Hospital. Well, they 'made the right call', say a group of top emergency medicine specialists.


Tan Tock Seng Hospital and the Singapore General Hospital were further away from the crash site than Raffles Hospital, which is privately run, but they are better equipped and staffed to handle such cases, said the group of five specialists.

The public hospitals are also part of the Ministry of Health's 'national emergency and trauma system', and as a requirement, they have the facilities, equipment and specialists available all the time to handle multiple emergency and trauma victims.

The group of specialists who issued the joint statement on Friday, May 25, are: Associate Professor Mohan Tiru, chairman of the Singapore Residency Advisory Committee of Emergency Medicine; Professor V. Anatharaman, chairman of the Chapter of Emergency Physicians at the Academy of Medicine; Associate Professor Lim Swee Han, president of the Singapore Society of Emergency Medicine; Associate Professor Goh Siang Hong, chairman of the Medical Advisory Committee of the Singapore Civil Defence Force (SCDF) and Dr Chiu Ming Terk, chairman of the National Trauma Committee at the Ministry of Health (MOH).

General manager for Raffles Hospital, Prem Kumar Nair, clarified that the hospital's specialists are not on site at all times, while those in SGH and TTSH had emergency-medicine specialists, surgeons, anaesthetists and radiologists on site, round the clock as minutes matter in emergencies.

Raffles Hospital's doctors were trained in emergency medicine and managed trauma cases regularly around the clock, said a spokesperson, but confirmed it did not have specialists trained in emergency medicine.

"Proximity is important, but more important is the degree and level of care available around the clock," said Dr Chia Shi-Lu, an SGH orthopaedic surgeon and member of the Government Parliamentary Committee for Health.

Said STOMPer Henry, after reading the report:
"I'm glad the specialists and the hospitals came out to answer our queries and to ease our concerns.

"I'm glad that we have such a good healthcare system here, but I also wish that not just the public hospitals but the private hospitals can also have an across-the-board medical approach so that in times of emergency, there are more options available to send the patients to."

Private Hospitals - Is the status quo acceptable?

A recent letter in the Straits Times Forum Page caught my attention because it addresses a chronic issue which has no solution in sight.

The Health Ministry and Singapore Civil Defence's diplomatic reply is reproduced below.

Madam Shirley Woon asked why the victims in the recent three-way Bugis crash were not taken to Raffles Hospital, but to the Singapore General Hospital (SGH) and Tan Tock Seng Hospital (TTSH), which are farther away ('Why weren't crash victims taken to nearest hospital?'; last Tuesday).

For severe and multiple trauma patients, the Singapore Civil Defence Force (SCDF) emergency ambulance will take them to the nearest accident and emergency department that is equipped to deal with such complexities of care.

In the accident referred to by Madam Woon, while Raffles Hospital is located close to the accident site, it is not equipped to deal with multiple trauma cases, and thus the SCDF had to take the patients to SGH and TTSH, which were the nearest fully equipped facilities to deal with such emergencies.


Bey Mui Leng (Ms)
Director
Corporate Communications
Ministry of Health

Colonel Yazid Abdullah
Director, Public Affairs Department
Singapore Civil Defence Force


Even more interesting is Raffles Hospital's reply today.

It is an established procedure that Singapore Civil Defence Force (SCDF) 995 ambulances currently take patients only to designated public hospitals ('Raffles Hospital not for multiple trauma cases' by the Ministry of Health and SCDF, Monday; in reply to 'Why weren't crash victims taken to nearest hospital?' by Madam Shirley Woon, May 15).

This was explained by the ministry and SCDF in last Saturday's report in The New Paper ('Why victims not sent to nearer hospital?').

However, Raffles Hospital receives emergency cases on a daily basis brought in by private ambulances and vehicles, and air ambulances.

Such emergency cases include victims of industrial and construction accidents, as well as overseas patients with traumatic injuries evacuated to the hospital by medical assistance and evacuation companies.

We manage such trauma cases as a matter of normal and regular practice.
In the past several years, our 24-hour emergency centre has received and treated casualties of road traffic accidents that had occurred in the vicinity of the hospital, and who were brought in by passers-by.

Such patients are resuscitated and stabilised by the duty doctors, and admitted for surgery or procedures and further treatment as required.

Our priority in all such circumstances is always to put the patients' needs first and to save lives.


Dr Prem Kumar Nair
General Manager
Raffles Hospital


And since I never read The New Paper, here's a link for those who are curious.

To help shed some light on the issue, one must define the term "MOH-designated".

There is a reason SCDF ambulances transport their patients exclusively to public hospitals, and this reason comes in the form of a service agreement, i.e. a contract of sorts where specific terms and conditions are stipulated, and which the hospitals MUST adhere to, or be found in serious breach of their obligations.
Terms include in-house ( i.e. on-site ) 24/7 specialist coverage, proper resuscitation equipment, and recognized qualifications of the frontline staff ( i.e. emergency room doctors and nurses ).

Suffice to say, to date, no private hospital is known to have signed this contract, which therefore prevents SCDF ambulances from depositing any of their patients at their doorsteps, regardless of how seriously ill or injured they may be.

So the next logical question is: should we allow this arrangement to continue? What are the predominant obstacles preventing the MOH-private-hospital agreement from becoming a reality?

Personally speaking, I don't know why the MOH isn't putting its foot down and forcing it down the private institutions' throats. Singapore is an urban, densely populated country with its fair share of healthcare problems, but much can be done to improve outcomes, especially in time-sensitive conditions such as certain types of heart attacks and strokes, which benefit from early diagnosis and intervention.

Any transport delay can result in fatal complications if the heart attack becomes a cardiac arrest, or if the stroke goes beyond the window period for therapy and the patient ends up debilitated for life.

In major trauma, the first "golden hour" is often quoted, but its validity has been questioned.

And while the SCDF reports that one of the crash victims was sent to TTSH within 8 minutes, if the accident had occurred in the midst of peak hour traffic, the poor patient would've probably expired en route.

Perhaps one of the reasons private hospitals can't fulfill the terms of the agreement is the fact that none of them has 24/7 emergency physician (EP) coverage. This is clearly indicated as a requisite, but is practically impossible in the foreseeable future.

First, there aren't enough EPs to go around the public sector, never mind the private side. Second, EPs aren't interested in better lifestyles and higher pay. Third, EPs enjoy the challenge public sector work - no matter how exhausting or frustrating - provides.

Perhaps it's time for MOH to address the issue with a greater sense of urgency, either by modifying the agreement's terms ( possible ), or by finding a way to boost their EP coverage ( unlikely ).

In any case, I don't appreciate Raffles Hospital's Dr. Nair's "established procedure" quote, which appears to absolve them of any form of accountability for the current state of affairs.

Fail to understand logic, fail to understand healthcare reform

I had wanted to comment on the latest series of article on SDP's website defending its "National Healthcare Plan" when the first one was posted last week, but decided to wait and read the whole series before commenting.

The writer is a health economist, but nevertheless there are some points in his arguments which I dispute. The three articles are too long to reproduce in full here, so I summarise and discuss each of the articles in the series below. Do read the original articles linked to yourself.

In part 1, the author begins by introducing the concepts of "disease burden", "mortality", and "morbidity", and argues that little is being done now to collect data for these indicators. Despite this lack of data (which is in fact available), the author believes that "between a universal healthcare system and one that is not, the former has a greater chance of saving lives, provided it gives priority to evidence-based policies".

Now intuitively one would agree with that statement - after all, if people do not or cannot access healthcare due to costs, then they will not benefit from the nation's healthcare system. However, this assumes that cost is a barrier to people accessing healthcare. Yet in SDP's "National Healtcare Plan", the possibility of a "buffet syndrome" is dismissed with the statement that "[t]he behaviour is less likely seen in chronic non-symptomatic illnesses like hypertension or diabetes, where it is more likely to encounter non-compliance with treatment or medication, even in patients who are having their treatment paid by third parties" (emphasis mine) - so if SDP believes that the problem with chronic disease management is non-compliance rather than cost, then how will a "universal healthcare system" be better at "saving lives"?

The writer then goes on to praise SDP's plan in generic terms, without giving specific reasons as to why he thinks that "[t]here are many proposals in the SDP’s plan to suggest that morbidity in the patient-population will be better managed", or that "SDP’s healthcare plan shows promise of better management and reduction of burdens that diseases impose on Singapore society".

In part 2 of the author introduces the concepts of "total healthcare expenditure" (THE), "cost of ill health in the economy" (CIHE), and "cost of ill health in a society" (CIHS).

Again, these are intuitive concepts which the laymen can easily understand and appreciate. The writer notes that the amount spent on THE may not be indicative of what the government spends on reducing CIHE and CIHS in total, because the resources expended on tackling many of the problems that result in a higher CIHE and CIHS are not in fact classified as our THE. At the same time, non-government expenditure by the people such as "hiring maids to provide home care" and "special needs teachers or extra tuition teachers for... children with learning disabilities" are costs that are not factored in when calculating the THE.

In short, the writer argues, the THE is not a good indicator of how much the government spends reducing CIHE and CIHS, and it does not measure how much the people spend on what is traditionally not included when calculating the THE.

So far so good. But of we look at what the writer thinks are the major health problems which are not being considered as part of our THE, being "alcohol misuse, drug addiction, gambling, smoking," and "families hiring maids to provide home care for their loved ones [with chronic diseases]" and "parents [hiring] special needs teachers or extra tuition teachers for their children with learning disabilities", then we need to ask ourselves how SDP's plan will be more effective than the current healthcare model in reducing the CIHE and CIHS arising from these "problems".

Now if "alcohol misuse, drug addiction, gambling, smoking," increase our CIHE and CIHS, then how will a buffet-style healthcare funding model reduce the problem? In other words: how will telling people with problems of alcohol misuse, drug addiction, gambling, and/or smoking that the government (and by extension the people) will pay for the health consequences of your choices even more than what they do now reduce the size of the problem?

As for spending on maids and special needs teachers, the question is: are these not problems which are better tackled with targeted help instead of a blanket 90% subsidy for all healthcare?

In the final part of the series, the writer begins by arguing that most nations already have universal healthcare, and points out that our current obsession with capping government healthcare spending is myopic as it fails to look at the burden that diseases impose on society.

He then argues that under the SDP system, healthcare spending will be more cost-effective "because SDP’s model is patient-centric, focusing heavily on alleviating patients' hardships, improving their well-being, and preventing their future health risks". However, he does not in fact tell us how this will be the case.

With regards to sustainability of the system, the writer believes that it "is sustainable as long as the universal healthcare system gives evidence-based policies due consideration and priority".

He summarises his series into the following two points.

1. Universal healthcare coverage is a "no-brainer", but the exact features of the system should be guided by evidence and not ideology, and the system must be evaluated continually after implementation.

2. When evaluating a healthcare system, we must not look only at THE, but also at the reduction in CIHE and CIHS.

On the whole the writer's arguments follow each other: if you have a universal healthcare system, people will have better access to healthcare and better health outcomes, and this will bring you returns in the form of lower loss to the economy and society downstream. Excessive cost can be prevented because the expenditure will be guided by evidence and not ideology.

Sounds great so far (except for the points which I disputed earlier).

But while the writer claims to be non-partisan, it is clear that his argument is guided by ideology when he wrote that (emphasis mine):

"the division in Singapore over universal healthcare is actually a division between the “I” group and “We” group. The “I” group is selfishly looking at just their own world in terms of how much more they must pay, how much longer they must wait in the queue, etc.

The “We” group gives greater priority to impact of healthcare polices on society at large. They are concerned with how many more lives can be saved, by how much hardship of patients and their families can be reduced, and so on."

Given that the whole "National Healthcare Plan" is guided by ideology and aimed at - let's face it - winning votes, how much confidence can we place in the executors of this system that its operations will be guided by evidence and not ideology?

Finally, I don't really see how our current healthcare system is different from the writer's vision of a healthcare system that is "patient-centric, focusing heavily on alleviating patients' hardships, improving their well-being, and preventing their future health risks", where the government is cognisant of CIHE and CIHS, and where operations are guided (in theory) by evidence and not ideology.

Indeed, I think the only difference between the current system and what SDP is proposing is not *why* we do it, not *how* we do it, but *who* pays for it.

How you run a healthcare system can in fact have nothing to do with how you pay for it - you can have a system where individuals pay for their own healthcare but where providers are guided by evidence, and you can have a system where patients do not pay out of their own pockets but where treatment is not guided by evidence. The writer's mistake in his entire argument is that he assumes that a "universal" healthcare system where the bulk of payment is subsidised (as proposed by SDP) will mean that policies will be guided by evidence and not ideology (when in fact the two can be totally unrelated), that people will access healthcare more appropriately (something which SDP itself believes is not the case), and that CIHE and CIHS will be reduced; and the reason why he makes that mistake is, I believe, because he is guided by ideology instead of evidence.

Health Freakonomics

Question:

How much healthcare must a Singaporean consume per year to "break even" under SDP's proposed "National Healthcare Plan"?

Working:

Under SDP's "NHP", the average Singaporean pays an annual contribution of $600. To offset this compulsory payment, he must consume $600 worth of healthcare to begin with.

However, since the "NHP" covers only 90% of that $600, he has now paid $660 to consume $600 worth of healthcare!

To make up that difference, he must consume another $60 of healthcare, which will mean he has to come up with another $6 out of his pocket, which put him out by another $6, which means he has to consume a further...

Answer:

$666...

(Yes, it's closer to $667, but that number is more dramatic...)


Now you may think that that is a joke (and not a very good one at that), but I will not be surprised if Singaporeans who previously spent fewer than a hundred dollars on healthcare each year mysteriously start chalking up $666-healthcare bills if SDP's scheme comes into effect.

You may ask why we do not already over-utilise services such as the police, ambulance and fire services since we have all already "pre-paid" for them via taxes. Well, for one thing, these payments are hidden in the sense that they are not separate accounts into which you pay, and the prices of these services are also not known, making it impossible to determine where the break-even point is. Secondly, people do in fact utilise them inappropriately, which is why there are penalties for calling the police, an ambulance or the fire department frivolously.

What about the Medisave account that we have presently?

Yes, that is a distinct account into which you are compelled to contribute to, but that money stays in your account if not expended - it is not "forfeited" at the end of the year if not consumed (like those eMart credits - ever seen a reservist buy more pairs of socks than he can wear out just because he has $200 left in his account?). Also, that amount is reserved for your own use or the use of your family, and is returned to your "estate" if sums remain after your death, so there is no incentive to ensure that you use all you can every year of your life while you live so that money doesn't go towards paying for some stranger's illness.

Yet...

Yet even under those terms, patients still make healthcare choices based on CPF policies instead of medical reasons. For example, they will decide on whether or not to undergo an investigation or procedure based on whether it is "Medisave-claimable". After MOH started allowing Medisave to be used for outpatient chronic care, my colleagues in primary care related to me how some patients would try to make sure their bills exceed the minimum co-pay amount so that they can utilise their Medisave (yes, actually wanting to pay more in total so that they can pay less out-of-pocket!), to the point of asking the doctor to prescribe a longer duration of medication, to not discontinue medications which are no longer needed, or to prescribe vitamins and supplements to bulk up the bill.

Sounds bizarre? Well, don't just take my word for it - ask a friend who is in healthcare if what I wrote in the second part is true, and what I wrote in the first part is likely to happen. Perhaps SDP should have asked some healthcare workers too before coming up with their... Wait a minute...

Insurance, Buffet, and the SDP "National Healthcare Plan"

SDP continues to try to sell its "National Healthcare Plan" on its website, now comparing it to auto insurance.

There are a couple of problems with this analogy: for one thing, when you get into a traffic accident, other people may be harmed; the insurance is not just to pay for your losses, but for other people affected by your actions - this is not always true of healthcare (except in the case of infectious diseases). Secondly, one may go through a lifetime of driving without getting into a single accident, but everyone requires healthcare.

Now I am not a fan of Mr Tan Kin Lian, but today I would like to borrow his wisdom, specifically in something he wrote about health insurance:

I want to be frank. Insurance may NOT be the answer. Here are my reason insurance works on the principle of risk pooling. Many people pay a small premium to buy insurance, so that a large payout can be given to the person who suffers the insured event. A good example is insurance covering death by accident. The expected claim rate is 1 in 2,000. If each person pays a premium of $50, the insurance pool can pay $100,000 to the single person who happens to die by accident. The actual premium payable will be more than $50 as the insurance company has to pay its expenses and wants to make a profit.

1. This pooling does not apply to health insurance because each person wants to be insured for a lifetime and every one will eventually have to get a serious illness, either by cancer, organ failure (e.g. heart) or other critical conditions. It is likely that every person will make a claim on the health insurance policy – the question is whether it occurs earlier or later
2. ...
3. Insurance has the tendency to increase the cost of treatment. The insured person is likely to go for more expensive treatment, as it is covered by insurance...
   
4. Every insured person wants the high medical bills will be paid by the insurance pool, i.e. by other people. Are they willing to pay for somebody else’s bill?

What this means in the context of a national health insurance scheme is this: collectively, the "premium" paid into the pool must be at least equal to the total payout; and since everyone is covered by a national insurance scheme, and "every one will eventually have to get a serious illness, either by cancer, organ failure (e.g. heart) or other critical conditions", and "every person will make a claim on the health insurance policy – the question is whether it occurs earlier or later", then it tells us that what is happening here is NOT a pooling of risk, but of some people being made to pay for the healthcare of other people.

Now you may argue that the premium or subscription to the health insurance is roughly equal despite one's income, but remember that the bulk of the payout is not funded by the subscription, but by other types of taxes. To carry on the analogy of the buffet from our earlier post, we have a situation where everyone is made to pay $5 for the buffet, but some people having to pay an additional surcharge of $45 to eat the same food as everyone else.

When I criticised SDP's plan in my earlier post, a reader challenged me to come up with a "better system".

Now I have little doubt that in the short term, before moral hazard and the silver tsunami bankrupt the system, SDP's proposed system is definitely "better" for the majority of Singaporeans: they get to pay less for consuming the same or even more healthcare, while the bulk of the tab is picked up by a small percentage of Singaporeans.

But "better" is not always fair, even when it is "better" for the majority of people.

"Hospitals Aren't Hotels"

"... recent research suggests that judging care in terms of desirable customer experiences could be expensive and may even be dangerous. A new paper by Joshua Fenton, an assistant professor at the University of California, Davis, and colleagues found that higher satisfaction scores correlated with greater use of hospital services (driving up costs), but also with increased mortality.

The paper examined patient satisfaction only with physicians, rather than hospitals, and the link between satisfaction and death is obviously uncertain. Still, the results suggest that focusing on what patients want — a certain test, a specific drug — may mean they get less of what they actually need.

In other words, evaluating hospital care in terms of its ability to offer positive experiences could easily put pressure on the system to do things it can’t, at the expense of what it should.

To evaluate the patient experience in a way that can be meaningfully translated to the public, we need to ask deeper questions, about whether our procedures accomplished what they were supposed to and whether patients did get better despite the suffering imposed by our care."

(full article here)

All You Can Eat

As predicted, SDP's "National Healthcare Plan" involves increasing the government's healthcare expenditure from the $8 billion this year (up from the figure of $4 billion last year) to $10.5 billion, with the projectd increase being be paid for in part by "[i]ntroducing luxury tax" and "[i]ncreasing corporate tax". So now the rich will not only not be allowed to "buy immediate and better treatment [while] the poor have to wait months on end to receive medical care", they will be made to pay even more for healthcare they do not consume themselves than they already do now.

You can read the details of SDP's plan following the links on their site which I linked to above, but what it boils down to really is a $500-a-year consume-all-you-can healthcare buffet, even as SDP dismisses the existence of the "buffet syndrome" with what is effectively an "Oh, I'm sure it won't happen".

Now you only have to read the comments to the few posts before this one to know that it already is happening, and that it is naive to expect that the situation will in fact improve when such a plan is implemented.

Granted, we don't all spend $500 a year on healthcare now, but eventually more than half of us will die of cancers, heart diseases and strokes, and in getting there consume many times more than $500 during each of those final year; when the "silver tsunami" hits, this great "Plan" will fall apart.

I'll end with the words by a fellow doctor-blogger, a comment he posted on my blog when I looked at the subject of free healthcare many years ago:

I am absolutely certain that having medical care free at the point of entry leads to complacency and abuse. I have watched it with increasing horror in the NHS for 20 years.

People attend for medical consultations for the most unmitigated trivia; they demand inappropriate tests and, in particular, inappropriate medication.

I am committed to good health care for all, and I never thought I would ever want to change the "free" principle but common sense has triumphed.

As I have argued many times (and people seem to thing it is a trivial debating point - it is not) why is food not "free at the point of entry to the supermarket"?

Food is even more important than health care.

Wage Depression

In the comment to the previous post, a reader commented that:

Given our lack of doctors, it appears that the public hospitals are resorting to importing doctors from 3rd world countries to make up the shortfall. Beware of wage depression. It hits. Everyone.

Today, we read in the news that:

Public sector healthcare workers can look forward to pay increases costing some S$200 million. This will be fully funded by the government.

On average, doctors will see an increase in their total remuneration of about 20 per cent by 2014.

Looks like angrydoc's colleagues won't having to worry about that impending "wage depression" for another couple of years then?

P.S. - S$200 million seems a lot of money to spend on something that is not a "commodity", doesn't it?

"Healthcare is not a commodity"

"But that's not the way things should be. Healthcare is not a commodity. It is a right." - Singapore Democrats


Interesting.

If healthcare is not a commodity, I wonder what I am (and for that matter what SDP's "team of medical doctors" are) being paid for doing every day.

It is very easy for wannabe politicians to label every need as a right and champion the people's right. What is not addressed upfront is whose obligation it then becomes to provide for that right.

Healthcare is not something that you can simply harvest or dig out from the ground like natural resources. It *is* a commodity provided by healthcare workers, pharmaceutical companies, medical equipment manufacturers, as well as the people who fund and run hospitals and clinics.

When someone says that healthcare is not a commodity but a right, he can mean two things:

1. That he thinks he has a right to the property and labour of those people who provide healthcare

OR

2. That he thinks that he has a right to having someone else pay for his consumption of healthcare.

If you believe that a man's need entitles him to other people's property and labour or money to pay for the same, then why stop at healthcare? As I stated before (and will no doubt have to again in the future), healthcare is the 'wedge argument' for welfarism; if today they can claim that they are entitled to the commodity provided by the healthcare workers (or having other pay for their healthcare consumption), then tomorrow they can claim the same for that produced by those who provide food, water, clothing and shelter.

SDP is acting coy about what their self-proclaimed "landmark publication" of a "National Healthcare Plan" will entail, but I will hazard a guess that it involves the government picking up more of the tab than it already is, and that the amount of money required to fund this should come from taxing the rich even more than they are being taxed now.

Let's see if I will be proven wrong...

Beware The Danger Of Complacency

Recently, there was some debate in the local press regarding the need for marathon runners to submit letters from their doctors, certifying fitness to participate.

I don't have a copy of the Straits Times article, but a Google search produced this statement on NTUC's website.

I'd like to highlight the following comment:

"While a medical certification does not guarantee that medical emergencies would not happen during a run, we believe that the doctor would be best placed to screen and advise the would-be participant on whether he is fit enough to do a physically demanding run."

I have a few burning questions:

1) Can any doctor - including GPs - write this potentially incriminating letter, or are only "experts", i.e. cardiologists, allowed to do so?

2) What are the criteria for certifying someone "fit enough to do a physically demanding run"? A normal general medical examination? A normal ECG? A negative treadmill stress test / CT angiogram? Perhaps a normal coronary angiogram ( also fraught with its own risks, and hardly inexpensive )?

3) What are the predictive values of negative cardiac stress tests / imaging studies? Literature has shown that no investigation - not even a coronary angiogram ( considered the gold standard in detecting coronary artery disease ) - is 100% accurate in predicting future adverse events.

Meaning: You may have a completely normal coronary angiogram, and still die from a heart attack shortly after that.

There's also a significant number of people with undiagnosed cardiac disease whose very first presentation comes in the form of catastrophic events - i.e. massive heart attacks, sudden deaths - with no preceding warning signs or symptoms whatsoever.

These are the same people who may exercise regularly without difficulty, but develop problems under severe duress - that's right, when pushing themselves too hard during marathons.

4) Did NTUC bother to consult any experts before implementing this questionable protocol?

5) What are the implications if someone who's certified fit by his / her doctor kicks the bucket during the run? Will the family decide to sue the physician for negligence? How will the SMC respond?


A medical expert from the U.S., who specializes in emergency cardiac care, recently visited Singapore and delivered a series of excellent lectures on the dilemma faced by doctors who manage patients with possible underlying cardiac disease. A couple of interesting - and rather alarming - anecdotes he shared include:

1) A 12-year-old who suffered an actual heart attack, caused by vasospasm of the coronary arteries, and

2) An adult male who dramatically collapsed at the door of a hospital, just after a myocardial perfusion scan was performed and found to be NEGATIVE. In fact, the poor chap was found clutching the normal report in his hand as doctors resuscitated him.

True stories.


Let's face it - a doctor's letter is woefully insufficient, designed only to protect the organizers, not the participants. It instils runners with over-confidence, and may even result in more deaths if they think it's okay to push themselves beyond safe limits.

Is there anything wrong with signing declaration and indemnity forms?

Your comments, please.