Singapore M.D.

"How Doctors Die"

2012-02-24T11:35:00.001+08:00

"But of course it’s not just patients making these things happen. Doctors play an enabling role, too. The trouble is that even doctors who hate to administer futile care must find a way to address the wishes of patients and families. Imagine, once again, the emergency room with those grieving, possibly hysterical, family members. They do not know the doctor. Establishing trust and confidence under such circumstances is a very delicate thing. People are prepared to think the doctor is acting out of base motives, trying to save time, or money, or effort, especially if the doctor is advising against further treatment.

Some doctors are stronger communicators than others, and some doctors are more adamant, but the pressures they all face are similar. When I faced circumstances involving end-of-life choices, I adopted the approach of laying out only the options that I thought were reasonable (as I would in any situation) as early in the process as possible. When patients or families brought up unreasonable choices, I would discuss the issue in layman’s terms that portrayed the downsides clearly. If patients or families still insisted on treatments I considered pointless or harmful, I would offer to transfer their care to another doctor or hospital.

Should I have been more forceful at times? I know that some of those transfers still haunt me. One of the patients of whom I was most fond was an attorney from a famous political family. She had severe diabetes and terrible circulation, and, at one point, she developed a painful sore on her foot. Knowing the hazards of hospitals, I did everything I could to keep her from resorting to surgery. Still, she sought out outside experts with whom I had no relationship. Not knowing as much about her as I did, they decided to perform bypass surgery on her chronically clogged blood vessels in both legs. This didn’t restore her circulation, and the surgical wounds wouldn’t heal. Her feet became gangrenous, and she endured bilateral leg amputations. Two weeks later, in the famous medical center in which all this had occurred, she died.

It’s easy to find fault with both doctors and patients in such stories, but in many ways all the parties are simply victims of a larger system that encourages excessive treatment. In some unfortunate cases, doctors use the fee-for-service model to do everything they can, no matter how pointless, to make money. More commonly, though, doctors are fearful of litigation and do whatever they’re asked, with little feedback, to avoid getting in trouble."

(full article here)

Well, at least you die happy...

2012-02-19T21:04:00.004+08:00

An interesting article in Medscape tells us something which most doctors already know: patient satisfaction does not always equate to quality healthcare - in fact, if this study is correct, the most satisfied patients are also the ones who "have the highest mortality rate and the highest hospital admission and healthcare expenditure rates".

In case you can't access the article, here are some abstracts:

"[A]n overemphasis on patient satisfaction could have unintended adverse effects on health care utilization, expenditures, and outcomes," write Joshua J. Fenton...

The prospective cohort study followed-up 51,946 respondents to the 2000 through 2007 Medical Expenditure Panel Survey (MEPS) and included 2 consecutive annual surveys for each patient. ... Mortality outcomes during a mean follow-up of 3.9 years were available for a subset of 36,428 respondents.

Patient satisfaction was assessed with the Consumer Assessment of Health Plans Survey; specifically, with 4 items pertaining to physician communication (which is strongly correlated with global satisfaction) and a fifth item that allowed patients to rate their care from all physicians and healthcare providers.

After adjusting for sociodemographics, health behaviors, healthcare access, propensity to use healthcare, and health status, the authors determined that the odds of any ED visit were lower among patients in the more satisfied quartiles (adjusted odds ratio [aOR], 0.92; 95% confidence interval [CI], 0.84 - 1.00; P = .06), whereas the odds of inpatient admission were higher among the most satisfied patients (aOR, 1.12; 95% CI, 1.02 - 1.23; P = .02).

Similarly, patients who were the most satisfied had 8.8% more health expenditures (95% CI, 1.6% - 16.6%; P = .02) in the second year, as well as 9.1% more drug expenditures (95% CI, 2.3% - 16.4%; P = .01) and a 26% greater mortality risk (adjusted hazard ratio, 1.26; 95% CI, 1.05 - 1.53; P = .02), compared with patients who were least satisfied.

...

... the authors... suggest a possible explanation for the findings.

"Physicians whose compensation is more strongly linked with patient satisfaction are more likely to deliver discretionary services," they write, adding that "discretionary services may lead to iatrogenic harm via overtreatment, labeling, or other causal pathways."

"The authors infer that efforts to cater to patient satisfaction may be ill guided," writes Brenda Sirovich, MD... "There is, however, reason to question the validity of the inference," she continued. "[T]he likelihood of an unmeasured confounder remains high. One nomination is that a patient's strong sense of connection to the health care system, related perhaps to (unmeasured) vulnerability or frailty, might predict more satisfaction, hospitalization, and death.

"And yet, the inference is entirely believable — and cause for concern," she adds.

"Practicing physicians have learned — from reimbursement systems, the medical liability environment, and clinical performance scorekeepers — that they will be rewarded for excess and penalized if they risk not doing enough.... It is time that we, as a profession and as a society, take responsibility for controlling this unrestrained system, by working to overcome the widespread misconception that more care is necessarily better care and to realign the incentives that help nurture this belief."

The authors of this blog will not be surprised at all by these findings - in fact, some have warned against such a phenomenon. Fact is, healthcare is a confidence goods, and what you want (or think you want), what makes you feel good, is oftentimes not what *is* good for you.

Until patients and payers (the "scorekeepers") alike wise up to the fact that it is not the criteria they set but the ones the clinicians set which are likely to have real health outcome significance, and until they are willing to incentivise clinicians for doing what the clinicians *know* and not they (the "customers") *think* is right, the situation will persist.

So feel free to disagree with the doctor you don't like and stick with the one you do - you may die earlier and poorer, but at least you will die happy.

Dreams vs Reality

2012-02-01T08:04:00.005+08:00

[ FYI, the title of this post is a playful tribute to the National Museum's current Impressionist painting exhibit. ]

Yes, dear readers, Singapore MD is attempting to resurrect itself from a 6-month-long slumber.

And no, our silence is not the result of The Powers That Be shutting us down. That usually entails an actual deletion of the blog, which clearly hasn't occurred here.

Still, one requires some form of inspiration in order to keep a blog running, and I found mine today.

Ironically, thanks to the MOH, muah-ha-ha-ha-ha... :)

A fellow colleague who worked the afternoon shift in the A&E yesterday described a bizarre phone conversation with someone who identified himself as part of the MOH administration's $$$ department. ( p.s. The symbols $$$ were chosen semi-randomly. )

Mr. $$$ asked what our waiting times were like, because he was contemplating arranging for our department to "help see Hospital X's A&E patients". Hospital X being another public institution belonging to the same cluster, but located in another corner of the island, i.e. far far away.

When my friend answered the call, she was up to her neck in cases, with patient trolleys crammed into every available nook, including the corridor just outside the P2 area. She very wisely told Mr. $$$ to speak to our HOD, after which she didn't hear from him again.

Here're a few burning questions for Mr. $$$ and/or the MOH:

1) Why didn't the query go through "proper channels" - i.e. boss to boss? Who in the world is this mysterious Mr. $$$, and why did he call the busy senior doctor on duty, when he should have called an administrative staff ( e.g. our HOD, or at the very least, department manager ) instead?

2) Shouldn't our hospital's own Powers That Be be consulted as well? Shunting A&E patients from one place to another doesn't isolate the problem to the A&E. What if they need admission? Surgery? High dependency or intensive care management? Do we have the capacity to accomodate transfers when we're already bursting at the seams?

3) Does the MOH really think waiting times accurately reflect an A&E's ability to handle patient loads? Short waiting times don't equal low attendances. Perhaps the turnover rate is high because our doctors are pushing themselves to the limit, skipping meals and toilet breaks in order to clear the queues? Most patients who have been seen don't leave the department quickly either. They hang around waiting for test results, specialist consults, procedures, admissions, and the A&E doctors who first attended to them also need to stop their queues frequently for reviews.

Plus, the limited space poses a huge problem for those in the P2 / critical care area. Such cases are usually seen within an hour, but once the observation ward fills up - trust me, this happens daily - the trolleys have nowhere to go, and walking routes become non-existent.

4) What is the exact reason Mr. $$$ feels compelled to ask us to help Hospital X? What is the casemix of the backlog there? P3 walkers, P2 trolleys or P1 sickies? If it's the first, make them wait! If the second or third, redistribute your MOs and make the P3 cases wait even longer ( or just tell them to see their GPs / polyclinics if their complaints are minor ). Or how about sourcing for ward MOs to come down and help? Short of a mini-mass casualty or worse, diversion should be considered the last resort.

MOH and our cluster / hospital's Powers That Be, for your attention please.

"There is no abuse" 2

2011-07-23T13:00:00.001+08:00

Just to re-iterate a point I made earlier...

Why health care is like water

DEPUTY Prime Minister Tharman Shanmugaratnam's proposed review of improved financing, regulation frameworks and clinical programmes to better integrate private and public health-care services bodes well for both health professionals and users ("Private sector to ease health care load?"; July 10).

While the mainstay of health care remains within the public sector, the private sector has reservoirs of reserves locked within, awaiting deployment once the Government can integrate the two with policies to overcome the major obstacles of cost containment and efficiencies.

Health care is a commodity that should be treated the way the Government treats water: essential and affordable, but with a price commensurate with its worth.

Like water, it starts with conservation of health through a conducive lifestyle.

Primary health care that is priced too cheaply and used as a political tool to garner popularity will be abused and fraught with wastage. Tertiary health care in hospitals will also be saddled with unnecessary and frivolous referrals.

However, the removal of the fee schedule for doctors, because it was deemed anti-competitive, has moved the cost of private health care sometimes to stratospheric levels.

A middle ground is sorely needed where general practitioners can practise good medicine without the price pressures generated by insensibly subsidised polyclinics; where private specialists can act as a valuable release valve from heavily utilised public hospitals, if only patients are assured that charges are capped at a fixed premium.

Dr Yik Keng Yeong

Well, I don't think that healthcare is like water - for one thing, healthcare doesn't fall from the sky like water, and I don't agree that the government automatically has rights over all the healthcare that falls onto Singapore...

But I certainly agree with Dr Yik's observation that:

Primary health care that is priced too cheaply and used as a political tool to garner popularity will be abused and fraught with wastage. Tertiary health care in hospitals will also be saddled with unnecessary and frivolous referrals.

Dr Yik recognises that abuse is a problem, and he diagnoses correctly (in my opinion) the reason why abuse is not tackled. However, by proposing that we solve this problem by re-siting patients to the private sector and making it attractive for the patients to want to be re-sited by capping how much doctors there can charge is merely punishing them for the lack of moral courage on the part of the politicians.

The problem, as Dr Yik has pointed out, is the "anti-competitive" "price pressures generated by insensibly subsidised polyclinics"; so if you cap GPs' charges at equal to or below that, then how will they make any profit? Or, if you cap the charges at higher than the polyclinics', then why would patients then choose to see a GP and pay more?

The way I see it, the real reason why abuse occurs is because we have a system where people are not required to pay for what they consume. As long as you are not willing to change that, you will have abuse; until you are willing to change that, or until you are willing to police for and stop abuse if you find it, the problem will remain with you.

Talk vs Action

2011-07-18T07:20:00.001+08:00

The exodus of doctors from the public sector continues to draw attention, as evidenced by recent Straits Times articles and Forum Page letters.

I'm glad that the ST's original feature - which suggests that money is the predominant draw to private practice - was quickly rebutted.

An invitation to a "physician engagement" luncheon 2 weeks ago helped debunk the myth further. With approximately 12 clinicians and 5 senior administrators ( also medically trained ) in attendance, it was a candid affair, allowing us to share concerns from the ground and suggest changes to ensure equal recognition for all areas of expertise.

While institutions currently favour those who conduct research, others who perform clinical duties full-time should not be overlooked. After all, without the latter serving as the department's backbone, the former may not be able to continue with what they're doing in the first place. What's the use of pioneering some new-fangled therapy, when there's no-one left to see patients in the wards and clinics?

Another issue that was highlighted: constraints imposed by the new residency programmes, especially in high-volume areas like polyclinics. Due to the stipulated limits on patient loads and working hours, it's obvious that non-residents will be required to bear the extra burden of clearing the backlog. This may in turn breed discontent among colleagues, resulting in more resignations.

One surgeon even remarked that the narrow scope of training for residents might render them less competent in the long run, compared to their predecessors who underwent the proverbial baptism of fire. And I agree with his prediction. Seeing few patients = less experience = poorer clinical judgment and procedural skills = suboptimal patient care.

And for the benefit of the administrators and corporate communications personnel: suboptimal patient care = more complaints = more lawsuits = hospitals lose more money settling out of court.

While the luncheon was attended by consultants, I hope that registrars are or will be included as well. Because they're the ones who tend to be treated like slaves, working inhumane hours, getting arrowed for everything, and unable to say no as they're the most junior in the department and are too afraid to offend their seniors.

As for the medical officers, they generally have it pretty good these days. Even the non-residents get to do half-calls, so instead of working 24- to 30-hour stretches, they come in at 9pm and go home the next morning. House officers also benefit from ECG technicians and phlebotomists in the wards. I never enjoyed any of these luxuries!

So it remains to be seen whether changes will be made, and how soon they will be implemented. I'd like to stay optimistic for now, and have faith in at least one of our leaders ( who was present that day ).

Let's hope it won't be another case of "all talk, no action".

You CAN put a price on everything...

2011-06-28T11:00:00.002+08:00

This news story made me smile:

Police to measure "the cost of crime"

SINGAPORE: In what will be the first study of its kind here, the Singapore Police Force (SPF) will commission an academic study to calculate the cost of the different types of crime committed here.

Modelled after a United Kingdom (UK) government research paper - The Economic and Social Costs of Crime - the study plans to use a "social cost approach" to measure the cost of crime in Singapore.

In response to Today's queries, police spokesperson Choo Hong Xian said the study "would provide valuable insights into operational policy-making, resource reallocation and police's strategies to deliver the mission".

The police release statistics on the overall crime situation here every six months but they relate usually to the number of cases, identifying key crime concerns and providing crime prevention advisories.

According to tender documents released last week, the study aims to derive the annual total cost of crime last year and "a preceding period stipulated" by the police. The final report from the study is expected to be delivered to the SPF within four months of the award of the tender, which closes on July 18.

Overall crime here fell by 0.6 per cent last year but the police highlighted three key crime concerns - cheating cases involving rental scams and phone scams, fighting youth crime and outrage of modesty cases.

The study aims to calculate the costs incurred as a consequence of crime, which includes "monetary loss in traditional terms" and "monetising the loss of life and trauma suffered by victims".

Costs of crime prevention and enforcement will also be tallied. The study seeks to find out costs borne by private entities - such as security expenditure and insurance - as well as costs borne by public bodies such as proactive police patrols in anticipation of crime.The police also intend to calculate the costs incurred in response to crime - investigating cases, apprehending suspects as well as the costs expended by the State in prosecuting, convicting and incarcerating suspects.

Several Members of Parliament had previously raised concerns over police resources being stretched. During the Committee of Supply debate in March, then-Home Affairs Minister K Shanmugam pointed out that while police resources will be increased, "they are not limitless".

While costs of crime prevention - such as installing alarm systems - and the State's response to crime could be measured, sociologist Paulin Straughan felt it might be "impossible" to measure the social costs of a spate of violence on a community. Social isolation and mistrust from these crimes would impact social capital on a community which would be difficult to estimate, she argued.

However, the former Nominated Member of Parliament felt calculating the cost of crime would serve as "a reality check" for any society.

"We live in a world that is driven by economics," Associate Professor Straughan said. "We can't understand or appreciate unless it is documented in dollars and cents. So, this is one way of documenting it (crime) in dollars and cents to show you that every burglary cost you this (amount) … and highlight the importance of crime prevention."

The UK study, published by its Home Office in 2000, found that crime in England and Wales cost society £60 billion (S$118.8 billion) a year, or more than £1,000 for every person.

Every murder cost the country an estimated £1.1 million, vehicle theft and robbery £4,800 and criminal damage £510 pounds, according to the Home Office report.

Assistant Professor Irene Ng Yue Hoong, who researches on youth crime and poverty at the National University of Singapore, felt any study on the costs of crime control should take into consideration the benefits from a decrease in crime.

"Do the marginal costs of crime control justify the marginal benefits from the marginal decrease in crime?" she wondered. "It will be interesting to study whether Singapore's crime control is at an optimal level in terms of the marginal benefits net of marginal costs."

As with healthcare and other valuable services, police work costs money; but as the cost is not borne by the user, the true cost is hidden and abuse occurs. Does this study by the SPF signal a desire on the part of the government to shift the cost of security from the public to the direct consumers? I certainly hope so. Now there will be people who will tell you that you cannot put a price on security (and health) - the truth is, you can: they just don't want to pay for it.

Scarlet fever, Hong Kong

2011-06-22T01:44:00.002+08:00

For the past few days, an increasing number of Hong Kong children have been diagnosed with scarlet fever, with two deaths to date. The Hong Kong Centre for Health Prevention now posts daily updates here. So far, one kindergarten in Sha Tin district has been closed, while two other schools in Kowloon and Yuen Long districts have reported cases.

Scarlet fever is caused by Streptococcus pyogenes (or Group A streptococcus for those of you who remember the antiquated Lancefield groups), a bacterium that is better known in the media as the "flesh-eating bug" because it can rarely cause necrotizing fasciitis. Residents (got to get used to this word!) know it as the bug that most commonly causes cellulitis (although hardly ever cultured), while those going for medical clinical exams remember it best as the cause of rheumatic fever and rheumatic heart disease.

But on a more prosaic level, it is carried in the throats of about 10% of school-going children (some reports put this as high as 28%), where it doesn't generally cause any disease. S. pyogenes is spread via contact, and better hygiene will help prevent transmission (always difficult in young children hence more schools in HK will probably be closed).

Given the unusual virulence and scale of this outbreak, it is likely that we are seeing a novel clone of S. pyogenes, as was the case with the Escherichia coli causing the huge outbreak in Germany recently.

Restructured hospitals in online posts

2011-06-14T20:29:00.002+08:00

There are probably many others, but I shall just focus on two today:

Alex Au blogged about the hospital bed crunch today, almost one year after his last post on this topic. His father, who apparently had a UTI, had to wait for four hours at the Emergency Department before being admitted. This is indeed a problem that is disturbing not only because it wasn't anticipated (or at least deemed not to matter), but because all the signs were present and the feedback available for the past several years. Restructured hospitals have become increasingly creative in dealing with this issue (mainly in terms of improving the time to actual care delivery and reducing the time where patients are stuck "in transit" in the ED observation rooms) - like NUH's aptly-titled "The Big Squeeze" - but the hospitals can only do so much with the limited number of beds relative to the growing population.

In the Temasek Review Emeritus, a Ms Serene XM Cai complained about the delays in her treatment at SGH, questioning whether she received 2nd class service because she was a B-class patient. Poor Dr Bok (her primary physician) must be wondering why he's suddenly notorious! But... I could not really find anything wrong with the way she was managed. She received an MRI within 24 hours of admission, and the ultrasound (TENS?) on the following day. How is that for speed of service in a public sector hospital for a subsidized patient?? Very few public hospitals worldwide can achieve this. Sure, Mt Alvernia specialists reached the diagnosis rapidly and prescribed treatment that was presumably successful, but then again, the last set of doctors patients see generally gets things right because of all that has gone on before. This is a case where the patient's expectations were much too high and they were perhaps not managed well.

GPs not "functioning"?

2011-06-07T19:16:00.005+08:00

The subject of GPs doing aesthetics came up again recently when Dr Woffles Wu wrote a letter to the ST Forum, arguing that liposuction should only be done by specialists.

MOH replied today; while I have no opinion on whether GPs should be allowed to perform liposuction, the final paragraph of the letter disturbs me:

The ministry is in the process of strengthening our primary- care sector by enhancing the training of GPs so that more of them could function as family physicians. This will eventually help to improve our primary-care capability, especially in managing chronic diseases in our ageing population.

Now the 'problem' of GPs doing aesthetics has two parts to it: "why don't GPs do primary-care?" and "why do GPs do aesthetics"?

The answers to the two questions are largely related: to the first part it's because GPs do not see doing primary-care work as rewarding to them, and to the second part it's because they see doing aesthetics work as rewarding. However, it would be wrong to think that if we stopped them from doing aesthetics it will automatically mean that they will all turn to primary-care work, specifically to "managing chronic diseases in our ageing population". They can still make a living 'selling' MCs and 'lifestyle' medications (remember this?), or running a high-volume low-quality corporate contract practice, or doing "health screening", where "problems" are "diagnosed" but not treated (that's where the lucrative end of the business is, you see...).

In other words, 'GPs doing aesthetics' is not the root of the problem for 'GPs not doing primary-care', but a symptom. If you stop GPs from doing aesthetics, then they will likely find something else to 'do'. We can only hope that it's not something like Subutex...

So why don't GPs want to do primary-care then? Is it, as Dr Chern seems to suggest, that they don't know how to? That they need more "enhanced" training before they can even "function" as family physicians? Now bear in mind that we are talking about doctors who have invested the time and money into learning how to perform the various treatment modalities that aesthetics encompasses, not to mention the equipment cost. You do not wake up one morning and say to yourself: You know what? I think I'm going to do aesthetics today. Dr Chern tells us that to do liposuction, a GP has to "be accredited by the Accreditation Committee on Liposuction (ACL) and their medical clinics have to comply with specific licensing conditions". Are such people really incapable of functioning as family physicians?

Now even if that was true - let's just assume for argument's sake that a doctor who has gone through housemanship is not capable of functioning as a family physician (and they are not) - we have a situation where a new doctor has the choice between learning how to do aesthetics, and going through the "enhanced training" that allows him to function as a family physician. Which path do you think he will choose and why?

The bottom line here is that primary-care work, specifically the"managing chronic diseases in our ageing population" part, is not financially rewarding. Part of the problem lies with the fact that our healthcare system subsidises primary-care indiscriminately - you may not qualify for full subsidy under means testing in the wards, but you can still get full subsidy at the polyclinics, and be referred to a specialist as such, no questions asked. Such a situation distorts everyone's perception on what primary-care costs and is worth, and the result is what we are seeing today. (Ironically, SMA's effort in trying to encourage GPs to stay away from a high-volume low-quality care with the guidelines of fees was ruled anti-competitive.)

To a hammer, every problem is a nail. To a regulatory group, the solution to the problem is more regulations. The 'authorities', when presented to a problem, will always be tempted to 'do something'. Perhaps it's time MOH took a step back and looked at the economic realities that are present, and asked themselves whether their existing policies have made the practising of primary-care unattractive to GPs. If you can make it rewarding to them, the GPs will train themselves to become good family physicians (MOH don't provide enhanced training for GPs who want to do aesthetics, do they?); if you make it unrewarding to them, then why will they want to train to be a family physician at all?

"There is no abuse"

2011-05-31T21:54:00.005+08:00

Earlier this month, in the comments section of one of our posts, a reader disagreed with me that abuse of the healthcare system exists. She asked:

I believe no one likes to fall ill. No one wants to be sick. Therefore,
tell me who is there to abuse system?

Well, in his first blog post as Health Minister, Mr Gan Kim Yong writes:

We will have to review our funding framework, as well as the various financial assistance schemes, and make the necessary adjustments to ensure they remain appropriate and effective in helping Singaporeans cope with healthcare costs and yet prevent wastage or abuse.

Bravo.

Now this does not mean that the Health Minister *knows* that abuse exists, but it does mean that the feedback he received from healthcare workers is that it does exist; so if you think that the existence of abuse is merely a figment of my imagination, well, now you know.

To simply say: "let's subsidise more" is the populist and easy solution in the short term, but it does seem that Mr Gan is not going down that route.

Longtime readers of the blog will know that I am against our current subsidised healthcare system because of the lack of moral courage in policing and stopping abuse, and that the way to stretch our healthcare money is not to simply put more into the budget, but to cut waste. Will a new minister and new policies make me change my attitude towards subsidised healthcare? Well, we'll just have to wait and see, won't we?

A Lifetime to Master

2011-05-27T06:17:00.015+08:00

A colleague recently remarked that being the (self opined “best”) expert that he was in his field, there was no one else he could discussed his cases with anymore. It is true that in this day and age you may end up as the only expert in your area (even internationally) especially if you sub (x n) specialize. However, whilst one might think one is the crème de la crème or the king of the hill, as a doctor, he must never assume that he can no longer learn from anyone. One can obviously turn to literature, research and international expert meetings but in truth, although background noise is aplenty, there are only that many substantial findings worth committing to memory, barring special breakthroughs. But when the science of medicine stagnates, it may be time for us to hone the art. Personally I find that I have learnt much from two groups of people.

It is an unfortunate (hard) truth that most doctors are narcissistic to begin with or will become one in the course of their training. It is already a daunting task to ask to experts to listen to one another much less to their undifferentiated juniors. However, this is silly as young bloods often have new ideas and have fresh eyes to some of the clinical problems we face. They are not burdened by the prejudices accumulated together with the years of experience and do not have preconceived notions. I often hear good ideas from MOs and Registrars and even if I may not agree with their ideas, it always good to listen to what opinions they have to offer when it comes to a difficult clinical scenario. Also, there are many junior Drs who may be extremely well liked by patients, receiving good comments (as well as cards and gifts) from them. I would observe (and learn from), albeit quietly, their mannerisms and attributes which endears them to their patients. The rapport that a doctor has with his patient often would make or break the management of the case and such soft skills had often been ignored by hardcore physicians and might not be the forte of many a senior Dr.

It may also come as a surprise that we often (consciously or unconsciously) learn from our patients. It does not matter how familiar you are with the literature, nothing beats having a firsthand account of the effects or side effects of a medication from a patient. We continue to learn about signs and symptoms presented in their many varied forms and often distorted in many ways by cultural overlays.

To illustrate, I had an elderly lady who came late for her appointment and complained of anxiety and itchiness in her womb. As she had been late and I was in a hurry to end my clinic, I was quick to dismiss her. My dismissive attitude continued for a few visits and I felt rather irritable with her persistent complaints of itchiness in the womb which I knew to be anatomically impossible. During one of her visits, my clinic was unusually empty and perhaps as I was less flustered that day, I chatted with her for an extended period of time. She told me that after her husband passed away, she had single handedly brought up her two children doing odd jobs. She had since retired as her children have all grown up and she was staying with her son, a successful engineer. Unfortunately, her daughter-in-law and her grandchildren found her uncouth and her son without putting in much thought was negotiating for her to move in her daughter. However, her daughter was not willing to take her in either due to space constraints. She was immensely disappointed and had worries that she would be abandoned. It became clear from her account was developing the anxiety due to the recent turmoil in her life particularly to the fear of being abandoned by her children. I felt ashamed of myself for having ignored this lady previously because she was late. Given her lack of education, she would have had difficulties maneuvering around our rather complicated hospital system to have made it to see me, thereby being late. More importantly, her accounts made me reflect on my own relationship with my parents.

It is important to sometimes slow down to look (at), listen (to) and feel (with) the people around our clinical practice. We may learn powerful lessons from the most unlikely person in the most unlikely place. For it may take ten years for one to become a fully accredited specialist but it will take a lifetime for us to master the art of medicine.

Dr BL Og

If healthcare in Singapore is unaffordable...

2011-05-25T22:33:00.002+08:00

... then who have been 'affording' these pills?

"Why Physician Compensation Plans Fail"

2011-05-25T17:00:00.004+08:00

Here's an interesting article from Medscape:

(abstract)

What is the number one reason why physicians leave their practice group?

Discontent over their compensation.

There are many ways to structure a compensation plan, and each has its pros and cons. A group may compensate its partners on the basis of productivity measured by relative value units generated, bonuses that are based on productivity and patient satisfaction, equal pay model in single-specialty groups, achievement quality and efficiency measures, or a number of other plans.

Unfortunately, many groups rush to create the compensation plan design before they bother to develop clear-cut strategies that would guide the building of the plan. They also neglect to reevaluate the plan on a periodic basis and to pay closer attention to critical signs of dissatisfaction with the plan.

For example, the compensation plan was a real sticking point for one 27-physician orthopaedic surgery group. They had a long-standing income- and expense-sharing plan in which expenses were shared on the basis of revenues. The 3 spinal surgeons produced more revenue, and so their expense allocation was greater than that of their partners.

However, because those 3 surgeons saw fewer patients in the office than the other partners, they used the staff (the major expense item) much less than their colleagues did. In addition, because those 3 surgeons' fees were higher than any of their fellow orthopaedists, the billing staff devoted much less time to billing and collecting those revenues.

The 3 spine surgeons wanted to change the expense-sharing arrangements and were ready to quit the group if the changes weren't made. The other surgeons didn't want to make the change.

The outcome? We recommended a minor variation in the expense-sharing formula that resulted in modest decreases in the incomes of 24 partners but in measurable increases in the spine surgeons' take-home pay.

The article refers to a private group practice in US, but I think it's just an example of human nature at work and that the experience is universal and applies not only to medical practices, but any other profession where contribution and renumeration are not consciously and regularly managed, and of course society at large.

Subsidy - the cure for all woes?

2011-05-12T19:22:00.000+08:00

The problem with the 'subsidy mentality' is that after a while, it becomes so ingrained that people begin to look at 'subsidy' as the solution to what we perceive to be a social problem. Now, it seems that a doctor (dentist?) is calling for doctors and dentists to be subsidised too!

GPs and the elderly bear brunt of foreign doctor influx

HEALTH Minister Khaw Boon Wan believes that his ministry's current 3M (Medisave, MediShield and Medifund) health-cost strategy facilitates even expensive procedures such as a heart bypass with minimum cash outlay ('Opposition has strange ideas on health care: Khaw'; last Wednesday).

Regarding doctors, Mr Khaw's present strategy seems to be to leave market forces to equilibrate. This means that doctors are left to fight for their survival, causing many general practitioners (GPs) to practise aesthetic medicine to supplement their income.

The influx of foreign doctors to fill places in government hospitals and polyclinics has resulted in a communication breakdown between elderly patients and their doctors. Our health-care system is in a lose-lose situation in which doctors and patients suffer.

Such a fire-fighting strategy could be avoided with proper planning. Our health-care system is well-developed, so why have health-care needs for the next 10 or 20 years not been forecast?
The full social impact of the influx of foreign doctors will be felt in a few years but local GPs and elderly patients are already feeling the pain.

As GPs cope with rising costs, the cost of medical care will rise with inflation. Lowering medical fees artificially will only result in poorer quality of care.

To help GPs contain operating costs, the Government should consider offering subsidised rentals in Housing Board neighbourhoods.

GPs and dentists must now compete with the likes of cellphone traders and bubble tea sellers for the same shop space. Which is a greater public service? Is return on investments more important than health-care affordability?

Dr Ng Yong Kheng

Now the thing is, if you fail to identify a problem correctly, you are not likely to come up with the correct treatment for it. Or even worse - if you begin by deciding on a treatment and then go back and try to frame the problem so it fits your treatment...

The first misconception here is that GPs do aesthetics to make ends meet. While GPs may initially go into or dabble in aesthetics to "supplement their income", my experience is that they soon find it so lucrative it becomes the main source of their income. I have had colleagues who started doing aesthetics "out of interest" or to "supplement income" or whatnot, and for a while even as they expanded their aesthetics practice they continued to keep a foot in primary care "as a form of social responsibility" or "to stay in touch with the basics" - but now they are in full-time aesthetics, operating out of full-fledged aesthetics clinics. Ask yourselves this: You have seen 'normal' GP clinics turn into 'aesthetic clinics' or the 'aesthetic branch' of a clinic chain - has the reverse occurred? Has a clinic ever turned from being an aesthetic clinic to a 'chronic disease clinic'? Have you ever had a doctor refuse to take on another botox case because he has made enough for his rent this month, and would rather spend that time slot looking after a patient's diabetes?

GPs may start aesthetics to supplement their income, but they do not stop once the overheads are all covered. The resources, in terms of training and equipment, once invested, just makes it economically more sensible to convert one's entire practice into aesthetics.

So will lowering rental for clinic spaces make GPs turn from aesthetics to primary care? Well, as I asked in the comments section of a previous post: if you are selling tea for $2 a cup when HDB halved your rent, and people are still willing to pay for your tea at that price, will you lower the price to $1?

And that brings us to the next point Dr Ng brought up when he asked: Which is a greater public service - GPs, or cellphone traders and bubble tea sellers?

I think the question to ask instead is this: Does the average Singaporean spend more on primary care each year, or more on handphones and bubble tea? What about cigarettes and alcohol? Hairdo, nails, spas? Now the fact that all these service providers can compete for the same shop spaces as the GP tells you something - they can turn a profit at the same rental. And the reason why they can do it is because Singaporeans are willing to spend money on what they have to offer. Granted the people whom we normally associate with spending on such things may not be your typical picture of a patient with chronic diseases, but you cannot deny that many will become such, and that the money not spent on those discretionary expenditures now can be saved to pay for one's healthcare needs later in life. If Singaporeans are willing to spend as much on primary care as they do now on all these things and on aesthetics, will GPs have any incentive to go into aesthetics or to let their spouse run a bubble-tea stall out of the same shop space? The players in this equation are not just the landlords and the tenants, but also the consumers. The consumers' choices determine to a large extent whether a business model is successful or not - just ask any Luohan fish seller.

I believe that this 'problem' of GPs doing aesthetics rather than primary care cannot be 'solved' if we continue to deny the economic realities, which is that patients help create that market by the choices they make, and they make those choices because of the perceived value of primary care to them, and because our subsidised healthcare system allows them to abdicate responsibility for their own healthcare.

Doctors & Nurses (and other healthcare staff)

2011-05-10T04:31:00.003+08:00

This article - "Physician, heel thyself" - was published in the New York Times on polling day. Written by an oncology nurse, it decried the fact that even today, a significant number of doctors do not respect nurses and the work they perform, dressing them down or treating them with condescension.

Such things also happen in Singapore. During my service in public hospitals, I have seen doctors yell at nurses, jeer at them with sarcastic remarks, and make fun of them behind their backs. Thankfully, only a minority of doctors do this, although more may feel that they are at the top of the pecking order in clinical care. The situation is not helped by the fact that more and more nurses (and doctors) are foreign-born, and adjustment to work in Singaporean hospitals is not the easiest thing in the world.

Nonetheless, good teamwork makes for more effective clinical care. Currently, nurses are doing more and more of the jobs previously performed by physicians - an advanced practice nurse is the virtual equivalent of a medical officer (except for prescribing rights), and may have more knowledge in their area of specialty. Conversely, this frees up more time for doctors to further their skills and knowledge.

GE 2011: The Aftermath

2011-05-09T09:56:00.002+08:00

The ruling party may have retained an overwhelming majority in Parliament, but the overall results for the PAP are less than stellar, as their national vote share dropped to 60.14%, "the lowest in all post-independence elections".

At Singapore MD, readership hit an all-time high of 1,532 on 6 May, as varied opinions from our contributors generated spirited debates. Prof. Tambyah's SDP rally speech was especially contentious, resulting in a steady stream of comments and rebuttals.

A number of S'pore MD's writers have met Prof. T in person, and have great respect for him as a physician and tutor. I sat at the same table with him at a wedding dinner a few years ago, and still can't quite believe that this mild-mannered gentleman could stand up in front of thousands at an opposition party rally, to lambast the MOH. Bravo!

As for rumours that he was asked to resign, these remain unfounded. However, a source indicates he may have been called up by certain powers-that-be for, ahem, "a chat".

So as the new government prepares to tackle the next 5 years, I hope the PAP will indeed "reflect" on what it's done wrong, and endeavour to rectify its mistakes. And since S'pore MD is featured in daily reports churned out at the MOH, I trust Minister Khaw will pay more attention to the issues being raised by our bloggers and readers, who comprise healthcare workers and laypeople.

From what I've read in recent weeks, the hottest topics appear to be:

1) manpower imbalance between the public and private sectors - how to plug the leak?

2) foreign doctors - boon or bane?

3) improving subsidized medical care for S'poreans - increase Medisave usage? increase GDP expenditure?

4) the plight of GPs - what can be done to channel them back into primary healthcare and away from aesthetic medicine?

5) assistance for singles caring for elderly parents with chronic illnesses - they should not be left out of the equation

Any additional suggestions are welcome in the comments section.

As for the "horror stories" about high-profile patients who punish innocent doctors, I suggest these doctors report the incidents to the Worker's Party. More ammo for the next GE.

Good idea, no? :)

Doctors And Politics VII

2011-05-05T23:03:00.005+08:00

The furious debates over healthcare issues affects me in 2 ways: first, as a physician in a public hospital, and second, as the only - and single - child of elderly parents with chronic illnesses.

As a healthcare worker, I am disappointed and appalled by how the MOH has managed the manpower issue.

17 years ago, it clamped down on the number of overseas medical schools with degrees which are recognized here, effectively preventing many foreign graduates from returning to Singapore to practise. Fortunately, I was one of the lucky ones, and was accepted at NUS after clearing the interview.

As time passed and the shortage of doctors became obvious, this restriction was gradually lifted. NUS began increasing its annual intake of medical students. Then Duke GMS materialized. Now a third medical school. Plus a huge influx of recruits from non-traditional sources ( e.g. the Philippines, India, Pakistan ) as the floodgates opened.

Prof. Tambyah echoes my sentiments that 'maldistribution' is the root of this problem. It has never been an absolute shortage, and I'm certain the MOH realizes this. But its strategy remains the same: plug the leak with more new graduates and foreign recruits, and everything will be fine.

Does the MOH wonder why there's a leak in the first place? Often, it is due to poor welfare for overworked and underappreciated doctors. Ridiculous patient loads in the wards, clinics and emergency departments. Minimal protected time for teaching and research ( unless you hold a fancy position like 'physician faculty' or 'clinician-scientist' ).

With 2 spanking new hospitals being constructed, the thinning medical workforce will only be stretched further, and more non-local HCWs roped in to fill the gaps.

KTPH opened without sufficient preparation, in an apparent attempt to pacify Singaporeans. Shortstaffed departments resort to pilfering specialists from other public hospitals to run their clinics, do ward rounds and supervise A&E medical officers. It may have come out tops in the recent patient satisfaction survey, but feedback from the ground is far from favourable.

Which leads to the next bane of my existence: those blasted surveys. I would like to get my hands on the forms used, and have a detailed explanation of the methodology utilized. How are respondents selected? Tell us every single KPI that was assessed. Do the patients' answers match objective data?

The last question deserves scrutiny, because my HOD informed us during a recent meeting that despite patients seen at our department complaining that waiting times are long, these do not reflect statistics collected from computerized records. In fact, our waiting times rank among the best of the lot, but patients' PERCEPTION is opposite to actual performance.

Instead, the Health Minister praises KTPH for maintaining its excellent service record ( transferred from AH ), and tells the rest to buck up.

Obviously, I don't work at KTPH. I belong to a department that has taken numerous measures to improve waiting times and patient care, and which is one of 3 important divisions that is regularly assessed in these hospital surveys. Do you know what such results do for our morale? It is gut-wrenching, especially when patients' ignorance is printed as fact, and facts are left out of the picture altogether.

We are indeed very fortunate to have a CEO who values clinical quality above such nonsense. Other institutions may not have such an understanding leader ( *cou-KTPH-gh* ).

Next, my role as an only child whose elderly parents have an assortment of chronic illnesses requiring long-term medication and assisted care. I do not have a maid, and thankfully, they are both still independent in most activities of daily living, though an unforeseen event ( e.g. an accidental fall, perhaps even a simple viral infection which develops into something much more serious ) could alter the situation drastically.

While they do have CPF reserves and personal insurance plans, in addition to my own Medisave funds as backup, benefits for singles are scarce. As a blog reader pointed out in a personal email to me, singles are not entitled to foreign maid levy relief, and eldercare leave is non-existent. The former is reserved for married couples, for the main purpose of allowing mothers to continue contributing to the workforce.

I contribute to the workforce on a full-time basis, compared to many colleagues who part-time for family reasons. Why do I not qualify?

Eldercare leave is also worth looking into, especially for those of us with less familial support ( no siblings, siblings who have migrated, etc ), parents who are home- / wheelchair- / bedbound, and/or require frequent medical follow-up for multiple co-morbidities or complicated diseases. I routinely use my off days to accompany my parents, but not everyone enjoys the luxury of a flexible schedule and 5-day work week. Caring for children may be challenging, but managing frail parents is no easy task either.

Last but not least, the use of Medisave for the treatment of chronic illnesses approved by the MOH. An annual withdrawal limit of $300 is allowed per account, and up to 10 accounts belonging to immediate family members ( spouse, child, parent, grandchild ) may be used. So again, since I am single and an only child, our options are markedly reduced.

My father has diabetes, hypertension, hyperlipidemia, renal impairment and severe DM retinopathy. He is fully compliant with medications and lifestyle restrictions, but still requires a fistful of drugs to ensure tight control. Despite all these measures, his vision continues to deteriorate. ( In case our doctor-readers are wondering, the retinopathy was already present upon diagnosis - not a result of poor compliance - so subsequent therapy was aimed at slowing progression, since prevention was no longer possible. )

A blanket sum limit of $300 is not enough for those with multiple co-morbidities, especially if disease control is a challenge. In such cases, more medications, or more powerful drugs - which are often also more expensive - are required, not to mention more frequent consultations involving multiple specialists. A one-size-fits-all approach clearly doesn't work.

Last but not least, as the mortals ponder their fate and suffer sleepless nights, I wonder if our well-paid politicians are subjected to the same policies they draw up and publicly support? Do they see polyclinic doctors? Do they consult specialists as subsidized patients? Do they stay in subsidized-class wards when they're admitted? Do they dig into their own pockets to pay for their medical expenses? Or do they choose only the best physicians and surgeons, skip the long queues for appointments and at crowded clinics, stay in A-class rooms, get treated like royalty and make the taxpayers foot the bills?

We can argue that government officials deserve medical benefits of a completely different scale. But how many government officials are paid such high salaries?

A few things the opposition should bring up in Parliament in the near future...

Doctors and Politics VI - Fisking Prof Tambyah's speech

2011-05-05T22:15:00.008+08:00

Well, as I promised, here is my rebuttal to Prof Tambyah's speech at the SDP rally.

The first few paragraphs are populist rants and jibes which I have come to expect for rally speeches, so let's get straight to the meat.

1. Medisave

Prof Tambyah asks how many Singaporeans "can afford to pay $250 a day or $7500 a month for medications for three to six months on top of the needs of their own families". Well, $7500 over six months translate to $45,000. Now if you lived in a private condo, and needed $45,000 to fund something in your life, what would you do? Do you expect other Singaporeans to help you pay for your need?

What if someone who lived in a private condo who needed $45,000 took some money from you without your consent to fund his need? Do you think that is fair? Wouldn't you ask him to explore other options of raising that money before he took it from you? Cut back on some discretionary expenditure? Sell some assets? Borrow from friends and families? Or even downgrade to a less costly home, perhaps? Charity? Why should "get someone else to pay" be the "solution" of choice?

Now ask yourself why things should be different when it came to healthcare?

It is easy to say "ask the government to fund", "ask the medical social worker to help", but we need to recognise that at the end of the day, that money come from all tax payers. By demanding that others pay for our healthcare, we are making our own health other people's burden.

2. Primary Care Proposals

It is perhaps impossible to get precise statistics on this (so feel free to ignore this section if you disagree with my basic premise), but our outcomes in the management of chronic diseases at the primary care level does not fail at the level of access or provision, but at patient compliance. Our polyclinics are already staffed with nurse managers, nurse practitioners, dieticians, physiotherapists, podiatrists, psychologists... all charging nominal sums for their advice and treatment. But ask your friend who works in a polyclinic what the take-up rate for these services is like.

Patients can afford these services which will help them understand and manage their health better, but they choose not to. Their health is not a priority to them when their diseases are still in the primary stage and they choose to invest their resources elsewhere; but when complications set in as a result of their decisions, it suddenly becomes everyone's problem?

3. GPs

It is often said that GPs go into aesthesics to make ends meet - I prefer to think that they do so because aesthetics is more lucrative. And that aesthetics is lucrative tells us two things: 1. Singaporeans are not too poor to afford healthcare that they want, and 2. Singaporeans choose to spend on aesthetics.

Can the government make GPs stop doing aesthetics by lowering HDB rents? Well, ask yourself this: if you are running a tea stall selling tea at $2 a cup and people are willing to pay for it, will you lower your price to $1 just because your landlord lowered your rent?

The reason why GPs can do aesthetics is simple: people can afford aesthetics, and they are willing to afford it. If patients are willing to show that they are willing to afford good primary care, then GPs will return to providing good primary care.

+++

My take on the speech overall?

It is true that healthcare can be expensive - if your health is valuable, then why shouldn't healthcare be expensive?

But is primary healthcare really out of reach to the average or low-income Singaporean? No. I reiterate my point that the key barrier to good control of chronic diseases at the primary care level is compliance and not access or cost.

Look at what Singaporeans spend on instead of investing into primary care, or setting aside for catastrophic illnesses: cigarettes, alcohol, hairdo (yes, I actually wrote that word), iPhones (what, you think iPhone users don't get diabetes?), that year-end trip to Perth - show me a polyclinic doctor who hasn't had a patient who can afford to go on a year-end holiday in Australia ask him or her for subsidised travel medication.

Cases like that related by Prof Tambyah are not unique, but it is disingenious to conclude from that one anecdote that Singaporeans are dying at a massive scale for want of healthcare, and that our healthcare system is heartless or has failed. Prof Tambyah wants you to think about the patient with a stroke and his son who lives in a private condo, I ask you to think of all the Singaporeans who by paying tax have a little less of the money they have earned themselves to spend as they wish to, to invest in their own health and their own future. If they wish to help, they can always donate to a charity - but to say that they must help? Is that fair?

What I do agree with Prof Tambyah though is this: Dr Vivian Balakrishna is an excellent ophthalmologist. I too think Singapore will be better if he returned to clinical practice.

Doctors and Politics V (Local)

2011-05-05T16:42:00.003+08:00

Election fever seems to have hit SingaporeMD as well - we have more posts (and more page views) in the recent two weeks than anytime since inception, robust discussion in the commentary (mainly our colleague angry doc defending his point of view against all comers), and no "groupthink" despite the similar careers of the bloggers.

In the real world, it seems that that the doctors actively involved in politics and civil society are divided as well. The initial prominence of doctors in the ruling party has given way to the surprising revelation that some doctors have also given their time and energy towards alternative policies. This is a welcome change as doctors worldwide tend to have a conservative outlook (no surprise as most doctors earn quite a bit of money and lead comfortable lives despite all the moaning) - most doctors in the US tend to vote for Republicans, for example.

Among newcomers in the PAP, we have Dr Janil Puthucheary, a bright and dedicated pediatrician and a great teacher who unfortunately chose to conflate his profession (saving children's lives) with national service, and Mr Chia Shi Lu, who literally "parachuted" into parliament without having been introduced to the nation. Now, I have only heard good things about the SGH orthopedic surgeon, and he is likely to do a good job as an MP. We should also not begrudge those who grasp opportunities firmly as they arise - if he had (and this is speculation) negotiated the Tanjong Pagar slot while his popular colleague Mr Baey was sent to buttress the former MND minister's team in Tampines, then kudos to him. It is good election strategy for both him and his party.

Among newcomers in the opposition, we have Dr Ang Yong Guan, a psychiatrist with very impressive credentials and experience. His rally speeches sound a bit strange to me, but perhaps that's the hazard of his profession. During my medical school days, I thought virtually all the psychiatry tutors and professors sounded a bit odd. Then there is the "outed" medical team that provided expert input for the SDP's shadow healthcare plan, many of whom are not actually SDP members. Prof Paul Tambyah, in particular, also spoke at the SDP's final rallies as a "guest speaker" along with Mr Tan Kin Lian. Prof Tambyah is well known in the medical and biomedical research community, and possibly more famous internationally than he is in his own country. He is an infectious disease physician by training, a prominent debater, and a member of the local human rights group Maruah. He was put up for the nominated MP position by the Singapore medical community recently, but was rejected by the governmental selection committee.

Many doctors (well-educated as we are) continue to express the fear that the votes are not secret, and that there might be future repercussions in terms of their career prospects (public sector-wise) if they voted "wrongly" or assisted the opposition parties. In this light, it will be interesting to follow the careers of Prof Tambyah and Mr Chia Shi Lu from now and see if such fears are in fact groundless.

Doctors And Politics IV

2011-05-04T17:37:00.001+08:00

As Polling Day looms and election campaigns heat up, I'm sure many voters have already more or less decided on their choices. I know I have.

Debates about the local healthcare system rage on, as they have for decades. Cliched as this sounds, no system is perfect. But as someone from the Workers' Party recently commented during a rally: What makes sense isn't necessarily right.

If the opposition wins more seats in Parliament and calls for change, only time will tell if new policies will prove superior to what we have now.

The main question we have to ask is whether the PAP is willing to implement these changes based on the feedback they've received - even if on a trial basis - or do we need members of the opposition to push them through?

However, I find it increasingly difficult to pledge allegiance to a government that, in my opinion, swept the hospital overcrowding problem under the rug, until the Health Minister got badly flamed on a prominent blog, after which measures were hurriedly taken to minimize ( public relations ) damage control.

Or to a government which employs an MP who was fully aware of the overcrowding problem, but when directly asked to highlight the crisis to the Health Minister, let personal grudges take precedence over patient care, and replied, "Of course I can, but why should I?" [ direct quote, by the way ]

I have also heard enough horror stories from medical colleagues - it's a very small community after all - about the consequences of treating certain high-profile patients, even when the patients' stubborn refusal to obey instructions resulted in complications.

And I honestly hope the practice of having A&E doctors and nurses drop everything during a busy shift to make house calls will not be revived. VVIP ambulances exist. Use them!

Choose wisely, my friends.

Shadowy Health Plan

2011-05-04T17:15:00.011+08:00

Blogger's impression of the James Gomez Wing of Chee Soon Juan Memorial Hospital

Since his fellow bloggers have touched on the topic of healthcare in politics, angry doc thinks he might as well join them... not that anyone can accuse Singapore MD of groupthink though...

Healthcare for those who need regardless of ability to pay it is an attractive concept, so much so that some doctors believe in it, and of course political parties promise it.

You can have a look at SDP's "Health Plan" here.

My visual gag aside, I find parts of the "Health Plan" worrisome...

I wonder, for example, how SDP plans to "encourage" "healthcare workers, general practitioners and senior consultants in private practice... to perform sessional work in public hospitals". You see, it is always easy for those who do not provide the funding or possess the skills to "volunteer" that of those who do. Somehow I am not "encouraged" by this part of the "Health Plan". Are my fellow healthcare workers?

SDP also proposes an insurance where "healthcare coverage is jointly managed by the Government and appointed national insurers". So the question here is of course: what's in it for the national insurer? Can they or can they not make a profit?

Well, the proposed insurance scheme "will not be a catastrophic policy with myriad exclusions like Medishield, it will be a truly comprehensive national health insurance policy that benefits from economies of scale and covers preventive healthcare rather than simply the expensive treatments at the end of life".

There are two problems with that.

First of all, if it is universal, and does not have a "myriad" of exclusion clauses and is "truly comprehensive", then most if not all Singaporeans will utilise it. For Singaporeans to benefit from it, they must be paying a premium that is less than what their claims amount to. That being the case, how can the insurers make a profit? It will be as though it were a lottery scheme where everyone wins more in prize money than they spend on the lottery ticket. When the insurance is "universal" and "comprehensive" and the insurer is not allowed to cherry-pick, then the only options for them are to make a loss or to charge a premium that ensures they don't make a loss, in which case the premium per capita will by definition have to be more than the pay-out per capita. There will be, at the end of the day, no free lunch.

Unless SDP decides to likewise "encourage" the insurers to... co-operate?

Secondly, the insurance does not cover (I may be reading it wrong, but the wording is vague here) "the expensive treatments at the end of life". Now this tells me that SDP actually realises and acknowledges the fact that the bulk of healthcare expenditure a person incurs actually occurs in the last year or the final months of his or her life. Add that to the fact that almost 100% of Singaporeans (yes, you never say always in medicine, especially since Mr Lee and Mr Chiam still seem to be out and about...) will eventually die regardless of how well they take care of their health, then you end up with either a) a healthcare insurance that covers you for what you can afford, but not what you cannot afford if SDP does not cover end-of-life treatment or abolishes the current 3M scheme, or b) a healthcare insurance that covers every Singaporean from cradle to grave, at either a premium too high to fund, or a loss too great to sustain.

And I haven't even touched on the issue of abuse yet.

So will it work?

SDP has given us the answer themselves when they write: If you do get struck by a serious illness, you will not have to sell your home if the SDP is in Parliament, we will make sure that all the money you have paid in GST, ERP and all the other taxes and levies go towards giving you the best medical care in the most appropriate manner.

It will work in the short and perhaps medium term (until the reserves run out) if the tax payers are willing to pay for it. It may not be a lot more than what you already pay now, but with "free" healthcare come moral hazard and abuse, and once the reserves run out, then whichever way they skew the income tax curve, someone's going to have to bear more of the burden. Are you that someone, or are you the person who thinks it's OK for that someone to bear more of the burden?

Healthcare issues: Responsibility

2011-05-04T12:26:00.003+08:00

Is it fair for other people to pay for your healthcare needs, especially if you fail to take responsibility for your own health? This is an emotionally-charged question that our colleague angry doc has raised several times, and it is quite clear what his answer is.

Where to draw the boundaries of that responsibility is less clear. Most people will agree that if you catch a flu because you are in a crowded MRT or workplace with people coughing and sneezing away, it is not your fault (yet why didn't you wear a face mask like some of the Japanese?). What about a child running onto a cycle track after a ball who then gets knocked down by a cyclist? That's probably not quite his fault too (after all, he's just a small kid - his parents could have taught him better, but there are limits there). A student who comes down with leukemia and then needs a bone marrow transplant? That's probably close to the ultimate in bad luck - and therefore thankfully extremely rare unless it happens to you. On the other hand, if you happen to be the sort who loves your weekly char kway teow with the fried crispy pork lard and cockles, and who dreads the weekly jog around the block that constitutes your exercise, perhaps you didn't do enough to prevent that AMI. If you are a diabetic with one foot lopped off for gangrene and you continue to smoke, most people and not just doctors will agree that you deserve the stroke or AMI that follows (although there is already a higher chance that it could have happened anyway). Just like if you started smoking today and came down with lung cancer 10 years later (but what if you were smoking in the 50's and 60's and no one warned you of these risks at that time?). God forbid if you have a hedonistic lifestyle and come down with HIV - but what if you are just the faithful spouse of such a louse and get HIV anyway?

Alright, personal responsibility for health is a tough one in most cases. How about personal responsibility for being able to pay for one's healthcare so that others (beyond your family) will not have to contribute part of their taxes towards taking care of you? We can ignore the flu example - it doesn't cost very much even if the doctor decides to tack on some antibiotics to cover his insecurity or increase his profits. The leukemia example is extreme. It can cost beyond $50k for the initial treatment and transplant - enough to wipe out the family's Medisave accounts and very few parents are wise or "kiasu" enough or have enough spare change to buy catastrophic health insurance for their kids from birth. In fact, many local patients end up depending on charity to pay for their treatment. But as said before, this is an extremely rare example. As for the rest, well, perhaps it's the fault of most people that they are unaware of the limits of Medisave (you probably only need to be hospitalized once for a major illness for this to be drained) and Medishield, or how hard it is to qualify for Medifund. We are not saying that the 3M's are bad - quite the contrary - but they are inadequate in ways that most "average" people don't realize until they are pushed against the boundaries. They will cover the majority of Singaporean's health needs, but it is a continually shrinking majority because of advances in health care and changing distribution of chronic diseases (for example, cancer). But private health insurance to cover the gaps in the 3M's is comparatively not cheap for the lower income groups, especially if you have other costs that you deem more important, such as money for your children's tuition.

So in essence, it may be better that access to health remains a public good in many ways (as it is in Singapore) and accept that there will inevitably be freeriders, while working on addressing the social factors (education, socioeconomic status, physical stress, etc) that contribute to health outcomes.

How about a priority system then? Rationing health care for those who are unable to pay on their own. It is illusive to pin down the exact amount of personal responsibility so let's have experts (like doctors and policy makers) decide for the healthcare system as a whole. No subsidization for cosmetic breast augmentation locally, for example, although you can perhaps still get it done for free in the NHS. Why not a case-by-case basis? Because it would be a bureaucratic nightmare (and also a political nightmare) and doctors tend to disagree on what is the best approach for an individual case (although there are guidelines), especially if their pockets are directly affected. The UK has NICE (National Institute for Health and Clinical Excellence) which is a fantastic idea as far as objective rationing goes, although unfortunately it can be politically overruled.

So all healthcare systems hold their patients accountable in some ways, and Singapore more than many developed countries except some like the US. The degree that patients are held responsible for their own health varies depending on culture and the social contract. Just as it is impossible to think of US developing an NHS-like system or UK dismantling the NHS even in the long term, the Singapore healthcare system will not morph into either "free" patient care or the predominantly private and capitalist system in the US. But it can change, for better or worse.

Healthcare issues: "No-Go Zone"

2011-04-30T02:19:00.003+08:00

Several local health care issues were raised at a prior blog post. The truth of the matter (I am refraining from using the much-abused "hard truth") is that it is better if health care is not brought up as an election plank, beyond cheap soundbites about sending the former Health Minister to JB. It is a complex issue that is well beyond the scope of a 10-day campaign period.

The cost of health care will only go up in the next several years, no matter whether PAP sweeps the House or several GRC's fall to the opposition. This is because of an aging population, the advance of medical technology and influx of new, expensive drugs for chronic diseases and cancer. Keeping health care expenditure at 4% of GDP (note that the government's share is only about a third of this) is well-nigh impossible in the medium term, as health care costs outstrips GDP growth.

Some, including fellow bloggers at SingaporeMD, have argued that it is necessary for individuals to take greater personal responsibility for their own health. This is certainly a persuasive line of thought, and the government has never held back from promoting this point of view, election or no. The whole business of cost-sharing and "health care subsidies" is an attempt at avoiding moral hazard and indirectly driving home the point of personal responsibility. Yet in all fairness, we recognize that personal responsibility can only go so far. Catastrophic illness can occur even if one lives a life of moderation. For lower- (and perhaps even middle-) income families, circumstances prevent many from leading healthy lifestyles. The health care system is also not structured in a way that promotes health, i.e. focusing on primary and preventive medicine, even though efforts are underway to do so.

Catastrophic illness, as the term suggests, can be devastating not just for the patient, but also for his/her family. If one depends on the 3M's, one cannot avoid paying far more than $8 for any major operation or hospitalization. Private insurance plans are available that can cover hospitalization and even outpatient treatment costs, but these are less well advertised and perhaps the majority are still unaware that anything other than the 3M's are required - until it is too late to apply. Or perhaps the cost of the premiums is too much of a burden in addition to the other costs of living.

What policies can we adopt or tweak that can reduce the burden of chronic and/or catastrophic illnesses on the lower- and middle-income households? Without becoming a welfare state or raiding the reserves, that is?

Doctors and Politics III (Local)

2011-04-27T01:49:00.008+08:00

Dr Tan Cheng Bock's and Dr Kanwaljit Soin's respective articles in 1999. Still worth a read. A similar point of view published in 2007 in the Hong Kong Medical Journal. We must wonder what Dr Tan and Dr Soin would make of the recent clumsy and divisive politicking by their medical colleague, Dr Balakrishnan, the ophthalmologist and current Minister for Community Development, Youth and Sports (Update: well, Dr Tan has made his views clear). Perhaps we can count it a small blessing that there were no other doctors on the Holland-Bukit Timah slate.

Healthcare issues: Singapore general elections

2011-04-25T03:02:00.002+08:00

It is interesting to observe the pre-election activities and exchanges that are taking place now. Are there any healthcare issues that might concern the small minority of the electorate that are interested/directly involved? Or the way the healthcare system is being (re)tweaked in Singapore? Here are a few possibilities that have been raised - please rebut or add:

Insufficient hospital beds - being belatedly addressed. "Slightly under-supply" being better than oversupply.
Medical tourism and its impact on healthcare costs and resources (and also the possibility of importing more infectious agents into our hospitals).
Cost of healthcare (Mr Leong Sze Hian is right on the money here). Means testing does not help to bring this down.
Shoving through the new residency training scheme with little consultation or discussion.
Private primary healthcare - more GPs becoming aesthetic doctors rather than dealing with an expanded scope of medical work like chronic diseases, etc.
Class system - do patients suffer only from reduced "hotel services"? Note that Prof Roy Chan carefully did not state whether subsidized patients with non-urgent skin conditions had to wait longer for an appointment compared to private patients.

On the other hand, there are more hospitals being built now (the next one will be up in 2014), the country still spends less than 5% of its GDP on healthcare, and the healthcare system ranked No. 6 in the world when last surveyed in 2000 by the WHO. And patients are seemingly more satisfied with the public healthcare system by the year.

Patient Satisfaction Surveys

2011-04-17T03:19:00.003+08:00

The results of the 2010 patient satisfaction survey - performed by an independent survey company (not sure which one) - was published recently. Overall satisfaction with the public health sector remained high compared to previous years, although the larger hospitals (SGH, TTSH and NUH) play musical chairs for the bottom spot (SGH is "it" for 2010) regularly. The detailed scores for the service quality attributes (i.e. care coordination, skills of health professionals, care and concern shown, etc) are not published, but presumably dedicated teams at each hospital pore over these results in search of areas of improvement each year.

It is unclear what the results really mean, especially when the "flower hospital" (you have to click on the KTPH button on the banner at the top here) comes up tops. Well done, of course, when the former AH team duplicate their award-winning patient-pleasing ways in the new hospital. These surveys have gone on for a number of years, and a neutral and careful review of the pros and cons of such surveys in general can be found here (only the abstract). It is important to note that patients who are healthier tend to report higher satisfaction as opposed to those with improvements in health - a consideration for why tertiary hospitals tend to fare worse when placed in the same bracket as smaller secondary hospitals.

The other kind of surveys published by MOH are costs of procedures/hospitalizations for a fixed number of common clinical conditions. These may be useful for indirectly keeping costs down (or at least relative to the public sector standard) for the most part.

But surely it is time that we find out a bit more about technical quality? The data should be readily available for such reports by now. The US has had hospital rankings for ages. If I have breast cancer (touch wood), which center will provide me better and longer quality of life (hopefully without exotic and expensive chemotherapy)? If I need a knee implant, what are the infection rates at various hospitals? If I have leukemia (touch wood twice!), should I just go overseas for treatment? How likely am I to get unnecessary tests and treatment if I visit a public as opposed to private hospital (alright, data for this last question never gets collected or compared)? For a country that has one of the best reputations for healthcare in the region, such data are hard to find. But they can help drive competition in another important direction, i.e. by focusing on patient-centric clinical outcomes

Doctors and Politics II (Local)

2011-04-16T19:25:00.003+08:00

Since the previous speculative post, the ruling party has completed introducing its new candidates for the upcoming election. Dr Tan Wu Meng and Dr Abdul Razakjr will not be fielded this time round. We may never know if this was a party decision or their individual decisions. Certainly, the response that Dr Janil Puthucheary received must have been an unpleasant surprise. He must have been perceived to be an ideal candidate in many ways: bright, young, articulate, a tireless doctor (who saves children's lives while teaching at Duke-NUS), a new citizen, the son of an estranged founder returning to the fold. Major miscalculation.

Well, there are other ways to serve for Dr Tan and Dr Razakjr. Neither will become too old by 2016.

World Health Day 2011

2011-04-08T06:08:00.002+08:00

Yesterday marked World Health Day 2011.

The theme for this year is Antimicrobial Resistance: "no action today means no cure tomorrow".

The statement by Dr Margaret Chan (WHO Director-General) can be found here, while the WHO's policy recommendations are available for download or viewing here. In brief:

Commit to a comprehensive, financed national plan with accountability and civil society engagement.
Strengthen surveillance and laboratory capacity.
Ensure uninterrupted access to essential medicines of assured quality.
Regulate and promote rational use of medicines.
Enhance infection prevention and control.
Foster innovation and research & development for new tools.

Tan Tock Seng Hospital held an exhibition at its atrium from 5th April until today. The details - including an online pamphlet - are available here.

Donations for immortality

2011-04-03T19:31:00.002+08:00

Yesterday's issue of the Straits Times carried an article reporting that Dr Tan Cheng Bock (former MP) had stepped down from the board of the upcoming Ng Teng Fong Hospital (formerly referred to as Jurong General Hospital) because he had moral issues with the idea that "a rich man could pay to have a public institution named after him".

I doubt most doctors/healthcare staff actually care enough - as long as they are paid on time - whether they are working at the Ng Teng Fong Hospital or the Middle-Earth Herbarium or the Dimwit Flathead Medical Center of Frobozz.

More to the point, this does not actually set precedence. Alexandra Hospital's replacement was named Khoo Teck Puat Hospital following a $125 million donation by the late tycoon's family, whereas the older local medical school was renamed the Yong Loo Lin School of Medicine (this is a particular mouthful) for a slightly less astronomical price of $100 million. Tan Tock Seng Hospital is also named after a man, but the circumstances were considerably different. He had contributed much more than just a once-off pay-out, as did Michael Bloomberg who has his family name on the John Hopkins Bloomberg School of Public Health (USD107 million in total donations over several years).

Should someone one day decide to contribute $150 million to any of the local hospitals/schools, will the current institutional names be replaced? That doesn't seem to speak very well of us, despite this creating sort of an incentive for huge public donations. Perhaps the practice should be reviewed and discontinued.

The Saga Continues

2011-03-31T08:00:00.004+08:00

Unless you've been living in a mountain cave these past few months, you would've read the newspaper reports about Dr. Susan Lim's troubles. After a month's adjournment, the sensational headlines are back in full force, starting with a claim that SingHealth CEO Prof. Tan Ser Kiat, who was appointed head of the newly set up SMC disciplinary committee, bears a 30-year-old grudge against her, after allegedly being romantically rebuffed. Of course, other factors were also mentioned, but who the hell cares when watercooler gossip has something so much juicier to latch onto? Casual conversation with medical colleagues - one of whom hails from SGH orthopaedics - reveals a unanimous sympathy vote for Prof. Tan. And it is certainly interesting that his version of events from that fateful evening 3 decades ago is poles apart from Dr. Lim's account. I'm curious as to whether an independent witness will come forward, especially if what Prof. Tan describes as a 'party' attended by others holds true. Isn't it sad that legal proceedings have degenerated to this level? Again, the colleagues I chatted with feel that Dr. Lim's legal team is overzealous in its attempts to undermine her opponents. While she no doubt has the financial means to engage top attorneys as she furiously defends her reputation, the tactics used glaringly border on desperation, and have probably earned her a fair number of enemies within the medical profession ( of which members of the SMC likely form a large proportion ). If rumours that she stepped on a lot of toes on her way up the hierarchy are accurate, then this is a perfect example of 'what goes around comes around'.

Doctors and Politics (Local)

2011-03-24T15:15:00.004+08:00

In the run-up to the Singapore general elections, up to three public sector doctors may possibly be fielded as new candidates for the ruling party. Dr Janil Puthucheary (KK Hospital) was introduced fairly recently, while presumably Dr Tan Wu Meng (National Cancer Centre) and Dr Abdul Razak (National University Hospital) will get their turn in the spotlight soon. I presume Dr Tan and Dr Razak will get less heated online discussion upon introduction compared to Dr Puthucheary, but that may not be a bad thing.

I have had the opportunity to speak to two of the three on occasion, and they have always struck me as being bright, full of good ideas, eager to help others, and (as far as I can tell) idealistic. It seems a shame to lose good doctors to the political arena, but perhaps they have a different calling and will achieve that higher potential. Certainly the current Education Minister, however many more millions he may have made each year as a private breast surgeon (although the gap seems to be closing), did not command the level of respect and authority then that he does now. And he would have had neither those millions nor the authority had he remained as a general surgeon in our public sector hospitals.

Browsing through the blog posts on this site as well as the many comments, one might come away with the impression that most doctors led privileged lives and blame the system or their patients (but hardly ever themselves) when things don't go right. And they complain about their earnings despite the vast majority being above the 80th centile in terms of income. The public can hardly be blamed for thinking that the SMC is opaque and doctors flock together to protect their own (irrespective of whether an actual wrong had been committed) when so many distinguished names in the medical community appeared to have stepped forward to protect Dr Susan Lim (the Director of NCC, one of the most respected and brilliant surgeons in the country, issued an explanation but it was undoubtedly too late). It must seem to many that our doctors "just don't get it".

Let's hope that these young doctors entering politics will help to give the medical community a better reputation, if only by proxy, at least locally.

How 'Informed' Is An Informed Consent?

2011-03-20T10:03:00.002+08:00

A recent headline put this topic in the spotlight again.

And a Google search served up this article from a 1992 issue of the SMJ.
Despite being published almost 20 years ago, the basic principles have not changed.

However, when you consider the amount of information involved, and the need to factor in Q&A if the patient has queries, one wonders how adequate this process is, especially in a public hospital setting where consultation times rarely exceed 5-10 minutes.

A detailed explanation alone, even for simple procedures, may take up to 15 minutes if the patient isn't highly educated, if there's a significant language barrier, or if the patient / spouse / relative has additional questions.

And I take serious issue with Prof. Eu's patient's lawyer saying that "the patient is not obliged to seek out further information on the risks, benefits and possible complications of the procedure on his own".

So, in typical Singaporean form, the doctor is expected to shoulder all the blame, even though the patient, Mr. Ang, is a businessman whom I assume is (1) not illiterate, (2) Internet-savvy, and (3) not mute or terrified of Prof. Eu to the extent that he is unable to verbalize his concerns about surgery.

I've always groused about Singaporeans' lack of interest in their own medical care. They seem to expect others to take charge of their health, then get upset when something goes wrong or they're slapped with a hefty bill.

While not all the facts of this particular case are available to the public - and who knows whether the press has presented a truly unbiased view - it looks like Prof. Eu may have gotten the short end of the stick here.

So the next time you're kept waiting 4 hours at a public hospital's specialist clinic, it's probably because the doctors are furiously documenting every consultation.

Thank you, Mr. Ang.

Arrogance of ignorance 2

2011-03-14T22:06:00.002+08:00

This letter to the ST Forum prompts me to ask: Which tests do you have in mind, Mr Lim?

Allow use of Medisave for more screening tests

IT IS heartening to learn of Health Minister Khaw Boon Wan's announcement ("Medisave can be used for cancer checks"; March 5). However, this is applicable to only two types of screening tests - colonoscopies, which detect colorectal cancer, and mammograms to screen for breast cancer.

Can Medisave not be extended to other types of cancer screening for a person over 50 years of age? Why restrict it to only these two?

Diagnostic screening is, in most cases, a necessity to determine the health condition of an individual. Why not extend the use of Medisave to cover all cancer screenings as well as all tests to detect heart disease?

To many people, the costs of these tests are a big burden.

Arthur Lim

Now I think the question: Why restrict it to only these two? is a very valid one, and I am pretty sure MOH will very soon come up with a reply on why these two tests were chosen.

What bothered me was how Mr Lim was so keen to promote "the use of Medisave to cover all cancer screenings as well as all tests to detect heart disease" before he has received an answer to his first question.

The truth is not all screening tests are equal, and more importantly, even when a screening test is accurate (yes, I chose to use this term because I am lazy) and we are able "determine the health condition of an individual", it did not necessarily mean that it was cost-effective to screen the population at large, or indeed a specific patient. Unfortunately, if someone was in a position that "the costs of these tests are a big burden" to him or her, an accurate diagnosis may just be the beginning of more financial burden...

But the cost-effectiveness of screening tests are really quite a technical issue that we cannot expect laymen (or even all doctors) to understand - that's not what bothered me about this letter. What bothered me was how a layman can think that a bunch of doctors and statisticians sitting in MOH can be blind to the benefits of "all cancer screenings as well as all tests to detect heart disease", which are so obvious to him.

Pricing, Cognitive Dissonance, & How To Charge More

2011-02-27T13:36:00.002+08:00

Something to ponder, especially with the recent publicity surrounding Dr. Susan Lim.

A few choice quotes ( no copyright infringement intended ):

"...I’ve met many, many physicians who under price their services. The primary reason that's given is that they have to have low prices to remain competitive..."

"This can be true — especially around mass consumer treatments like Botox and laser hair removal — but whatever the reason, charging too little for your services is self-sabotage for two primary reasons:

1. When you don’t charge enough you end up resenting your clinic. You do too much work for too little money. It’s not worth it. (Try to tell me this isn't the primary reason that so many physicians would like to leave clinical medicine.)

2. A low price tells patients that you’re not worth it. It may be all smoke and mirrors in the beginning, but if you want to be perceived as the best, you’d better price your services accordingly. Low prices are THE primary indicator of low quality."

Comments, please.

24 Million Dollars

2011-02-24T00:24:00.003+08:00

An incident that has been simmering in the background for some time has finally gained prime time in the local newspapers.

Four years ago, local surgeon Susan Lim treated a woman linked to the Bruneian royal household for a period of 7 months and issued a bill of $24.8 million. The Bruneians sought a discount (it does not appear that they had pressed charges from the local press reports) and our MOH lodged a complaint with the Singapore Medical Council. Things have deteriorated to the point where the surgeon has dragged SMC to court, and it appears that she has assembled quite a powerful team of lawyers to press her suit.

Whatever the result, the local medical profession will not come out smelling like roses. On the one hand, there is no escaping the perception that the SMC (especially its disciplinary committee) will appear incompetent. Even the judge had suggested as much. It's very well to slap warnings and penalties on small-time GP's overprescribing sedatives; it's another matter to take on someone with the resources and capability to hit back hard. On the other hand, although we understand that the Bruneian royal family is fabulously rich, and that Dr Susan Lim is not the sole recipient of the 24.8 million dollars (some of it will go towards paying off expenses, as well as other specialists who were undoubtedly called in to assist), it is hard not to believe that she was greedy. Charging as much as the market will bear is an accepted practice in business, but there are limits beyond which virtually all views of such transactions become negative, particularly in healthcare.

And the question that inevitably arises - does she really need that much money? Dr Susan Lim was the first person in Singapore to successfully perform a liver transplant, she is featured on the Monash University website as one of its prominent alumni, and has a wax replica of her hands in Madam Tussaud's. She also has more awards than most and has doubtlessly inspired whole generations of doctors and surgeons. One is left pondering the question: why did it go so wrong?

A New Low for SMA

2011-02-15T17:50:00.004+08:00

I am used to SMA's weak stance against alternative medicine, but this letter in the ST Forum today is a new low for the "professional" association.

Unwise to criticise alternative medicine, says SMA

DR ANDY Ho wrote that he was disappointed with the local medical profession for not warning the public about the dangers of chiropractic neck manipulation ("Perils of chiropractic neck manipulation"; Jan 21) and criticised homeopathy ("Indefensible ideas behind homeopathy"; Jan 22).

His scathing commentary on acupuncture criticises the Singapore Medical Association (SMA) for suggesting that the ethical code of the Singapore Medical Council (SMC) be amended to allow medical practitioners to refer to traditional Chinese medicine (TCM) practitioners and acupuncturists ("Pinning down acupuncture: It's a placebo"; Saturday).

While Western-trained doctors do warn their patients about the risk and safety profile of what they prescribe and voice their opinions on various kinds of alternative medicine to their patients, it is another thing to advocate that the local medical profession collectively criticise alternative medicine groups.

This is especially so when doctors and alternative medicine practitioners are seen to be competitors and criticising alternative medicine can be construed as self-serving.

Dr Ho's column on Saturday failed to take SMA's proposal to amend the SMC ethical code in context. When the current code was introduced, TCM practitioners and acupuncturists were not state-registered. They are now.

We do not think doctors will refer widely to TCM practitioners even if the code is amended. However, patients do request from their doctors medical reports and summaries when they seek care from TCM practitioners. The present code disallows such formal communication. Amending the code will facilitate better communication between a patient's various caregivers so that the patient's interest is best served.

The SMA does not encourage its members to refer to alternative medicine practitioners. But we have to be realistic. They exist and are here to stay. Most public hospitals already offer acupuncture services. Several have TCM clinics on their premises.

Continuing this "iron curtain" of no formal communication between doctors and alternative medicine practitioners is impractical and anachronistic.

Finally, many alternative medicine forms are steeped in cultural and religious beliefs, such as TCM and ayurvedic medicine.

From the perspective of safeguarding social cohesion in Singapore, getting the local medical profession to collectively criticise various alternative medicine modalities is unwise.

In Singapore's social context, journalists should not try to pit one group of caregivers against another. It is best for an impartial and respected body such as the Government to step forward
to decide what is safe and unsafe for patients.

Dr Abdul Razakjr Omar
Honorary Secretary
Singapore Medical Association (SMA)

Notice how Dr Razak had not addressed Dr Ho's main focus, which were on the lack of evidence behind alternative medicine.

Instead of accusing Dr Ho of failing to "take SMA's proposal to amend the SMC ethical code in context", Dr Razak should perhaps ask himself why SMC's ethical code specifically makes that distinction between medicine and "complementary medicine" - as I have argued in my previous posts, just because practitioners of a certain mode of alternative medicine are registered does not mean that there is any evidence backing their claims; reality does not alter itself because of cultural beliefs, political decrees, economic conveniences, or public opinion. Hopefully, as a professional society representing (about) half of all doctors in Singapore, SMA understands that.

There are many forms of alternative medicine out there which are being sold to unsuspecting patients. Just because they are a part of our "cultural beliefs" or that they are renting shop spaces in our hospitals does not mean that doctors as a profession must accept them or not speak up against them. If you know that certain forms of alternative medicine are ineffective or indeed potentially harmful, but choose not to advocate against it because you do not want to be seen as "self-serving", what does that say about your strength of character? Will we rather our patients be harmed by such therapy than we be falsely accused of being self-serving?

If we claim to be a profession that is built upon science, if we claim to be advocates for our patients, then we must speak up even when we know it will not be well-received, even when we know it will offend.

Thus, that line about "safeguarding social cohesion" is really a betrayal of what this profession and SMA should be about. If you go through the SMA's constitution, you will find nothing that states that it is its aim to safeguard social cohesion. In fact, this cowardly defence of alternative medicine can be said to go against a few of the stated aims.

SMA needs to ask itself whether it will choose what is expedient over what is right, and whether it is more important to be popular or to be intellectually honest.

Should doctors check the daily horoscopes of their patients?

2011-02-14T21:20:00.001+08:00

Good question indeed, Dr Ho.

Lipstick on a Pig 4

2011-02-07T19:35:00.003+08:00

It seems that Mr Yap is not only a member of the Asian Executive Council of the World Federation Chiropractic, but also the Correspondence Officer for The Chiropractic Association (Singapore).

Chiropractors' body all for regulation

DR CHARLES Siow's allusion to the alleged unreported cases of stroke caused and occasioned by chiropractic treatment is moot ('Concerns over titles, X-rays, treatment packages'; Jan 31).

Let us not go down this slippery slope as the same question is equally relevant to any profession, including the medical profession.

A significant portion of the chiropractic curriculum in accredited chiropractic colleges includes radiology. Chiropractors are taught in detail to operate, process and interpret radiological films.
The Chiropractic Association (Singapore), TCAS, has a radiology protocol as part of its ethics, rules and regulations based on international standards. Unfortunately, chiropractors outside our association may not follow the protocol.

As part of our ongoing effort to self-regulate as mandated by the Ministry of Health, TCAS has made a clear stand against unnecessary and large treatment packages. As membership to any professional association is voluntary, we do not have jurisdiction over non- members.
TCAS has maintained that all chiropractors must be graduates of an accredited international college. They also have to show good standing with their previous chiropractic association and they should not have criminal records.

This is the reason TCAS hopes chiropractors will be included in the Allied Health Professions Act to uphold the integrity of practice in Singapore.

We are not against meaningful regulation. Thus, we agree with Dr Yik Keng Yeong's opinion ('Regulate chiropractors'; Forum Online, Jan 31).

The latest studies - The Mercer Report and The Bronfort Study - support chiropractic treatment for its efficacy as well as its cost-effectiveness in neck and lower back pain management.

No professional system can hold a monopoly on health care - we should leave it to the public to decide. Patients' welfare is paramount.

Terrence Yap
Correspondence Officer
The Chiropractic Association (Singapore)

A busy man, Mr Yap must be, and no doubt made busier by the spotlight on chiropractic and the incidence of stroke.

Mr Yap would of course want us to not go down "the slippery slope" of questioning the association between neck manipulation and stroke, seeing as it is other mainstream medical therapy does sometimes cause harm instead of good. But the question is not whether or not other forms of therapy cause strokes, but whether or not neck manipulation, for whatever therapeutic benefits it purports to have, justifies the risk of stroke. If, as Mr Yap once again points out to us, chiropractic has only been found to be effective only for neck and lower back pain, and not the myriad of ailments many chiropracters claim it is good for (and which the Brontford Study has shown it is not), then we need to ask ourselves: is stroke an acceptable risk for neck or lower back pain?

The rest of the arguments for creating a register for chiropracters miss the main issue at hand: chiropratic is a pseudoscience. It does not matter whether a chiropracter is "trained" or "accredited", or indeed eventually "registered" - an astrologer can similarly be "trained", "accredited" and "registered" with a professional body if the law so recognises one, but that says nothing about whether or not astrology actually works.

Faced with such a situation, Mr Yap takes refuge in that same cry that those with no evidence to back their claims do: "leave it to the public to decide".

Of course. Why bother with science when there is such a thing as public opinion, right?

10 Ways To Protect Yourself From Patient Complaints

2011-01-27T23:25:00.007+08:00

This entry is prompted by a recent question from one of my MOs. I believe we have quite a number of young doctors reading the blog, so I hope you will find this useful.

Administrators, consider yourself warned that you may find the following content 'disturbing'. :)

10. Avoid high-risk patients.

If you're wondering whether I can quote at least 1 randomized controlled trial, preferably triple-blinded, with p value less than 0.0000001, you are sadly mistaken.
Is there a one-size-fits-all high-risk profile? Probably not. Based on personal experience, we tend to develop our own sets of criteria, and with time, through trial and error, you will discover yours.

I know what mine are, but posting them on a public site may be construed by certain 'sensitive personalities' as an example of 'causing societal disharmony', if you catch my drift.

However, the one characteristic I would probably consider a universal precaution is any patient who's 'high-profile', or who has a relative who falls into that category, i.e. celebrities, political figures.

Also, I would be VERY wary of journalists. Don't give them something to write about!

9. Attend risk management workshops and apply what you learn.

This is low on the list for me, for a good reason.

During my rather lengthy career, I have attended a total of ONE such workshop, and I refuse to attend any more.

Why? Because days after learning a wonderful method - complete with a catchy pnemonic - of handling difficult patients / relatives, I managed a guy who couldn't give a rat's ass about my newly acquired skills. He was clearly malingering, blew his top when I refused to issue a medical cert, loudly declared he's 'a lawyer', that he would 'write to the Forum Page' about me, then stormed off to the administrative offices upstairs to lodge a complaint.

He didn't get the MC, and I didn't make any headlines in the newspaper. But don't expect me to bother with any of these workshops ever again, because they obviously don't work on PSYCHOS.

But if you need CME points, be my guest.

8. Spread the shit - oops, I mean blame - around.

What does this mean? Well, if you're still an ikan bilis, so to speak, you will have seniors available to act as buffers, i.e. to review and vet your cases, handle difficult patients / relatives, etc.

While my generation of doctors ( yes, I consider myself a little old ) used to tahan all sorts of nonsense and clinical catastrophes until just before we dropped dead, rather than consult a registrar or consultant, things couldn't be more different now.

My MOs drive me insane with their bizarre updates, which are completely separate from the medical management. I honestly don't care what time the relative is coming to bring the patient home, as long as the patient is fit for discharge, okay?

But this is truly a savvy move on the MO's part. They love to tell me they're discharging a case, after all the tests done are normal and the patient is super-well. Why are you consulting me then, I ask. The reply: Oh, I just wanted to let you know.

Took me a while to fully understand their strategy. If they document having 'consulted a senior', if a complaint materializes, you have to answer it, even if it isn't about you per se.

In fact, some MOs may escape the patient's / relative's wrath completely, if the latter somehow latch onto YOU for whatever reason, even though your interaction with them lasted less than 5 minutes.

Very smart indeed.

7. Look busy, even if you're not.

True story. a patient's email feedback was circulated around my department, in which the patient criticized everything from the waiting time to nursing issues. However, she reserved the highest praise for one of my MOs, for 'working so hard', just because he was observed to be 'running around while everyone else was taking their time'.

This is a direct quote.

Doesn't matter if this particular MO was one of the least productive we had ever had. Yes, he ran around a lot, often with a stressed / harrassed expression on his face, but mostly because he had no clue what he was doing, and failed miserably at multi-tasking.

But the most important lesson to learn here is: the patient / relative rely heavily on APPEARANCES. So make sure you look as busy as possible, because they don't know the difference!

6. Offer freebies.

If you run clinics, check the cabinets for free samples from pharamaceutical companies. Patients LOVE medications and vitamins they don't have to pay a single cent for, and these could come in very handy if you sense a complaint coming your way.

Just present the person with a couple of boxes and wait for the smile.

Never fails. :)

5. Market yourself.

One MO was famous for shamelessly bragging about his venepuncture skills, convincing patients that they had the worst venous access in the universe, and that he was the only doctor who could take their blood / set their IV cannulas on the first try.

As a result, he consistently received compliments from patients and relatives, for his 'exceptional care'.

But make sure you don't come across as obnoxious. This MO managed to pull it off, and I only wish I had learned from him before he finished the rotation, heh!

4. Flirt.

Yes, you read correctly.

Never underestimate the power of pheromones. This tactic can be a powerful tool, but of course, you gotta have skills, and know how to pick the right targets.

E.g. If you're a young male, the ideal patient who will be susceptible to your charms is a young female, and vice versa. Even those in the middle-aged group appreciate it when a young doctor showers them with attention.

One of my ex-MOs, a strappingly handsome Caucasian dude, was lazy and unpopular among his medical colleagues, but a huge hit with the patients, especially the young ladies.

Remember, a patient who's hot under the collar will never hurt you.

3. Give the patients whatever the hell they want.

See point #9.

Don't be stingy with MCs. Prescribe antibiotics if they demand it, even if it's clearly a viral infection. Why put yourself through hell when they won't listen to reason?

2. Be generous with your time.

This is guaranteed to please any patient / relative, because in Singapore, that is how a doctor's competence is measured.

Never mind if you spend 30 minutes talking about family, kids, travel, food and shopping. As long as they know it's a damn busy clinic / ward / A&E, they will LOVE you for giving them such VIP treatment.

Just ignore your poor colleagues who're working their butts off to clear the changes and patient queues. You see the bigger picture. Service quality awards are 10 times more impressive than actual clinical acumen, conscientiousness and efficiency!

1. Be extra nice! Bedside manner 99%, clinical skills 1%.

Aside from spending loads of time with the patient, always ask whether [ where applicable ] (a) s/he has had his/her breakfast / lunch / dinner yet, (b) you can get him/her a drink of water if s/he's thirsty, (c) you can get him/her some food if s/he's hungry, (d) you can get him/her an extra blanket if s/he's feeling cold... you get the idea.

Sayang the patient - preferably in front of relatives - as much as possible. A reassuring hand on the shoulder or arm. A sympathetic smile. A kind word. Never interrupt. Nod your head repeatedly, even if you're thinking about that nice sports car you want to buy, or that date you have this evening. Unless you're treating a professional magician who's telepathic, you're safe.

Because Harold Shipman, the infamous doctor/serial killer, was so beloved by his patients and their families, that even when his horrific crimes were made public, remained exalted by many.

In fact, one of the victims' sons remarked that were his mother still alive, he would want Dr. Shipman ( her killer ) to remain their family physician!

Let that be a valuable lesson to you all.

Here endeth the tutorial.

Lipstick on a Pig 3

2011-01-27T23:19:00.007+08:00

The problem with discussing alternative medicine is that oftentimes its proponents do not quote specific studies to back up their claims, so I am in fact quite delighted to see a reply in the ST Forum today that bucks the trend:

Chiropractors have meaningful role to play

I REFER to Dr Andy Ho's commentary ('Perils of chiropractic neck manipulation; last Friday').
To date, there has been no documented case of vertebral artery dissection (stroke) caused and occasioned by chiropractic treatment in Singapore.

Dr Ho did not mention very important facts stated by the Bone Joint Task Force in the journal Spine (2008). The authors concluded that there is no evidence of excess risk of vertebrobasilar artery stroke associated with chiropractic care. The risk - if any - is no different from that associated with a primary care provider such as a general practitioner.

An independent report by the Rand Cooperation concluded that the risk, if any, is estimated at one in a million, lower than that of being struck by lightning (one in 700,000).

The Mercer Report (2008) by two Harvard-trained medical doctors concluded that chiropractic care is more effective than other modalities for treating neck and lower back pain. It is also highly cost-effective. This is supported by the Bronfort Study (2010) from Britain.

The Chiropractic Association (Singapore) has made representations to the Health Ministry to be included in the Allied Health Professions Bill. As a trade association, we adhere to an international code of ethics and we do require our members to upgrade their skills annually with training.

Chiropractic does not have a genesis rooted in mysticism but rather in the biomechanics of the human frame. As in any profession, we have evolved through the years to become a profession that draws its conclusion based on facts and results.

Chiropractors are playing an important role, and being recognised, in hospitals in Canada, the United States, Saudi Arabia and China. Australia is currently in the preliminary stage of utilising chiropractors to serve in hospitals. We believe that sensible national legislation and a proper sense of internal regulations will bring about a higher level of professionalism in Singapore.
Chiropractors have a meaningful role to play in the Singapore health-care system. Although we regret that we are not currently included in the Allied Health Professions Bill, we have been - and will always be - playing a meaningful role all these years.

Terrence Yap
Asian Executive Council
World Federation Chiropractic

Now we are cooking with fire.

One wonders of course why despite all the evidence that Mr Yap quoted, chiropractors are nevertheless not included in the Allied Health Professions Bill. If we are going to put lipstick on TCM, why not chiropractic too, right?

Now you can read the Bronfort Study in its entirety here. It will take me a few days to read through the thing and track down the individual papers reviewed (if I can find them), but let's for argument's sake say that its conclusions are true; the question then is: if, as Mr Yap claimed, chiropractors are "a profession that draws its conclusion based on facts and results", does that mean that the World Federation Chiropractic are committed to censure all its members who claim that chiropractic is "effective" for neck pain of any duration, mid back pain, sciatica, tension-type headache, coccydynia, temporomandibular joint disorders, fibromyalgia, premenstrual syndrome, and pneumonia in older adults, asthma and dysmenorrhea, Stage 1 Hypertension, otitis media and enuresis in children, infantile colic, knee osteoarthritis, fibromyalgia, myofascial pain syndrome, migraine headache, and premenstrual syndrome?

Added: Out of curiosity I googled "Singapore chiropractor" and looked at the first few sites that came up. Do try the same and see how many of them advertise a cure for those conditions that the Bronfort Study had found chiropractic to be ineffective for.

I believe this is what the young people these days call self-pwnage?

The Numbers Game - Again

2011-01-13T20:37:00.005+08:00

I trust many of Singapore MD's readers came across this articletoday.

To be frank, I was taken aback by the number of foreign doctors being recruited - approximately 800 out of 1300 newly registered physicians.

I guess the MOH ( or MOHH as it's called these days ) deserves some credit for taking steps to ease the shortage ( though relative and far from absolute ).

But yet again, numbers aren't everything. Sticking your finger in a hole can plug a leak, but you still need to fix that damn hole.

And who oversees the quality of these foreign doctors? There used to be strict regulations on recognized universities / degrees, but it seems just about anyone can get their feet through the door these days.

Do they need to take a theory or clinical test before being accepted into the local workforce? I'm guessing no, since quite a few of the foreign MOs I work with can't take proper histories, do simple physical exams, read ECGs or x-rays, or interprete basic blood test results.

They're also not very productive, so you need approximately 2-3 of them to cover the workload of 1 competent junior doctor.

And there've been many near misses, so the supervising senior doctors also have their hands full.

With the recent implementation of the residency programme, the overall patient workload will become even more unequal, as residents have clearly stipulated patient numbers which MUST NOT be exceeded, leaving the extra cases to be distributed among the non-residents ( many of whom are now - say it with me - foreign-trained ).

I see a vicious cycle starting.

p.s. KTPH is now hitting full bed capacity in terms of admissions. I wonder if MOHH can get JGH's contractors to speed things up.

Lipstick on a Pig

2011-01-06T17:43:00.004+08:00

To me, the question on whether or not TCM "specialists" should be allowed to call themselves specialists is as meaningless as a discussion on whether an astrologer should be allowed to call himself a "specialist astrologer" (in maybe the sign Aquarius?); you can legislate to regulate something, you can have Bills and Gazettes to stipulate who can or cannot call themselves by what terms, but at the end of the day, it doesn't change the fact that if the body of knowledge behind something is not based on reality, a "specialist" in that field is as much a charlatan as a "non-specialist".

Dr Ong gives us a summary of the problem with the status of TCM in Singapore in his letter to the ST Forum today:

It opened Pandora's box

WHEN the Health Ministry followed China's example by registering and certifying practitioners of traditional Chinese medicine (TCM), it opened a Pandora's box by not defining the limits of practice and putting in place clear regulations to safeguard patients' welfare ('Health Ministry to probe TCM 'specialists'; Monday).

Singapore has a double standard regarding medical practice. For practitioners of Western medicine, mistakes such as omission of a test, missed diagnosis, failure to inform the patient of possible treatment complications and well-intentioned misjudgment would land doctors in legal trouble.

But TCM practitioners seem to enjoy an exemption from such obligations. Strict oversight of medical practice is highly desirable and it should apply equally and consistently to all healers of diseases.

It is not right that one school requires scientific proof and evidence for its practice and is held responsible for possible errors, while the other is exempt from the need for scientific scrutiny and is free of legal responsibility of the outcome.

China has its reasons for promoting TCM. We appear to have followed suit for reasons of affordability, medical tourism and the muddled belief that freely allowing all schools and methods of medical practice will lead to progress and innovations.

Based on my 50 years of medical practice, including teaching in medical schools, and my knowledge as a person primarily educated in Chinese, I can categorically declare that if TCM follows a scientific path, it will eventually become Western medicine as we know it.

But the reinvention of the wheel has a long way to go.

Dr Ong Siew Chey

Not much more needs to be said besides that, is there?

Hospital Bill Size: Bargain Hunting?

2011-01-04T03:30:00.003+08:00

Channelnewsasia featured an article on hospital bill sizes today. If you go to the corresponding MOH webpage, you will be able to compare the median (and 90th centile) hospital bill sizes for a variety of conditions and interventions across all public and some private hospitals in Singapore.

Although the bill sizes for many common conditions are available, there are obvious omissions, especially with regards to cancer care (only the bill sizes for lung cancer, and early prostate/breast cancer by inference, are available). Perhaps it is harder to quantify these with the broad array of surgical and chemotherapy options now available, depending on the stage of disease. But the increased transparency is certainly a step in the right direction.

However, the bill size is only one side of the equation. More importantly, any prospective patient "shopping around" for elective procedures will definitely want to know what are the expected outcomes for getting, say, a coronary angiogram at TTSH (the cheapest median bill size for A and B1 wards, but surprisingly the most expensive median bill size for B2 and C wards). He/she may also want to know what are the complication rates. Unlike buying a car, one cannot "test-drive" a surgical procedure. There are also no warranties. One cannot surf the net looking for reviews (if such exist, they are more likely to reflect the bedside manners of the doctor rather than his/her clinical competence). When things go wrong, there is no refund - it just gets more costly in almost every way.

Of course, it is very hard to compare outcomes and complication rates between doctors or hospitals. An adjustment has to be made for the type of patients treated (i.e. casemix). Otherwise a hospital treating patients who are more frail or sicker will generally have worse outcomes compared to one where the patients are generally more healthy, even though the second hospital may have second-rate doctors/surgeons. And the current methods for deriving casemix are crude at best.

Still, it is important to work towards having the outcomes and complication rates reported equitably for the different institutions. Otherwise just knowing the bill size is not enough for an informed decision on where to seek treatment. "Bargains" might come back to bite one in the worst possible way, and premium prices are no guarantee of quality or even a satisfactory outcome.

What Happens When Disillusion Sets In?

2010-12-20T05:00:00.003+08:00

A number of career milestones occurred in 2010. Events which, by all accounts, should've encouraged me to strive for greater achievements.

So it was unexpected - and strange - to come to the realization that I dislike my job. ( On really bad days, 'dislike' turns to 'hate'. )

Not so unexpected: other colleagues sharing the same sentiment. Some blame 'the system' ( i.e. public sector bureaucrats ). Others cite 'early mid-life crisis'. A number of them have already left, or plan to leave, for private practice. Me - not a viable option, for complex reasons.

Funny thing is, I rather enjoyed being a doctor for a whole decade before these negative feelings set in. There isn't a specific tipping point, but more of a slow build-up of unpleasant experiences.

Life was much easier when I was a junior physician. Yes, I was a slave to my seniors, but that also meant I was shielded from office politics, administrative chores and bureaucratic bullies.

With increasing seniority came budget proposals, power struggles and endless public relations debacles. Requests for essential equipment got rejected if you didn't know the right people, not based on the merits of the proposal itself. You started noticing major flaws in fellow colleagues' characters. Patients and relatives rarely show any form of appreciation for your hard work, writing complaint letters to the media whenever it strikes their fancy.

But the thing that really gets to me are the yearly performance appraisals.

It's divided into different categories, e.g. administrative, teaching, research etc. You earn points for each section based on your level of involvement, and it's become quite clear to me over the years that it benefits a very select group of people, often those in the upper echelons of the department / hospital.

How many of us junior physicians get assigned to perform medical cover for VIPs ( something that commands a ridiculous points weightage, considering the fact that the person performing this medical cover is effectively absent from the department, and others have to cover his / her duties )?

How many of us become prolific medical researchers, or get invited to speak at international conferences?

While a small number of doctors may be able to attain such recognition, what then becomes of the rest of us mere mortals? Aren't the powers that be sending a message that drones aren't considered valuable? That if you spend more time doing ward rounds and running clinics, but aren't very interested in research, it's only right that you end up with a lower appraisal grade, and thus, smaller bonus payments.

Perhaps that's one of the motivating factors for those who leave for the private sector. No grading system that penalizes the lack of research or administrative duties. Much higher financial returns for doing ward rounds and running clinics. That, and the ability to have fulfilling personal lives.

If remaining in the medical profession isn't tolerable, a number of my friends have gone on to succeed in non-medical fields, from F&B businesses to piloting commercial jets.

But if switching jobs isn't viable ( yes, dear reader, not all of us can uproot ourselves at the drop of a hat ), then the next best thing is to pursue an activity or activities you love, and not let medicine define your existence.

Last but not least, a suggestion with regards to possible modifications of the appraisal forms - include the number of clinical hours worked per week ( ward rounds, clinics and shifts ), with sensible allocation of points. I guarantee it will level the playing field and make us drones feel a lot more appreciated.

15 Great Films Every Med Student Should See

2010-12-11T13:55:00.001+08:00

Thank you, Kate Rothwell, for the link. :)

And The Band Played On is a personal favourite of mine. Probably the best medical drama I've ever seen.

I also recommend Awakenings. Bawled my eyes out.

No mention of Lorenzo's Oil and Patch Adams, both of which made huge impressions on me when I was a med student. The former's a harrowing account of a couple's struggle with their young son's terminal illness, the latter an inspiring true story boasting one of Robin Williams' best career performances.

TV shows-wise: nothing beats ER. :)

My foot!

2010-12-02T18:12:00.002+08:00

This news article comes right at the time when we are discussing "alternative medicine" on Singapore MD, which leads me to this video...

Sense and Sensitivities

2010-12-02T17:39:00.004+08:00

It's heartening to see the discussion on the subject of "alternative medicine" continue on the ST Online Forum today.

I am in particularly happy to read this letter from Mr Oon, which I reproduce below (emphasis mine):

...No, but it's the be-all, unlike alternative healing

I REFER to the letter by Mr Richard Seah ('Mainstream doctors shouldn't be insensitive to alternative medicine'; Nov 19).

Mr Seah's polemic against Dr Andy Ho's article ('Sending out the wrong signals'; Nov 6) completely misses the point and grossly oversimplifies the view of allopathic medicine on complementary and alternative medicine (CAM).

Mr Seah's contention that Dr Ho and Dr Ang Peng Tiam ('Food for thought'; Nov 18) displayed 'rudeness and insensitivity' by dismissing CAM as pseudoscience fails to take into consideration the duties of the two medical men.

Medical professionals are accountable only to the health and well-being of the patient. 'Culture' and political correctness take a backseat when providing information concerning patient care. Mr Seah's implied assertion that doctors should permit CAM on grounds of sensitivity thus, holds no water.

Doctors acknowledge that the patient has autonomy in matters of his health and is free to choose his choice of therapy. This does not preclude doctors from speaking out against quackery and 'snake oil' salesmen brazenly promoting a panacea that provides little benefit beyond a placebo effect. Doctors must provide necessary information verified by the scientific process for patients to make informed choices.
Mr Seah implied that CAM holds more value than allopathic medicine is wont to give. However, CAM is a body of unverified practices that have questionable outcomes and doubtful methodologies.

Homeopathy, for example, has long resisted the golden test of efficacy - the double blind trial. Mr Seah's argument that 'qi' and other pseudoscientific concepts in CAM are 'holistic' is a tired argument raised countless times. It is puzzling that the public demands drug trials and testing for drugs but yet does not demand the same rigour from CAM.

Certainly, not all aspects of CAM are worthless. Pharmaceuticals recognise the value of traditional Chinese medicine (TCM) - for example Artemisinin, a first-line antimalarial derived from herbs. However, the fact that once CAM has been accepted by the scientific and medical community, it becomes 'mainstream' rather than 'alternative' seems to fly over CAM proponents' heads.

Singapore has come a long way in the field of science and it is precisely because of its 'advanced medical technology' that old practices that have little footing in science are abandoned.

Oon Ming Liang

The next time you read a defence for a form of "alternative medicine", dig up and re-read this letter - the arguments contained therein will almost certainly address those used in the defence. From what I can gather, Mr Oon isn't a doctor; but I hope he chooses to become one.

I have less kinds words, however, for a collegue, Dr Lim, who wrote thus (emphasis mine):

Mainstream medicine isn't a cure-all...

I HAVE been a practising family doctor since 1994 and seen my fair share of chronic debilitating diseases and cancers causing much suffering and death over the years.

Often, I find myself helpless in preventing the onset of such illnesses or providing relief to my patients even with advanced Western medicine.

Our body has a remarkable capacity to heal itself, much more quickly than people realise, when we address the underlying causes of illnesses. And for many people, the choices they make each day and what they eat each day will determine their health in the long run.

We should not begrudge those who prefer a vegetarian diet and seek alternative treatment. It is their choice and who are we to decide for them when we don't even know ourselves?

In short, we are all learning. I remember years ago when traditional Chinese medicine (TCM) was not recognised by medical practitioners. But now, there is a TCM practice even in major hospitals.

As doctors, we should keep an open mind as there is always more to learn.

Dr Benny Lim Jit Biaw

Well, patients have always had the choice to accept or refuse any form of treatment, Dr Lim, Western or "alternative" - that bit was never the question - but "choice" does not determine whether a form of treatment works or not. Mr Oon, a layman, seems to have grasped that concept despite not having 16 years of clinical experience.

As for the plea of "we don't even know ourselves", well that's a falsehood and an abdication of our responsibility as doctors: we do know a lot about most forms of "alternative medicine" (whether it be a lack of evidence of efficacy or evidence of a lack of efficacy), and when it comes to new forms of "alternative medicine" that has little evidence, we at least know that there is very little evidence to support the claims made by those people who are selling them to patients. Do not, Dr Lim, assume that your ignorance applies to the rest of us; besides, ignorance is not license to condone, but a reason to become educated.

So I am not sure what the score stands, but I am as I said happy to see that arguments like those presented by Mr Oon are making it to an open forum (and doubly so because the letter was written by a layman!). It gives me hope that if scientific literacy has not sunk in to someone who had practised medicine for 16 years, it has at least made an impact in the younger generation.

I think I will sleep easier tonight.

"Caveat Emptor"

2010-11-28T12:09:00.004+08:00

I was planning to write a post on the subject of "alkaline water" this weekend but unfortunately a quick search on Pubmed did not turn up any good-quality study on human populations (I'm being polite here).

However, on googling I did find this blog which has been archiving the letters and articles on the subject.

I hope the author will continue to look at the claims of "alternative medicine" as they come into the limelight, and remind everyone: let the buyer beware.

Loss 4

2010-10-28T21:07:00.003+08:00

I actually missed this clinical practice guideline when it was released, but thanks to a letter on Today, I managed to unearth it in my pile of unsorted mail.

Beware miracle cure claims
With expert advice, those with special needs can avoid useless, risky treatments
Letter from Dr Noel Chia Kok Hwee

I refer to "Baby dies after injection in the brain" (Oct 25) and want to applaud Today for this timely news report.

I am an assistant professor in early childhood and special needs education.

Most parents who have children born with moderate to severe learning and behavioural disorders such as autism, cerebral palsy and sclerosis are often desperate for some form of miraculous cure such as the stem cell treatment, as reported.

Indeed, there are countless treatments available in the market worldwide today. Their developers claim their approaches work well for individuals with special needs.

However, a number of these treatments either have not been scientifically validated or have been studied and found to have little or no worth.

Parents and even professionals tend to forget that many of these so-called treatments are still at an experimental stage and have not been subject to scrutiny and scientific validation.

Hence, it is important for parents and those working in allied health and educational professions to be well informed about the various treatments targeted at individuals with special needs.

Recently, the Singapore Academy of Medicine and the Ministry of Health (MOH) jointly published clinical practice guidelines in the Singapore Medical Journal (Vol 51, No 3), providing doctors and patients here with evidence-based guidance on various treatments to manage medical conditions relating to autism spectrum disorders. This important information is also made public on the MOH website.

I believe more can also be done to inform the public on the clinical practice guidelines on other disorders, including rare syndromes like Prader-Willi and Angelman.

Moreover, empirically-sound treatments are not always universally appropriate for all individuals with special needs.

According to Dr Richard Simpson, a professor of special education at the University of Kansas, such treatments are often involved in controversies related to individualised use, outcome claims, exclusive and extensive use, and so forth.

As the list of treatments for individuals with special needs continues to grow rapidly, the challenging problem confronting parents and professionals in terms of choosing the most efficient and effective interventions becomes exacerbated.

Hence, it is often very difficult for parents and professionals to recognise and judge the scientific validity of a treatment designed to be used with individuals with special needs.

Perhaps the relevant authorities and experts in the fields of biomedical science and special education can serve as guiding signposts to advise parents and professionals accordingly on issues relating to treatments for individuals with special needs.

You can find a summary of the clinical practice guidelines Dr Chia mentioned here.

I am quite surprised by how little we know about autism - most of the 'positive' recommendations are Grade D.

What I am more surprised by was the number of alternative therapies being touted as effective for autism, many of which I have never even heard of - "wearing of weighted vests"? Seriously?

Perhaps Dr Chia does have a point - we need to be more proactive as a profession in looking at what unproven therapies are being touted to our patients; not in the name of "integration", but with a critical eye and the moral courage to judge and tell our patients when something is ineffective or harmful.

Great Expectations

2010-09-29T22:11:00.002+08:00

today in the ED, was a bad day. or disaster. or madness. however way you want to call it, our shopfloor was full and overflowing. don't ask me why, but all sorts of patients came streaming in - from knee pain to workplace lacerations to high fevers. they came in fast and furious, and were hence admitted just as furiously.

it doesn't take a genius to figure out then, that when the emergency department is full, the wards will be full. so the back log became progressively worse and patients piled up outside the main area and they were made to wait for many hours before their beds were ready.

and it didn't help that just last week an article was published in the papers about a new fangled bed management system that has helped cut down waiting time for beds. we all know what the reality is, but the public of course believes in the magic two hours mentioned almost four times in the short article.

so what happened? relatives and patients began to yell at the poor nurses, who are the ones tasked with speaking to them about their beds and ward allocations. "why does it take one hour just to clean the bed?" one son yelled, completely unaware that his father was one of the lucky ones who got a bed within two hours of admission.

what does yours truly think is the problem?

expectations.

i recall a patient who fumed,"i am also in the service industry!" just because she was not getting the "service" she was expecting - an admission. we have become a society where we are spoilt for choice. if a particular retailer is unable to provide us with what we want, there's always another next door. hence the customer is always right, and whatever he asks, must be done.

medicine is not and should not be a service industry. it is already prevalent in the states, and even amongst the doctors in the private sector, but this should not be the case - and the public should awaken to this fact. you cannot walk into a hospital and decide how you should be treated. we are not a hotel in which you can order a room and room service to come with it.

but of course, with all the medical tourism and competition going around, "service" has now become very important and many times takes priority. we have now become afraid of complaints, much more than those big multinationals who have billions of dollars to lose. i remember a time when mcdonalds barely batted an eyelid when people got hurt trying to rush for some "limited edition" hello kitty dolls, or mattel getting bashed by psychologists for glorying the wrong body type in barbie. these companies know that people will always be hooked on big macs, and that little girls will always love brushing barbie's hair. -we- know that people will always fall sick and need our attention, but every complaint letter is dealt with the utmost respect and fear, even though that we could have had the patient's best intentions in mind.

we are now mindful of everything we do, everything we say. thou shalt not greet the patient with an unsmiling face (even though it's now 4pm and you haven't eaten/peed/pooped in the last 8 hours). thou shalt not make the patient wait for more than two hours for bloods/beds/specialist reviews (even though all these are way beyond your control, especially as a lowly MO).

the hospital is now a hotel, that's what it is.

A Taste for Your Own Medicine

2010-09-22T17:17:00.005+08:00

This little story has been making the rounds during lunchtime:

Doctor told 74-year-old patient to attend talk, stop medication
Letter from Frances Ong Hock Lin

ON THE morning of Aug 30, my 74-year-old mother-in-law went to the Accident and Emergency Department of the Singapore General Hospital because she was having an asthma attack.

A doctor attended to her. He also told her to attend a talk that he was giving every Monday evening at a shopping complex in town. At the same time, he convinced her there was no need to take medication as the body could heal itself.

My mother-in-law returned home and proclaimed that she was fit enough to work and that she would not take any more medication. She claimed that a doctor had told her so and that she believed him.

My mother-in-law has just undergone a heart bypass because six of her blood vessels were blocked. Her doctor from the National University Hospital had prescribed medication for her which she is now planning to stop taking.

Her cardiologist at the NUH could not certify that she was fit enough for work yet she said that she believe that she was. A check on Facebook showed that the doctor who had attended to her at the SGH belonged to an organisation that I believe is into neuro-linguistic programming (NLP). I would like to ask the following questions:

- As a doctor practising Western medicine, is there a conflict of interest in promoting one's own interest in NLP?

- Is it ethical to convince a patient who has a medical condition to consider alternatives when she is most vulnerable?

- Do the SGH and the Singapore Medical Association have any policy regarding doctors using neuro-linguistic programming

I'm not suprised by the fact that such doctors exist, or that patients will believe and trust them - if you were a patient who had to take many medications every single day, wouldn't you want to be told by a doctor you don't have to? People want to believe in what they want to believe in, but unfortunately a little thing called reality tends to get in the way of that.

What I am pleasantly surprised by are the skepticism displayed by Ms Ong (something rare to see in a newspaper forum), and the responses from SGH and SMC:

Suggestion to attend free talk was inappropriate: SGH
Letter from Mark Leong (Dr) Head, Department of Emergency Medicine Singapore General Hospital

I REFER to the letter by Ms Frances Ong Hock Lin. We are sorry for the anxiety experienced by Ms Ong and her family.

Patients seen at the Emergency Department are given advice based on their medical condition.

In light of the patient's pre-existing illnesses, our doctor had encouraged her to modify her lifestyle after rendering the appropriate treatment. Prior to discharge, he mentioned an opportunity for her to attend a free talk. This suggestion was inappropriate. The doctor has since left our employment.

We require our doctors to adhere strictly to the Ethical Code and Ethical Guidelines set out by the Singapore Medical Council. Professionalism and integrity must be upheld at all times. Every action should withstand professional scrutiny and not breach the trust of patients.

Adhere to guidelines: Council
Letter from Singapore Medical Council

THE Ethical Code and Ethical Guidelines (ECEG) sets out the fundamental tenets of professional conduct and behaviour expected of all doctors practising in Singapore.

Among other things, Section 4.1.6 of the ECEG states that "A doctor shall not in his professional capacity support the services provided by persons or organisations that do not provide legitimate medical or medical support services".

The Singapore Medical Council would like to advise all doctors that they are required to adhere to the guidelines set out in the ECEG or they may face disciplinary proceedings if they are complained against and found to be in breach.

They basically stopped short of calling the doctor a quack.

One thing that I think bears mentioning is the last sentence in SMC's reply: the SMC may only initiate action when a complaint has been filed - if no one actually files a formal complaint against this doctor, then despite the incident being mentioned and acknowledged in a newspaper, no binding action will result. So if we want to rid our profession (or if you want to rid our profession) of dubious practitioners, then sometimes we have to take the effort and act so the proper authorities can act too.

When The Whistle Blows

2010-09-21T15:41:00.001+08:00

Not too long ago, a blog entry about KTPH A&E's lack of 24-hour senior support triggered a comment that basically asked its writer to be careful about the consequences of "whistle-blowing". Something about Singapore MD being shut down, maybe its contributors being hurled into outer space, or having their limbs ripped off, I can't remember.

First of all, at least one of S'pore MD's co-authors has faced a possible shut-down before. Not because s/he wrote something which was untrue, but because the truth proved too painful a pill for the powers-that-be to swallow ( and more importantly, because his/her blog just happened to be featured by a prominent overseas newspaper, causing a spike in international readership ).

Soon after, I came across a Time magazine article about WikiLeaks, which I happen to think is damn cool. Direct link to the website here. :)

So let's think about this a little bit: what is the main purpose of whistle-blowing?
Answer: to expose an injustice to the public, and hopefully, right a terrible wrong.

In the local context, exposés regarding medical issues usually stem from 2 sources - journalists and patients. And oftentimes, the latter blabs to the former, and it makes headlines.

It is widely known that members of the medical fraternity are expected to adhere to a "code", a code that I don't have to spell out for you. And while many would like to believe that such a code only exists in the medical circle, it in fact does not. Other examples: any profession that involves uniforms and the legal possession of firearms; law; finance; the Catholic church.

Wouldn't it make much more sense for doctors to be exempted from such a code? Why protect someone who's endangering the lives of his/her patients? Why protect organizations that know a serious problem exists, but do nothing to resolve it?

As you can see, the KTPH issue has been kept out of the press. Perhaps the powers-that-be issued an unofficial gag order, but rest assured that they're aware of the issue and are at least taking some action, according to a source I spoke to. It's a rather feeble attempt, but at least it's something.

Last but not least, I hope the powers-that-be will view Singapore MD is a valuable sounding board, and not as a threat. We are not gunning for people to lose their jobs here. We'd just like the administrators and the public to know what's happening at the frontlines, hopefully early enough so as to prevent a major catastrophe.

Carbapenemase-producing Enterobacteriaceae

2010-09-20T06:04:00.003+08:00

You will find the brief recorded history of the NDM-1 gene on Wikipedia - it is fairly accurate, and saves ploughing through several case reports and full length journal articles. However, it is likely that this gene - one of a superfamily of carbapenemase enzymes - has been around way before 2009. If you look through publications in Indian medical journals (one example here), or conference presentations, you will start to get the picture that carbapenem resistance in Enterobacteriaceae started to become a significant problem around the early to mid-2000's, with export to other countries occurring once a certain critical prevalence was reached. It is important to note that the NDM-1 gene is only one of a large number of carbapenemase genes found in Enterobacteriaceae such as Escherichia coli or Klebsiella pneumoniae, although only one other has so far demonstrated epidemic potential - K. pneumoniae carbapenemase (KPC) gene that was first discovered in the US (North Carolina) in 1996. Several variants of this gene are now found in Enterobacteriaceae causing intercontinental outbreaks, notably in Israel where a KPC-3 producing K. pneumoniae caused a nationwide outbreak in 2007 that is still ongoing despite a national effort to contain the problem. Both sets of genes (NDM-1 and KPC family) are found on plasmids, which are mobile genetic elements capable of transferring horizontally between related bacterial species. This is therefore a more efficient (for bacteria!) way of dissemination and is far harder to deal with in terms of infection control. The gene that causes methicillin resistance is (largely) fixed to the bacterial chromosome of Staphylococcus aureus, therefore one only has to try to control the epidemic/outbreak clones (sounds easier than it is to achieve!). When the gene itself is mobile and can hop across species, multiple epidemic clones can appear (and disappear) and it becomes almost impossible to stamp out by conventional methods of control such as case detection and isolation.

Despite the relative success of KPC-producing Enterobacteriaceae at causing outbreaks worldwide, I consider NDM-1 producing Enterobacteriaceae to be a far larger problem potentially. The reason is relatively straightforward if one cuts through the political claptrap: there are just far more people from the Indian subcontinent traveling for medical reasons (i.e. medical tourism) than Americans, and they also tend to be sicker, with longer exposures to their own healthcare facilities (where there is a possibility of picking up these bacteria). Just look around any of the private or public hospitals in Singapore (try the 'A' class wards) and you will see that there are not that many Americans at all. The human and social factors driving NDM-1 spread are just far greater than that for any of the other carbapenemase enzyme-bearing bacteria, including KPC-1. Whereas we have yet to isolate any KPC-producing bacteria in Singapore after almost 15 years post-discovery, two local cases of NDM-1 producing K. pneumoniae carriage (not infection) were recently reported from the Singapore General Hospital (doubtlessly identified by researchers from the hospital's microbiology laboratory rather than MOH, as ST would have us believe), both from individuals who had recently been in contact with healthcare facilities in the Indian subcontinent. As a disclaimer, this is not saying that all the patients from the Indian subcontinent will carry NDM-1 producing bacteria, but invariably, some will be positive, and in the course of their treatment in hospitals outside their country, opportunities will arise for the dissemination of these bacteria.

Why should we worry about carbapenemase-producing Enterobacteriaceae when we have had relatively high rates of carbapenem resistance in other Gram-negative bacteria such as Pseudomonas aeruginosa and Acinetobacter baumannii for years?

On a general level, carbapenem-resistant bacteria are a huge concern because these drugs (imipenem, meropenem, ertapenem and recently doripenem) literally represent the last line of safe and effective antibiotics for the treatment of severe Gram-negative infections, and there are no new drugs that are active against these bacteria over the next 5-10 year horizon. Many clinicians in Singapore have had experience with polymxyin B (intravenous) and colistin (inhaled and intravenous) - now the "gold standard" antibiotics for treatment of carbapenem- and multidrug-resistant non-fermenting Gram-negative bacteria (i.e. Pseudomonas spp., Acinetobacter spp., etc). This class of drugs has seen a revival worldwide in recent times, but there were good reasons for discontinuing their use in the 60's and 70's when the newer antibiotics such as later-generation cephalosporins were developed - they are far more toxic and considerably less effective than the beta-lactams in head-to-head studies. Bacterial susceptibility and clinical effectiveness are two separate matters, as most ICU and ID physicians can attest. Then there is tigecycline - a new antibiotic that is closely related to doxycycline. While most bacteria remain susceptible to this drug, inadequate plasma levels at conventional doses and lack of activity against P. aeruginosa limit its usability.

On a more specific level, Enterobacteriaceae such as E. coli and K. pneumoniae are far more common than the nonfermenters (they can be found as commensals in the human gut), and far more virulent, having a lower threshold for causing infections. Can you imagine trying to do bowel surgery on an NDM-1 or KPC-producing K. pneumoniae carrier? Or a hypothetical scenario where a significant proportion of the population carried such bacteria in both hospitals and community? If we continue on our current trajectory, this scenario may well happen.

Superbug Intro

2010-09-17T21:25:00.002+08:00

There has been a large number of bacteria bequeathed with the title of "superbug" - usually by the press - in recent times. These include - not in any order of importance - MRSA, VRE, penicillin-resistant Streptococcus pneumoniae, multidrug-resistant Acinetobacter baumannii and Pseudomonas aeruginosa, ESBL (extended-spectrum beta-lactamase)-producing Escherichia coli and Klebsiella pneumoniae, KPC (Klebsiella pneumoniae carbapenemase)-producing K. pneumoniae and E. coli, and lately, NDM-1 (New Delhi metallo-beta-lactamase)-producing K. pneumoniae. The term "superbug" connotes antibiotic resistance rather than hyper-virulence, a common public misconception. Some isolates of Acinetobacter baumannii are resistant to all known antibiotics, but this is a relatively weak opportunistic pathogen, largely incapable of causing infections in healthy individuals (although fulminant infections continue to occur in ICU patients, burns patients, or hospitalized patients with various tubes sticking in and out of them). On the other hand, the pneumococcus - while not particularly antibiotic resistant - can infect and kill individuals of all ages and health states (and therefore the critical importance of vaccination in childhood or when immunocompromised).

Generally, when a bacterium first develops resistance to an antibiotic, a fitness cost is imposed on the organism that comes from maintaining a new and additional "process" (that may well be alien to the bacterium - many of the antibiotic resistance genes found in bacteria capable of causing human disease are actually horizontally transferred to them from other bacterial species that may not be pathogenic). One inexact analogy would be the slowing down of your computer (especially if old) when you are running several applications at the same time. The bacterium then seems to be less capable of causing infections, a phenomenon observed with organisms like MRSA or multidrug-resistant tuberculosis when these first appeared. However, this fitness cost is not by any means static: after a period of time, the bacterium generally adapts to this and resumes "normal function" when causing infections.

As an example, when MRSA first appeared in the 1960's, physicians and scientists observed that infections only took place in the hospital setting among immunocompromised patients, and the organism disappeared after discharge from the hospital (this may take up to a year, however), replaced by other staphylococci from the community. For the longest time, this was held to be true until community-associated MRSA appeared in the late '80s and '90s. It took a long time for the scientific and medical community to actually believe that MRSA can cause infections in healthy individuals outside the hospital setting - something that most young doctors today may find hard to imagine, particularly with what we know about evolution. How did the organism evolve to do this? By replacing larger and "clunkier" methicillin resistance gene cassettes with more streamlined and smaller versions, and by assembling heterogeneous cell walls made with a variety of penicillin-binding proteins rather than homogeneous cell walls comprising mostly of the alien PBP-2' that confers methicillin resistance. Such changes enabled CA-MRSA to compete successfully with other staphylococci in the community setting, and to cause infections even in healthy individuals, resulting in outbreaks in almost all continents worldwide.

Next up: NDM-1 and why this is (IMHO) the most important antibiotic resistance phenomenon to have emerged after MRSA. Or you can look it up on Wikipedia.

An Exercise In Futility

2010-08-20T17:32:00.000+08:00

Does anyone agree that the SMA's appeal to restore the guidelines on medical fees was a huge waste of time?

And correct me if I'm wrong, but wasn't this triggered by a certain medical professor's editorial in the Straits Times, criticizing the removal of these guidelines?

I wonder how much the SMA spent on legal fees.

And what's become of the lawsuit involving a prominent liver transplant surgeon, who charged a foreign patient a gazillion dollars, only to have him die in the end?

Priorities

2010-08-14T11:38:00.002+08:00

It seems every time I read a newspaper article about Alexandra Hospital - now Khoo Teck Puat - it mentions waiting time and all the terrific measures being taken to shorten it.

Here's something for its CEO and journalists to chew on - its Emergency Department does not have round-the-clock senior coverage. And when I say "senior", I mean registrars and consultants.

I.e. senior medical officers and resident physicians run the show on a regular basis, night shifts included.

Apparently, this is because the number of senior ER physicians is lacking, reasons for which I am not privy to. Compare this to the newly established Jurong General - now parked at the old AH premises - that is practically overflowing with consultants.

As patient attendances at KTPH continue to rise - it's already hitting 200+ per day - the powers that be should pay less attention to waiting time, and be more pro-active in attracting specialist talent to the ER.

Being the only local restructured hospital without 24-hour senior supervision in the ER is a step in the wrong direction. Patients should be aware of this, and the administrators should find a solution as soon as possible.

Palliation and Death

2010-08-11T08:00:00.003+08:00

I had the pleasure of reading Atul Gawande's latest essay on National Day. Written in his typical eloquent style, "Letting Go" tackles the issue of dying and how modern medical care is ill equipped to deal with it. Much of the writing revolves around patients with terminal cancer, a particularly difficult subpopulation in the sense that there are so many new therapeutic agents now available (with far more to appear over the horizon), yet these patients remain in a situation where death seems "more inevitable" compared to patients with end-stage heart failure or obstructive lung disease.

Most of the new (and old) therapeutic agents for metastatic cancer offer more hype than hope, and the symptoms they ameliorate at remarkable financial costs (in Singapore, few chemotherapy drugs are subsidized in the public sector) are sometimes replaced by the toxicities of the drugs. I am sure virtually all oncologists understand that with most chemotherapy, they are providing symptomatic relief and prolonging life by several months on average, but the patients and their families generally do not truly understand this at the start, wishing against hope for a miracle that almost never appears. And in some patients, this hope can go too far when they search desperately for ever more experimental drugs and miracle cures on the internet that less scrupulous practitioners may be willing to provide.

Errant Doctors

2010-08-09T20:18:00.001+08:00

From the latest issue of the SMA News.

Comments, please. But keep it civil. :)

Whose "health" is it anyway?

2010-07-30T12:37:00.000+08:00

The problem with us doctors is, we can't quite make up our minds on what constitute "health" or "real medicine".

Take this letter from Prof Feng in the ST Forum today:

Good health not just about weight, says a 'lighter' doctor

I AGREE with Dr Yik Keng Yeong ('Excellent doctors despite wide girth; July 19) that doctors should look their part.

Since my girth has been mentioned, your readers may wish to know that I have lost 10kg after three years, but am still trying to lose another 5kg, which so far has proven to be mission impossible. This is because I enjoy food, in particular, roti prata, cheesecake, char kway teow and ice kachang.

However, obesity is only one of the risk factors of poor health. Recent research has shown that about 20 per cent of obese people are perfectly healthy with normal cholesterol and blood sugar, and a good family history. They also live a long and healthy life.

My late friend, Professor Chao Tzee Cheng, used to tell me that 30 per cent of people who die suddenly of heart attacks are not obese, but they indulge in unhealthy habits such as smoking, excessive alcohol intake, lack of exercise and risky sexual behaviour, and have a poor diet and poor family history.

Good health is a lifelong journey and you start when you are young. Parents must instil in their children healthy lifestyle habits such as having a good diet, regular exercise, not smoking and not drinking alcohol, as well as prevent childhood obesity.

Good health is not a number, be it your age, weight, body mass index, how often you jog or the number of kilometres you run. It is a sense of well-being physically, mentally, socially and spiritually.

In this regard, the National Arthritis Foundation, together with a geriatrician, is organising a number of seminars and talks in the latter part of the year and next year to address issues of health literacy, active ageing and patient empowerment.

We need to change the whole concept of health, focusing more on prevention and self-management. The present debate of 'girth and health' is simplistic and does not address the more important issues of good health.

Professor Feng Pao Hsii
Chairman, National Arthritis Foundation

Now, leaving aside the fact that from the figures given by Prof Feng, about 80 per cent of obese people are NOT "perfectly healthy with normal cholesterol and blood sugar", and 70 per cent of people who die suddenly of heart attacks ARE obese (see my take on the 'fat but fit' argument here), and that Prof Feng has written in a previous letter of obesity being "a serious medical problem and [that] studies in the United States show that obesity will be the No. 1 public health problem and cause of death in five years' time", I am amused by Prof Feng's definition of good health as "not a number... [but] a sense of well-being physically, mentally, socially and spiritually".

Now much of what we do in "medicine" today is about numbers. Your "weight, body mass index, how often you jog or the number of kilometres you run", your "cholesterol and blood sugar", your smoking, alcohol intake, exercise, sexual behaviour, diet and family history are all quantified and studied, because they give us an idea of your risk for certain diseases. Our interventions, pharmacological or otherwise, aim to modify or reduce these risks. These are numbers that translate to concrete events in real-life.

You may argue that one can have bad risk factors and still have a sense of "physical, mental, social and spiritual well-being", in which case you don't need a doctor or drugs to make you feel better - but that doesn't mean you are not going to die of a heart attack at 40 either.

(I can't recall what training I had in medical school that taught me how to improve a patient's "spiritual well-being"...)

The problem with using the term "well-being" in defining something as important as healthcare or medicine, is that it is a vague term (a weasel word, I like to call it) that allows quacks to ply their trade, and for people to medicalise their problems of living - and that is something Prof Feng disapproved of, isn't it?

Do I have a better definition for "health"? Well, not yet - but I certainly don't think my job is only about giving people "a sense of well-being".

Interesting Blog Entry Re: Bed Crunch In Singapore

2010-07-29T20:59:00.001+08:00

From Yawning Bread.

10 Ways To Irritate Your Doctor

2010-07-28T07:10:00.000+08:00

Thank you, Ms JS, for the link. :)

Confidence Goods 15

2010-07-19T10:42:00.008+08:00

I am no longer surprised that laymen tend to judge doctors based more on style than substance; nevertheless, I am amused by how justified they feel they are in doing so, as exemplified in no fewer than 3 letters in the ST Forum today.

Mr Lee Seck Kay believes that

"... doctors need to care about their looks; never mind if they are not handsome, but at least they should not give the impression that they are lackadaisical. It is a moral responsibility that many doctors tend to neglect, much to their detriment."

(emphasis mine)

Mr Anthony Goh's contribution is:

"The doctor's personality and the way he conducts himself speak better than looks."

Mr Javern Sim shares his experience and wisdom thus:

"I have occasionally come across doctors who are more interested in getting the
diagnosis and prescription of medicine over and done with, rather than
communicating properly with their patients.
It is imperative for doctors to be skilful not only on the treatment table, but also in terms of patient management and communication."

(emphasis mine)

Curious. I would have thought that making the correct diagnosis and prescribing the appropriate medicine and letting the patient know the two constituted patient management and communication.

Why do the writers seem more hung up on how the doctors look or conduct themselves than on the quality of the medical care or advice, as if the clinical encounter was more a date than a consultation? My suspicion is that lacking the means or inclination to assess the quality of care, patients instead base their judgement of a doctor on things they can assess. It's a natural thing to do - it makes us feel we have control over the situation - but then how a doctor looks or behaves towards you may have very little correlation with the quality of care he provides. If patients choose to judge doctors on style than substance, then perhaps that is what they will get.

The irony, of course, is that doctors too sometimes judge patients by their appearances...

Obesity - a KPI? How silly can you get?

2010-06-26T14:39:00.001+08:00

Mr Liak Teng Lit, CEO of Alexandra Hospital and the coming Khoo Teck Puat Hospital was reported as saying "....All things being equal, if you are grossly obese, we won't promote you."

Perhaps Mr Liak should also penalize those who can't pass their IPPT (Individual Physical Proficiency Test). Not to mention the elderly, myopes, diabetics and hypertensives as well.

More at Gigamole Diaries.

Teaching a new ball old tricks...

2010-06-15T17:40:00.005+08:00

I was reading this interesting account about the new Adidas ball they've been using for the 2010 World Cup. The Jabulani ball.

Not very well received so far. Many complaints. But for intents and purposes, a technologically superior ball compared to previous versions of the football.

I found it quite interesting.

So here's a question to ponder.... is everything better always...better?

I can think of the software upgrades we keep getting. Each versions gets better and more powerful ...but invariably bigger, messier and more difficult to use. In many ways they become less intuitive and we need more keystrokes to get to the same point. Is better, better?

Our work 'software' has the same problem. Office and management 'improvements' keep destabilizing the work process , and I often wonder if productivity is improved.... or actually degraded through these frequent changes.

Seems like there is a certain efficiency in familiarity, and a certain loss in efficiency when we operate on the learning curve. If changes occur frequently, even though they may ideologically be 'improvements', a certain inefficiency is introduced by moving workers from a position of familiarity (and its associated efficiency) to an unfamiliar uncomfortable position on the learning curve.

Not everything that is better, is actually better.

Closer to home....I think our health care system as well as medical education environments need a period of stability so that we can all start mastering the processes rather than keep chasing endless series of changes.

Ignoring the Elephant

2010-06-07T22:46:00.003+08:00

I read this news article with no small degree of amusement:

MTI says no to excluding doctors' Guideline on Fees from Competition Act

SINGAPORE: The government has thrown out the Singapore Medical Association's (SMA) request for its guidelines on fees to be excluded from the Competition Act.

After consulting the Ministry of Health (MOH), the Ministry of Trade and Industry (MTI) has determined that the guidelines could create anti-competitive behaviour, and cannot be excluded from the Competition Act.

The guidelines were introduced in 1987 by SMA and the Association of Private Medical Practitioners of Singapore (APMPS), following the MOH's calls for a guide on medical charges.

This was to equip patients with pricing information on consultation and surgical fees, and to prevent private doctors from overcharging.

In April 2007, the SMA removed the guidelines voluntarily on legal advice that they could contravene the Competition Act.

It then sought to have the guidelines excluded from the Act.

The MTI said in a statement that in the absence of other information, the guidelines would have been useful in providing information to patients on medical fees.

But the MOH is already publishing actual medical fees at hospitals on its website.

In May this year, the government announced that all hospitals making Medisave claims will have to submit basic billing information from early next year.

Public hospitals have been doing so for the last seven years and this is part of the government's plans to make pricing more competitive and realistic in the private sector.

Dr Chong Yeh Woei, president of SMA said: "We hope that the mechanisms to protect the patients will be sufficient, but the downside of this is that there will be a risk that there'll be an erosion of trust between the public and the profession.

"Now, it doesn't matter whether it's the private sector or public sector, the public will perceive it to be an industry-wide sort of situation."

While he admits that there are black sheep in the industry, Dr Chong pointed out that most doctors still charge reasonable fees.

SMA said it will continue to publish data on specialists' fees to give patients some information on pricing in the private medical sector.

It had filed a separate notification with the Competition Commission of Singapore in February last year, and the commission said it hopes to conclude its evaluation shortly.

Now it seems to me that if the government was truly anti-anti-competition, then perhaps we shouldn't just be looking at the competition between the private sector and non-subsidised healthcare in the public sector, but at the more unequal competition between subsidised and non-subsidised healthcare, shouldn't we?

More importantly, why would the Ministry of Health want healthcare costs in the private sector to be lower?*

* - Those of you who know the answer, please do not reply - it will be our little secret...

Yet more about MRSA...

2010-05-29T16:55:00.004+08:00

In the space of two days, our busy Gigamole has produced 2 articles on MRSA in Singapore hospitals. The statistics may be confusing for some.

But first, it is important to acknowledge that there is no single measurement that captures the burden of MRSA on the hospitals as well as the impact of hospitals' activities directed against MRSA. One can use a basket of measurements, but the effort of collating all these results will increase, and some degree of specialization becomes necessary in order to make sense of the results collectively.

The figures quoted in Today a few days ago reflect the prevalence of "new MRSA infections". This somewhat-difficult-to-understand measurement attempts to reflect MRSA infections acquired within the hospital, and is therefore a measure of potentially preventable (within the hospital - as a consequence of transfer of MRSA from other patients or staff) MRSA infections. So if a patient had MRSA infection in the past or is known to be colonized by MRSA, then any MRSA infection within his/her hospitalization is not regarded as being "new" (and by extension, is not a consequence of a new transfer of MRSA from other patients or staff). Confused already? Well, join the club!

The practical implications of this, as both Gigamole and Salma Khalik have both pointed out, is that MRSA infection rates appear to drop substantially. Part of this is because of a change in reporting, and part of this is because of MRSA screening - especially true in hospitals where there is widespread screening of patients for MRSA colonization upon admission. Because those patients who test positive are then subsequently probably not counted if they develop an infection within that period of hospitalization. This does not mean that the true burden of MRSA has not declined in our hospitals - it probably has - just that you should not draw too many conclusions from the figures given. One real danger is that these results gives the impression that the MRSA problem is halfway to being solved, therefore fewer resources might be allocated towards tackling a problem that the hospitals are just coming to grips with.

The UK Health Protection Agency only tracks the incidence of MRSA bacteremias (duplicate culture results removed). This measurement is a surrogate for "severe MRSA infections", and the data are relatively simple to collect and analyze. However, this is again not reflective of the actual burden of MRSA infections in the hospital because the complexity of patients being treated at each hospital takes on greater importance. The proportion of MRSA bacteremias among all MRSA infections is higher in patients who are more ill, have more lines stuck into them, and/or are more immunocompromised. Community hospitals flooded with MRSA-colonized patients may have relatively few bacteremias compared to tertiary hospitals where many surgical operations are carried out. Also, many of these infections may not really be preventable in the sense that we understand - no hospital in Singapore can achieve 0% MRSA if such a measurement (or similar measurement) is used for assessment of the impact of its interventions.

Many hospitals measure the percentage of Staphylococcus aureus infections that are MRSA. This is the simplest but probably least useful measurement because it is dependent on way too many factors, including the number of methicillin-sensitive Staphylococcus aureus infections.

Ultimately, at least 2-3 different measurements of the hospital MRSA burden are required to enable interested parties to have a real grasp of the situation, and for hospitals to have some degree of accountability.

Gigamole also posed a question about the who actually pays for an MRSA infection in the financial sense. I suspect Gigamole already knows the answer and the question was rhetorical. Nonetheless, as the majority of MRSA infections occur in "subsidized" patients in our hospitals, it is likely that the patients pay a small amount (not taking into account the morbidity and mortality from the infection itself, just the money) on average, and the ministry - and therefore ultimately the taxpayers - bear the burden for the majority of the financial costs. To what extent the hospitals themselves pay, is not certain.

Private sector allure

2010-05-29T06:50:00.003+08:00

It is about the time of the year when senior specialist doctors in the public sector consider leaving - or have just left - for the private sector. The timing revolves around consideration of annual bonuses, etc.

The number choosing to leave does not seem to have gone down over time, despite efforts at public sector hospitals to achieve parity of income (especially for surgeons). A significant part seems to have been played by Healthway Medical Corporation Limited in recent times. Good luck to those who have gone out to join their clinics (or perhaps good luck to Healthway for this venture?)!

For the majority, it is no longer quite about the money, but rather, hospital push factors. Many in the early days (and some even after many years) of private practice feel that they have returned to their "roots" - doing what they have been trained to do and providing real individualized medical care. Not being forced to do a modicum of research (or to pretend to enjoy/espouse it) or to sit in time-consuming committee meetings is a heady feeling. Being able to spend more time with one's patients rather than having to deal with administrative grouses about "patient waiting time" (because clinics get overloaded with patients - several of whom are slotted at 10-15 minute intervals like a factory line) feels just great. The whole great balancing act of clinical service, research, education, and administrative duties can itself be overwhelming, and most do not have the power to change this very much (without appearing to be prima donna's, for example).

There are the drawbacks, of course:

One can get called back at any hour of any day.
One does have to pander more to one's patients.
Bad debts can accumulate and they are one's problem (unless one is in a large group with administrative services to deal with these things).
One can rarely deal with complex multi-disciplinary medical problems the way that tertiary public sector hospitals are able to.
Regulatory oversight of the private sector is poor (although some may see this as a plus).
One has to get over the guilt trip that some may feel for no longer treating the "poor and underserved".

Private specialist care is evolving rapidly into group practices and multidisciplinary practices - perfectly understandable given the nature of the market - and this may offset some of the drawbacks above. All in all, most people are happier once they have left the public sector, although working up the courage to leave can be nerve-wracking.

Top 10 Challenges In The Emergency Department

2010-03-27T10:03:00.002+08:00

This entry is meant to provide a broad perspective of what EDs in Singapore are currently facing.

Different hospitals may experience the following issues in varying degrees of severity.

Powers that be -*ahMOHem* - please take note.

10. Patient loads

An article in the ST today about the impending opening of KTPH helpfully highlighted the daily patient attendances at TTSH and CGH EDs, which now exceed 500.

SGH's numbers average 400-500, up from a tally of 300-400 just a couple of years ago.

Compared to many EDs overseas - even those in large cities - this is often double what many foreign institutions see.

Possible reasons?

9. Unnecessary referrals

Cases referred from polyclinics and GPs are of course inevitable. But one of my main grouses involves referrals for minor orthopaedic conditions which usually require no further treatment and may or may not warrant follow-up in the orthopaedic outpatient clinic.

Examples: minor toe or finger fractures - some of which were sustained more than a week ago -that do not require any intervention except oral painkillers and medical leave.
Such patients are ambulant and able to continue with daily activities with little difficulty, but chose to see the primary care physician because of persistent bruising or mild pain.

So the x-rays are done, a fracture is reported, the patient is told to come to the A&E and duly complies, only to have the ED doctor tell him/her that there's nothing more to be done really, and I'm sorry you have to fork out $80-$90 just to hear me say this.

I've had to endure a number of irate outbursts, not just because of the extra cost, but also due to time wasted waiting for hours at the ED.

Friends who work in the polyclinics tell me that all fractures MUST be referred to the A&E no matter what. Perhaps the protocol should be modified.

Other unnecessary referrals: patients with uncontrolled diabetes and hypertension who defaulted their meds but are otherwise symptom-free. Err, we already know why their glucose levels and blood pressure are high. So restart their meds, do a few baseline blood tests and review them in a few days. Reasonable, right?

The best one so far: a memo that asked the attending ED doctor to "please bring forward the patient's clinic appointment, which is 3 months away, and patient is very anxious because we're unable to arrange an earlier date."
Well okay, I suppose "anxiety" can be considered an "emergency" of sorts.

8. Self-referrals

Singaporeans are a savvy bunch, so walk-in cases are on the rise. It gets especially frustrating during office hours when you see a long list of upper respiratory tract infections and mild backaches / headaches / stomachaches in the ED, cases that could've been assessed by the primary physician and referred to us if necessary.

Our most loyal clientele? None other than NS boys. If you're referred by an SAF MO or turn out to have a real and acute medical / surgical condition, then the ED visit is certainly warranted.

But when you have a minor complaint and could've easily consulted your camp MO, or if you have a record of numerous ED visits and MC-seeking behaviour, and are observed to be laughing with your girlfriend while waiting to see the doctor, that really raises my hackles. Because you're just wasting our resources and lengthening the waiting times for other legitimate cases.

Note to the SAF: revise your policy regarding MC endorsement. How about assigning certain polyclinics or GPs to see these guys?

7. Long waiting times for Specialist Outpatient Clinic appointments

A chronic problem, now aggravated by an ever-increasing number of referrals from the A&E and primary care facilities.

We see symptomatic patients who come to the ED because they just couldn't wait any longer. Hernias get incarcerated or strangulated, chest pains turn into heart attacks, gastric ulcers perforate.

At my institution, cardiology appointments average 4-6 weeks ( that's even with an urgent A&E referral ). Some departments allow force-ins for urgent cases, but these are rare and based on good faith, so don't expect the ED physician to do this for every single patient who's anxious and insists on being fast-tracked.

6. Primary care in Singapore

I often ask myself if this is adequate, and the answer almost always comes back as a negative.
The polyclinics are overcrowded and understaffed. Medical officers see up to 80 patients in a 4-hour morning session which includes both simple and more complicated cases. Far from ideal.

GPs don't face such harrowing conditions, but it's common knowledge that many have turned to more profitable pursuits - e.g. aesthetics - because managing chronic illnesses and bread-and-butter stuff ( like coughs and colds ) simply can't sustain a practice.

Reason? An oversaturated GP market and paltry subsidies from the government, resulting in significantly higher fees which the patient himself has to bear.

So he either turns to the polyclinic, or comes straight to the A&E, not just to bypass the long waiting time at the former, but to enjoy a flat fee ( less than $100 ) at the latter, which includes x-rays, blood tests, standard medications, even a specialist review in the ED that very same day if indicated.

Most EDs now also offer observation protocols for various conditions - e.g. chest / abdominal pain, asthma, stable head injury - allowing the use of Medisave funds for treatment and specialized tests such as CT scans.

Compared to the GP clinic, which may charge a couple of hundred bucks just for x-rays and bloods alone ( and which the patient has to pay for out of his own pocket ), it's a steal.

And let's not forget the standing policy that all SOC referrals from GPs are considered paying class, so patients are charged B1/A class rates when they attend these clinics ( including investigations and procedures ). Only polyclinic and ED referrals enjoy subsidized rates.

Something for MOH to consider changing?

That said, I also hope our family physicians will spare a thought for the stressed-out ED doctor at the other end of their referrals. Surely a memo that says only "Giddiness ( or chest pain, headache etc ), please manage", with no other details about the patient's symptoms, physical findings, vital signs or treatment already instituted, can be construed as unprofessional? Even the polyclinic MOs can do better than this.

On the flip side, a posting with a well-established ( and pretty famous ) GP during the 4th year of medical school opened my eyes to the possibilities of running such a practice. This enthusiastic doctor conducted treadmill tests for his patients with chest pain, right there in one of his consultation rooms! He also did minor surgical procedures like abscess drainage. It still amazes me to this day.

5. Waiting times for admissions vs lodgers

I'm not familiar with any specific time-frame for lodgers, but my personal definition is "a patient awaiting ward admission, who still has no bed allocated after 2 hours".

2 hours because that's when the ward MO covering the ED is activated to come down and clerk the case, as per international JCI standards.

The admission process is a tedious one. Contrary to what many people think, it doesn't involve the simple click of a button and presto, you've got a bed!

First, the ED doctor books a bed by entering data fields in the patient's computerized records. The most pertinent info would be which department you're admitting to, and the ward class.
This triggers a cascade of events, where the Bed Management Unit is alerted and starts hunting for a suitable location. If there isn't one available, the case is highlighted as "lodger" status.
When certain departments' designated "mother wards" fill up, subsequent admissions start to overflow to other wards.
But the main hiccup occurs when the hospital runs out of beds in a certain class - most commonly B2 - and the BMU starts assigning B1 or even A class beds to these patients.

I've worked at 4 different public hospitals ( wards as well as EDs ) in my lifetime, and can tell you that there's a significant difference between institutions where parking B2 patients in higher class wards is concerned.

One has no qualms about putting C class patients in A class rooms ( a huge bonus for the lucky ones ), while others balk at the notion, and refuse to allocate these wards despite the availability of beds.

Timing of admissions can also be a key factor. Whether it's politically correct or not to comment on this, I feel it's pertinent to the delay in transferring ED patients upstairs, so it should be mentioned.
It's no secret that ward nurses refuse to accept transfers during shift changes because they're "passing report", but this is acceptable up to a certain extent. There're instances where a 2-hour period is completely blocked off - i.e. 1 hour before and 1 hour after the actual shift change. If it's a seriously ill patient who doesn't qualify for ICU care, the case will inevitably take up one cubicle in the resus room, with at least 1 doctor and a couple of nurses tied up with monitoring him/her continuously.
And considering how EDs regularly juggle 5-6 critical cases at a time, not being able to send the patients to the wards can be extremely taxing on the A&E staff.

Sometimes, we're told the patients can't go up because someone was just discharged and they need to clean the bed. Inexplicably, this can take 3-4 hours to complete.

One institution has a strange system where the ward nurses have to click on something in the computer software before the patient can be sent up. So the nurses refuse to click on it so they don't have to accept the case. And it appears that nothing can be done even though everyone knows about the problem.

Is there a shortage of beds in public hospitals? You bet.
But are there other reasons for the EDs' lodger headaches? I'll leave it to our reporters to go do some digging.

4. Shortage of ICU / High Dependency beds

I've been experiencing this a lot at my workplace this past year.

Contributing factors:

a) many sick patients admitted from the A&E and also transferred from general wards after deteriorating acutely

b) a steady stream - or perhaps increasing number ( no official stats available ) - of elective admissions who also need ICU / HD care post-procedure

c) little expansion of ICU / HD facilities

The challenge lies in balancing the need to reserve beds for the electives ( which generate money ) vs the acute cases ( don't generate as much money and also occupy ICU / HD beds for longer periods ).

The first thing that certain institutions need to address is the space constraint. 5 HD and 10 ICU beds aren't enough for a huge discipline like Medicine.

So it isn't uncommon to have HD cases lodging in the ED for 12 hours, and ICU patients with nowhere to go when even the overflow ICUs are full.

3. Surge capacity

A reader asked if our healthcare system can cope in the event of a major disaster.

Of course not.

But this is a global problem, so Singapore has nothing to be ashamed of.

I've participated in a number of mass casualty exercises. While useful in theory, I have my doubts about its application in a more realistic setting.

Who will be hit the hardest should such an event occur? Unquestionably, the A&E.

Based on personal experience, I would give the following estimates as the threshold for an ED's breaking point:

a) minor casualties: up to 50

b) major casualties ( requiring some form of resuscitation or urgent intervention ): 20

Once, I was on shift during a mini-mass casualty incident involving inhalation of fumes from an unknown gas. 11 casualties arrived at the ED - 1 major ( Priority 1 ), 10 minor ( but still classified as Priority 2 ). It took me 4 hours to manage the major case, and another 2 doctors the entire shift to clear the minors.
The incident occurred on a busy Monday afternoon.

If a disaster hits during peak hour and casualties number in the hundreds or thousands, WE ARE DEAD.

Sorry, just stating a fact, no matter how unpleasant it may be.

2. Managing patients' expectations

Think I may have discussed this in a previous entry, but as you can see, it remains an important issue and still doesn't receive the attention it deserves.

The culprits responsible for patients' unreasonable demands haven't changed much - the media, referring doctors, our own Health Minister ( remember his comment about how all ED cases will be "seen immediately"? ) - and I can only surmise that nobody reads the local papers since we get no sympathy despite all the articles highlighting bed shortage, patients abusing hospital staff and what-not.

If there's ever an opportunity for me to design a brochure stating the A&E's many limitations ( be prepared to wait if it's busy; no MRI, no MIBI / echo / Holter, no treadmill, no gastro- or colonoscope; looooong clinic appointment waiting times; no fancy-shmancy meds like Nexium and COX-II inhibitors; no specialist consultant to come down to see you so be satisfied with the MO okay? ), I volunteer my services.

1. Manpower

My biggest grouse, and the root of many of our difficulties.

Why we need to bulk up:

a) patient attendances are rising steadily

b) EDs are doing more for patients - observation protocols, investigations, procedures, etc. These take time and slow the queues down if there aren't enough staff

c) patients are also getting sicker - more staff are required to manage such cases

d) the residency programme is starting - with clear guidelines that restrict the number of patients residents are allowed to see during a shift, absolute MO numbers are no longer accurate gauges of sufficient manpower

e) more foreign-trained doctors in the ED - they need more time to adjust, have different learning curves, face language barriers and are generally less productive than the locals. So again, absolutely numbers don't mean much.

f) more junior MOs in the ED - we no longer turn away 1st posting MOs, and A&E is not compulsory for medical and surgical trainees ( it used to be about 10 years ago ). Inexperienced doctors require much closer supervision and work at a slower rate. Put 3 of them together during a busy shift and you'll understand what I mean.

g) more doctors and nurses needed during night shifts - aside from the warranted cases, I see quite a few patients ( mostly foreign workers ) who come in the middle of the night just because they clock in 12-hour days and the clinics are closed when they finish work. So now the A&E is a glorified poly- / GP clinic eh?

Checklists for Your Hospital

2010-03-22T05:24:00.004+08:00

The New York Times' interview of Dr Peter Pronovost was just emailed to me. He is a US anesthetist (John Hopkins Hospital) who has done remarkable work both as researcher and activist for patient safety. He is perhaps most famous for having drastically reduced the rates of central venous catheter infections in both his own institution as well as participating hospitals in the state of Michigan via a simple checklist (and not some fancy expensive drug-coated catheter or futuristic robotic insertion technique).

The final part of the interview is particularly interesting. When asked how patients could protect themselves from hospital errors, he mentioned that patients should have a clear idea of the hospital's infection rate. If this was high or the hospital did not track its infection rate, the patient should go elsewhere. Patients should also be their own advocates and ask if healthcare staff have washed their hands, or if their venous catheters were necessary. These last bits are very tough for local patients (or their relatives), but I have worked in public hospitals in Singapore - and these conversations are necessary to move things forward.

HIV in Singapore

2010-03-14T15:30:00.002+08:00

Sometimes - perhaps tragically - it takes a prominent foreigner to publicly state unpleasant truths about Singapore. Dr Francoise Barre-Sinoussi, 2008 Nobel laureate for her work as a co-discoverer of HIV in 1983, expressed strong criticism of the way HIV was tackled in Singapore when she came for a visit 2 weeks ago. Her comments were published by BusinessWeek among other news agencies, and of course, mentioned in local websites. In essence, she felt that the prevalence of HIV in Singapore was now somewhat higher than her own country France, and that "the stigma, the fact that they have to pay for everything, it's the worst conditions for stimulating people to be tested and treated".

MOH has replied in its usual way.

This matter is not new. Singaporean HIV activists and healthcare providers have long highlighted these issues to MOH but they have been stonewalled, brushed aside, and/or chastised, among other things.

The essence of the matter is that HIV care is comparatively substandard in Singapore, and this I should add is not really the fault of the healthcare providers. Baseline investigations, including viral load testing every half-year, are not cheap. Testing for viral resistance as is recommended by international guidelines? Research only. HIV drugs, as Stuart Koe and others have pointed out, are expensive mainly because generics cannot be legally imported and prescribed in Singapore. The cheapest HAART regimen in Singapore will set a patient back about SGD800.00 a month. If he/she requires second-line therapy, the cost rapidly escalates beyond SGD1,500.00/month. SGD550.00/month can be claimed from Medisave for the purchase of HIV drugs, and as of this year, Medifund has also been made available for HIV patients. Even if Medisave was inexhaustible, SGD250.00/month just for drugs is not trivial for the majority of HIV patients who are in the lower income bracket (or jobless).

The cost (to the patient) of HIV drugs in the developed world, parts of Africa, Cambodia, and even our neighbour Malaysia? Free... These are not the foolish and impractical actions of socialistic governments, but rather, cold and hardheaded utilitarian policies.

What do most HIV patients in Singapore do? They turn to unofficial "buyers clubs" where generic HIV drugs are bought in Thailand and smuggled into Singapore at a cost of about SGD120.00/month. That such enterprises have existed for more than a decade and that MOH has had to turn a blind eye to them is the surest sign that the healthcare system has failed in this particular instance. Healthcare providers at CDC (Singapore, not Atlanta) try to help in other ways, like participating in industry-sponsored and international HIV treatment trials. Subjects enrolled into these trials can then receive standard-of-care therapy or trial drugs free for a limited time beyond the duration of the trials. None of these seem good or sustainable in the long term.

HIV is not a disease like cancer, diabetes or cardiovascular disease, even though with adequate treatment HIV patients will surely outlive most cancer patients (and have equivalent survival compared with the other two). It is transmissible, especially during the early and late phases of the infection, and therefore of considerable public health importance. MOH's response has been to ramp up testing (especially of males) but it has neglected the issues of social stigma and treatment costs. It is no wonder that relatively few people come forward for testing. Why should they when the benefits are outweighed by the considerable downsides of a positive test?

Happy Chinese New Year

2010-02-14T07:41:00.001+08:00

To all those who celebrate this, Happy Year of the Tiger! May you have a prosperous and peaceful year ahead.

To all the rest, have a wonderful holiday!

?

2010-02-13T16:36:00.000+08:00

Quote from "ER" - They say you're not a real doctor until you've killed a few patients.

Foolhardy?

2010-02-04T17:53:00.002+08:00

Seems I've been out of the loop for a while.

Recently discovered that NUS YYLSOM now has medical students on its entry interview panel.

Previously, panels consisted exclusively of senior physicians / surgeons.

My questions include the following:

1) What advantages do young, inexperienced medical students provide at such an important screening process?

2) How are these students selected for the panel? Class chairman? Med Soc president? Dean's list?

3) Is this practised at overseas institutions? Locally, do other courses - e.g. law, dental, etc - also have students on their interview panels?

Your views, please.

Trust

2010-02-03T18:30:00.002+08:00

I don't have anything insightful to say about this news story, except to say that the longer that I'm in this business, the harder it is to know whom to trust.

Lodger Medicine

2010-01-30T21:14:00.003+08:00

Excerpts from a colleague's recent tongue-in-cheek email, before the A&E lodger issue made the Straits Times earlier this week.

"Lodger Medicine is a promising new branch that allows effective medical firefighting skills to be nurtured and used.

The trainees will benefit from the endless number of lodgers littered in the Emergency Department (ED).
Our unique monitored bed shortage allows trainees to get hands-on experience in handling p1L cases— [ stable ] cases that become priority 1 [ i.e. collapse or deteriorate ] while they are lodgers.

Other training highlights:

- How to prevent patients from dying in the ED before they get a bed
- Keeping patients alive on a diet of Milo and biscuits
- Coaxing zombified nurses to carry out orders
- Facing family members with sore butts and deep vein thrombosis from sitting out for >12 hrs
- Fine art of converting Intensive Care Unit-grade patients to General Ward to get a bed"

It remains to be seen whether adding 2 new hospitals will ease the bed crunch, but ED overcrowding is a completely separate entity, not merely governed by ward capacity, but by Singaporeans' abuse of already overstretched resources.

Our government is obsessed with numbers, and the Ministry of Health persists in its mistaken hypothesis that creating more beds is the best solution, the same way it maintains that pumping more doctors into the public sector is a magical elixir which will cure all our manpower shortage problems.

H5N1 vaccine stockpiling

2010-01-30T18:00:00.002+08:00

It was announced on Thursday that MOH is looking into buying a stockpile of pre-pandemic H5N1 vaccine. One million doses - or around SGD15-20 million if one assumes the price is similar to current influenza vaccines.

It is unclear why this is taking place now, just after the fiasco of the H1N1 pandemic (Gigamole has written a fine piece about this on his/her/?it's blog). Perhaps the policy makers were influenced by the work and projections of local experts. Which would be a mistake because that paper - while using fairly sophisticated models - assumes equivalent transmissibility between influenza viruses of different virulence and linear outbreak projections.

One would hope that none of our colleagues providing input to MOH were in favor of stockpiling the H5N1 vaccine. Used judiciously, one could do quite a bit in healthcare with several million dollars - enough so that officials should be able to resist the temptation to have unusable "insurance" that will allow them to sleep just a little bit better at night.

Breast cancer screening and adoption of evidence

2010-01-27T19:55:00.003+08:00

In November last year, the US Preventive Services Task Force stunned many cancer groups and experts by doing a U-turn and publishing a new set of guidelines that advised against routine mammography in women aged 40-49 years who did not have any known risk factors for breast cancer. In women aged 50-74 years, annual mammograms were of little benefit (the Task Force recommended biennial mammograms instead for maximal benefit vs. risk). At no age was breast self-examination found to be useful.

For women aged 40-49 years who had no risk factors (i.e. family history of breast cancer, hormone replacement therapy, etc), the harm resulting from screening considerably outweighed the benefits when considered as a population. Up to 1,900 women would have to be screened to save one life. Harm from screening (psychological trauma, unnecessary and costly tests/biopsies, inconvenience) had either not been factored into previous recommendations, or were given a smaller weightage compared to potential benefits.

A search through the websites of local organizations suggest either a 'wait and see' attitude or ignorance of the controversy. Our Health Promotion Board recommends annual mammograms for those age 40-49, and biennial mammograms for women age 50 and above. It also recommends monthly breast self-examination. This seems a bit contradictory (unless perhaps when viewed from an economic perspective). The Singapore Cancer Society follows the HPB recommendations as a matter of course.

Consumerist Healthcare

2010-01-24T05:56:00.002+08:00

This question was floated at a yakking session at the lounge the other day: should a doctor (or medical group) provide any treatment that a patient requests, as long as he/she is willing to pay for it?

We are not talking about the situation where a doctor offers "unproven" or experimental therapy (although this is probably still the more common situation here - I even know several patients that traveled to Shenzhen for their p53 gene therapy), or the well known but yet controversial healthcare inequities that arise when patients who can pay more get better care. Rather, internet-savvy and/or well-educated patients nowadays may request for medications or therapy that they believe might help with their conditions/illnesses.

This may be particularly difficult when patients have a terminal disease. What do you do when you know that whatever you provide (especially if it is the therapy requested by the patient), the patient will (99%) die without necessarily having meaningfully extended his life?

Some doctors go ahead with the requested therapy, reasoning that the patient knows what he/she is getting into, and anyway, the therapy will only be provided elsewhere (by rival doctors) if said doctor rejected the request. A rare few try to talk the patient out of it, and refuse to provide that therapy when counseling fails. In the private sector, I suppose the equation is more straightforward. There is a chance for a miracle (always good for one's conscience) and anyway, there is revenue to be considered. In the public sector, this is more troubling because resources (doctor's and other healthcare professionals' time, hospital bed and other services) that might be better utilized elsewhere are taken up by such cases - even if this was an A1-class patient. But then the public sector might well be accused of NHS-style practices...so where does one look for an ethical compass in such a situation?

Take That, MOH

2010-01-16T18:15:00.001+08:00

This link will expire after 7 days.

And of course, nothing will be done.

New Year 2010

2010-01-09T17:55:00.002+08:00

We are now a week into the new year, and it would be good to contemplate what might possibly happen for the rest of the year for healthcare in Singapore. Not all indications are positive (in fact, most are not), but feel free to add to the list:

More regulation of the healthcare industry, particularly doctors - lawyers chairing the SMC Disciplinary Committee, doctors getting fined 10 times more than they currently do now. The $1 (or several) million dollar question - can the 'wild wild west' of the private sector be reined in? Will there be more prominent doctors investigated rather than the usual 'uncle-type' GPs who have prescribed excessive sleeping pills?
H1N1 hype - we will end up with a huge stockpile of unsold vaccines.
Chaos when the Residency program starts in May, as the public hospitals struggle to cope with increased teaching requirements while the junior doctors try to deal with the 'express' vs 'normal' stream divide that will arise.
Nurses and nurse-clinicians taking over more of the responsibilities of doctors.
A boom in compulsive behavior studies as the casinos (sorry, integrated resorts!) open.
Even greater congestion at hospitals and emergency departments, even with the welcome opening of (part of) the KTPH.
More money poured into cancer and infectious diseases research (especially basic science) - will we see anything useful for the common folk coming out this year rather than just claims of breakthroughs in the ST??
Big GP chains and conglomerates squeezing out more and more single GP establishments. A reprise of Sheng Shiong vs wet markets?!
More complaints about junior doctors on this blog....

Headlines

2010-01-09T17:19:00.004+08:00

A recent case has put the medical profession in the harsh limelight once again.

Understandably, there is much speculation about what could have happened. And this particular incident has more than the usual impact on me personally, as one of the doctors at the centre of the tornado is from my medical school cohort.

Of course, that is completely beside the point. This could've happened to anyone. The big question is: what exactly DID happen?

This entry isn't meant to be a medicolegal commentary. I know nothing about this procedure, but invite those who do to give their opinions, preferably in an unbiased manner.

Pertinent issues at hand:

1) Did the doctor who performed the procedure follow proper protocol?

2) If the patient died as a result of a procedural complication - even if it is an expected one ( i.e. something the patient must be aware of when giving consent ) - could it have been avoided?

3) What is the global safety profile of liposuction performed by doctors who aren't qualified plastic surgeons?

4) Why did this unfortunate patient, who by all accounts appeared wealthy enough to have consulted the best plastic surgeon in Singapore, choose a general practictioner?

5) Should those who carry out invasive procedures of at least moderate risk, and for purely aesthetic reasons, be subjected to more stringent guidelines?

6) It was mentioned that Mr. Heng was not considered overweight by those who knew him, yet fretted over "love handles". However, it is not known whether he consulted only one clinic, or perhaps multiple establishments, before undergoing liposuction.
Is it possible that another doctor may have advised him against having this procedure?
Or perhaps the GP who's currently being investigated also issued similar advice, but later acquiesced to Mr. Heng's wishes, for a variety of reasons?

A GP friend of mine says such a procedure can easily net S$5000 for a single session. Doesn't take a genius to estimate the earnings of a practice which chooses to do this exclusively, even if it's just a handful of cases a day.

Which brings me to Prof. Lee Wei Ling's commentary in the Straits Times today ( apologies that the online link is unavailable ). In it, she mentions this case, and makes the correct observation that contrary to what the Ministry of Health keeps drumming into our heads, Singapore does NOT suffer from an absolute shortage of doctors, but rather, a relative one.

Many of us have known this for ages, and I wrote to The Forum Page in 2009, highlighting this problem in the wake of NTU's plans for a 3rd medical school. Because what is the use of pumping hundreds of local and foreign doctors into the system every year, when most of them eventually leave the public sector?

I reiterated the need for a major revamping of public institutions, from the polyclinics to tertiary hospitals, in order to retain medical staff for the long haul. MOH issued its usual media-friendly reply; who knows whether any actual steps have been taken...

But I digress. The constant efflux of doctors to private practice, in particular General Practice, has resulted in an oversaturated market. And it is absolutely true that when it comes down to nickels and dimes, why would a GP persist in treating chronic illnesses, coughs and colds, when s/he can easily improve profit margins by "specializing" in aesthetics?

The floodgates opened years ago, and we are now witnessing the consequences of those actions.

Tough Love

2010-01-01T15:46:00.001+08:00

There's been some discussion about this within my professional and social circles recently.

Are we becoming too soft with our juniors, and is this turning out to be a bad thing?

When I was a medical student, houseman and medical officer, stern seniors were pretty much the norm. Oftentimes it was something subtle, like a raised eyebrow or a frown, maybe a pause or a cryptic "Really?" in response to your statement.

Of course, there were a handful of explosive characters - surgeons who throw instruments, internists who pass sarcastic remarks, the occasional screaming session ( all of which I haven't personally experienced ).

The general impression I get is that such behaviour was tolerated in the past, but not anymore. I'm not saying it should be tolerated as a rule, but worry that being too nice is having a detrimental effect on our juniors.

It isn't my imagination that I'm encountering an increasing number of MOs, HOs and even med students who give me attitude even though I far outrank them. It seems no amount of telling off works unless you send an email directly to his/her Head of Department and threaten his/her chances of a) getting a good performance appraisal grade, b) securing a traineeship, or c) becoming a registrar.

I recall my first MO posting with a medical specialty notorious for its no-nonsense, obsessive-compulsive consultants and demanding work ethics. It was a rotation that was nowhere on my list of requests, and I started my first day with great trepidation.

It took me a month to get into the swing of things, but found myself adopting my seniors' attention to detail and constant sense of urgency. The consultants were extremely strict but also reasonable. Laziness and disrespect were considered cardinal sins.

Perhaps this paved the way for my current work ethos. I'm willing to grant an adjustment period, and always start off believing the best of my juniors. But if you demonstrate no interest in learning, slack off every chance you get, take advantage of your colleagues or show no remorse after making a mistake that jeopardizes a patient's life, I guarantee a severe reprimand.

Over the years, I've noticed a shift from simple rebukes to milder admonishments, even for cases where a junior doctor was clearly reckless. Peers who used to fry MOs for sloppy work now opt for gentle counselling, while some take the easy way out, i.e. act oblivious.

I have also toned things down somewhat, though I'm still considered one of the most sharp-tongued among my colleagues. However, that first MO posting I did 10 years ago taught me that:

a) if you're not performing up to a certain standard, it's only natural that your senior won't be happy;

b) you can choose to mope / curse / swear and stay in a rut, or you can evaluate your own shortcomings and rectify them;

c) earning the respect of a senior who is almost impossible to please is an extremely rewarding experience.

My bosses subscribe to the soft approach - or what I like to call the "New Age style of teaching" - and encourage me to do the same.

I try to humour them, but still have a reputation for being "a little too fierce" for my juniors' liking.

Doesn't bother me one bit. :)

H1N1 vaccination part 2

2009-12-23T07:24:00.003+08:00

This is written in response to the previous question (Nov 18) raised, as well as to provide a brief update on the H1N1 vaccine.

"What do you feel is the most prudent/cost-effective way of spending $6 million of taxpayer's money (with regards to low H1N1 fatality and 200,000 vaccine doses set aside for essential government personnel)?"

I have been reluctant to respond, because it is clear that the answer will vary depending on one's perspective and priorities, and the circumstances at that point in time. There are many interest groups in health that will appreciate a $6 million injection - research (even though the funding has already been exceptionally generous, especially to a few focus groups), cancer care, elderly, mental health, dialysis, safety initiatives, community coverage, etc. Try to cater to all, and even $6 million starts to look rather miserly. Disburse the money to a few, and the others will inevitably wonder about priorities/favoritism.

MOH has chosen to spend this money on H1N1 vaccine doses for essential government personnel, all of whom no doubt can afford the vaccine on their own (but probably only about half who would otherwise have spontaneously gone to get themselves vaccinated). That is its prerogative, and the decision is not as bad as it has been made to look.

Now, about the inactivated H1N1 vaccine (or the various types of inactivated vaccine - they are more or less similar):

Its efficacy in published studies is anywhere between 61% to 92%. Obviously less effective if one is older, or one's immune system is less robust. On average, the vaccine will probably not trigger off a protective response in 1 of 4 persons. These figures are similar to the usual seasonal influenza vaccines. Of course, if you have already had H1N1, there is no need to get vaccinated.
The side effect profile is the same as seasonal influenza vaccines as well. Most people with adverse events have fever, while a rare few will have a more serious adverse event. Anywhere between 0.8 to 6 persons out of every 1,000 vaccinated will develop an adverse event. In short, the vaccine is far safer than getting H1N1.

Many doctors I know have not received the H1N1 vaccination - even though it is free for healthcare staff in the local public hospitals. There are a plethora of reasons (including convenience and work schedule issues), but the gist of it essentially boils down to this: the fear of getting a rare but serious side-effect outweighs the (higher) risk of getting a largely benign illness that one is familiar and experienced with. It is a known psychological issue, and it is not because the doctor has somehow obtained secret/unreleased knowledge about H1N1 vaccine risks.

Subsidized healthcare

2009-12-17T06:37:00.002+08:00

I am one of those who read Dr Lee Wei Ling's (i.e. the MM's daughter and NNI director) articles in the Straits Times regularly. Although her writing is sometimes somewhat divorced from the reality on the ground, her pieces are often thought-provoking and she is one of those with the capability of pointing out unpleasant truths in our system.

Yesterday's piece was no exception. In just a few short lines, she has laid bare some of the issues of subsidized patients in our public hospitals. If you are not a full-paying patient, you cannot choose your doctors - that is well understood. What is less well understood is that sometimes, the doctors may not choose you. Usually there is a senior doctor on call each day for each specialty who will review all comers for that day. But the subsidized patient may be operated on by a junior doctor (for a surgical case) if the condition is not sufficiently complex, or be followed up as outpatient by a junior doctor. If you are better connected (i.e. if you are related to the powers that be or if you know Prof Lee), the rules may be bent. Sometimes to a degree that is quite disturbing (a bouquet of flowers!), if you read her article.

Access to services can be a bit slower as well for the subsidized inpatient. We are not talking about the former notorious NHS-style speeds, but that CT or procedure may just be a day or two slower than for a full-paying inpatient. Part of the medical officer or intern's job scope (and this is not spelt out in medical school) is to improve the efficacy of service delivery by trying to get that procedure or scan done faster. Sometimes, these junior doctors lie outrageously or pull strings, but hey - whatever gets the job done.

Does this difference in treatment between subsidized and private patients in public hospitals matter? MOH has always been careful to suggest that it doesn't. But you cannot find many published studies that have examined this issue with any amount of rigour. You might want to ask why not - after all, it is a very relevant area of study with regards to health policy locally.

The more myopic question is - why won't some (I have to reiterate that it is "some" and not "all) senior doctors see subsidized patients more regularly? I am sure this is not a problem at NNI, where the director would come down like "a tonne of bricks" on errant doctors. The answer has probably to do with incentives and how senior-grade doctors are remunerated in the public hospitals. Ultimately, they just get paid more for seeing - or performing procedures on - private patients. Or better yet - foreign private patients that fuel our medical tourism industry (where a surcharge above even the private rate can potentially be levied).

Interesting Article About The ER

2009-12-05T19:09:00.002+08:00

Forwarded by someone who reads my personal blog. Thank you. :)

Something to remember with the holiday season coming. This piece may come from the U.S., but we face the same situations here.

Choice quotes:

"We have people who've called an ambulance for earwax impaction or prescription refills."

"Even if it happens to be less busy on a night or weekend, the staffing is lower. There may only be five people ahead of you, but it will take a while to get seen."

"People will come in and say 'I'm on five different drugs,' but that isn't as helpful as knowing the actual names."

"He recommends keeping the names of your medications on a card in your wallet. Or throw your medications into a bag and take them to the hospital to show the staff."

"Try to be understanding: The reality of the ER is that unless you're dying, you're going to be treated after someone who is in much worse shape. "Going up to the nursing station and yelling and raising your voice about a relatively minor complaint is often counterproductive." "

H1N1 Vaccination

2009-11-18T17:49:00.002+08:00

Thank you, medicalgrounds, for your suggestion. I've emailed our ID physician blog member to seek his response.

With regards to the H1N1 vaccination exercise, MOH has ordered a million doses of the new vaccine, of which 20% are set aside presumably for 'essential' government personnel. This translates to 200,000 doses at approximately $30 each, which comes to about $6 million, paid for by the government (excluding manpower and logistics/administrative costs).

H1N1 fatality rate: 0.007 to 0.045% (comparable, or less than an average seasonal flu according to the Reuter's report linked below).

Medifund disbursement for the needy (FY 2008): S$1.66 billion

Qn: What do you feel is the most prudent/cost-effective way of spending $6 million of taxpayer's money in light of the above?

a) Vaccinating all essential government staff (including low risk groups)
b) Vaccinating only essential government staff at risk of H1N1, save the rest of the money.
c) Spending the money on other healthcare initiatives (eg Medifund)
d) Others (feel free to elaborate)

References: http://sg.news.yahoo.com/cna/20091025/tap-650-singapore-receive-batch-h1n1-vac-231650b.html

http://www.reuters.com/article/healthNews/idUSTRE58E6NZ20090916

http://www.moh.gov.sg/mohcorp/hcfinancing.aspx?id=308

Residency - A Canadian Perspective

2009-11-11T21:02:00.002+08:00

Thought I'd put this comment up as a separate post.
My thanks to DrFire for his/her input.

I trained in Canada and am now working as an attending here, having left Singapore in 2001 for med school. I think if Singapore switches to the US residency program, it will have to modify its medical school training to reflect the degree of clinical exposure that US/Canadian medical students get to the "system" even before graduating.

Here, in a 4yr program, the 3rd and 4th yrs are entirely clinical. The students are designated as clinical clerks. Typically they carry a maximum load of 4pts - and they are expected to know those patients in and out. They do an average of 1-in-7 call, which is less than the intern's average - but it is the same 36hrs of torture.

The Canadian system is similar to the US system except for the ACGME rules on work hours. There are no such rules here. The typical call is 1-in-4, 30hrs or so. But judging from what I've heard from my friends back home, the key difference has been that a lot of the scut that you guys deal with isn't something we had to worry about as much.

We have lab techs drawing the bloods, nurses starting IVs. Resp techs draw blood gases and can even intubate should the need arise. Don't get me wrong - you have plenty of chances to become good at doing all these things, since you are expected to do these throughout the senior years of medical school. And in the intern year, you're called if - God forbid - the techs/nurses are unable to obtain the line or gas. You get first dibs on all procedures - but after the 100th IV you've placed, it is a huge help to have ancillary staff who can look after the scut, who don't view it as scut.

Is this system better? I don't honestly know. What I do know is that I am happy that I finished my residency when I was 26, passed my boards at 27 and I don't feel the worse for having done it the unconventional, quick route. But the biggest issue I foresee with changing Singapore's UK-based system into a US-based residency is that one must be very careful as to how it is done, especially taking care that the medical curriculum is also changed to provide medical students with greater clinical exposure.

I would say that when I was going through clerkship, chatting with my friends gave me a greater appreciation of just how vastly different the two systems are. In the 5th yr in a UK med school, they were placing IVs - by the end of my 3rd year, I had placed IVs, 3-4 central lines, arterial lines, and more.

Did that make me better-trained? No. The expectations of our respective training models were different. In the end, it is not an issue of which system is better, but more an issue of whether the training is adequate for what lies ahead. To implement a residency system for which the medical student has not been prepared would be dangerous and a disservice to one's training, I believe.

Just my two cents' worth.

A Typical Singaporean Patient...

2009-11-11T09:29:00.002+08:00

1) Doesn't know the actual names of the medications s/he takes.

2) Thinks telling the doctor, "It's a round, white pill" actually helps.

3) Tolerates even the most severe symptoms ( e.g. chest pain ) till the weekend or public holiday period is over before flooding the clinics and ERs, hence the dreaded Monday surge.

4) Has lots of concerned relatives who don't communicate with one another and hound you constantly for repeated updates.

5) Has relatives who would rather spend 15 minutes chasing nurses than bring the patient to the toilet themselves.

6) Signs consent forms for procedures and retains less than 50% of the information given.

7) Thinks by taking diabetes / hypertension / hypercholesterolemia meds, this entitles him/her to eat whatever the heck s/he wants.

8) Thinks waiting an hour warrants a letter to the Forum Page.

9) Thinks the Forum Page is a great way to scare healthcare workers.

10) Assumes that "all my medical records are in your computer, what."

Back to the residency programme....

2009-10-26T18:56:00.003+08:00

An anonymous request to be posted on SMD...

Anonymous said...: hi, could you please post this up on singaporemd. These are two articles written by a friend of mine who is a final year medical student. I think it pretty much sums up the desperation some of us are feeling now. Not everyone in the class is against the residency programme, which in fact makes those against it worst as now our class is totally divided, hence we are unable to stand up against the DMS.; (links deleted per author's request.); Thanks.

Punishment

2009-10-19T07:08:00.002+08:00

It was reported last week that Dr Martin Huang - a well known plastic surgeon - was fined $5,000 and censured by the Singapore Medical Council for injecting animal fetal cells into his patients (a dubious and unproven practice). It appears that he was caught only because he was foolish enough to "advertise" this in a health and beauty magazine (therefore who knows how many out there are doing the same). This was further touched upon by no less than the Director of Medical Services in the MOH blog, which fell just short of accusing Dr Huang of not having his patients' interests at heart.

A comment by fellow blogger Angry Doctor questioned whether the punishment meted out was fair - a similar offense in a different setting (i.e. outside healthcare) would have resulted in harsher penalties. After all, $5,000 is little more than pocket change for the plastic surgeon. And the censure? Well, very few will remember that after a few years.

This touches upon an old issue with court justice. It is well known that the wealthy are able to bear the costs of legal fines better than the poor (in many cases, their legal fees - for cases that do go to court - already outweigh the fines considerably). Does this mean that punishments meted out by the law court are disproportionately heavier on the poor? Many have argued that this is not quite the case. The social costs are purportedly far higher for the wealthy (and powerful) than for the poor, so the incentive to avoid wrongdoing (or being caught!) is the same for everyone.

But what happens in a situation where it is hard to catch the perpetrators and where the punishments are mild? Well, the thin wall holding back the flood is medical ethics, and the "brainwashing" that goes on in medical schools and training. From the various comments on this blog and postings in others, it would seem that these are now (and perhaps have always been) almost wholly insufficient.

Discussion 2

2009-10-15T21:42:00.002+08:00

Another reader has submitted a topic for discussion on Singapore MD:

"I received a letter from MOH the other day outlining DMS' vision for transforming postgraduate medical education. It ended with a call for participation in dialogue sessions.

I threw the letter away.

The fact that MOH has decided to hold dialogue sessions only after all the major decisions have been made only goes to show that MOH deals with our professional body in a paternalistic manner. Dialogues inevitably end up becoming monologues. Little wonder why MOH's initiatives rarely gains any support from the ground.

If I may suggest, perhaps, we can have a discussion on what it would take for MOH to gain the confidence and support of the body of physicians that it needs to work with, rather than dictate to."

angry doc

I tend to agree with our contributor's observation - I just yesterday received a letter from MOH informing me that the planned amendment to the Medical Registration Act will pretty much carry on: SMC will still have "the option" of appointing a legally-trained person to a disciplinary tribunal, except that now that person may be appointed as either the chairperson, or as a voting member.

How this round of "dialogue" will alter the plans for a new training system I do not know, but I am keen to attend one of these sessions just to get a ground feel.

See you all there.

Question

2009-10-13T22:24:00.002+08:00

Interesting how a topic about service quality vs cost veered off on a tangent.

So with the raging debate about doctors in general "earning too much", what say you about the salary discrepancy within the medical community, i.e. between the public and private sectors?

Should those in private practice be viewed any less favourably than their counterparts in public institutions?

Is it considered wrong for doctors to treat affluent patients exclusively when so many others belong to the lower income brackets?

I always wonder about those medical school interviews, when candidates are asked, "Why do you want to become a doctor?"
You can expect the usual spiel about "wanting to help my fellow human beings, comfort the sick, ease suffering, etc."

While it's true that you can do all this in a private setting, your clientele would differ quite significantly from those visiting restructured hospitals.

Your comments, please.

Yeesh

2009-10-11T21:11:00.004+08:00

NUH nurses play Facebook game at work

What message is the person who posted this photo trying to convey?

1) That healthcare workers aren't entitled to some R&R during downtime, and should instead stare into space and let their minds go blank when there's nothing to do - and probably be accused of slacking off as a result?

2) That certain people like to sneak around counters with the hope of catching HCWs in compromising positions? ( I'm told this picture can only be taken if you walk all the way round to the back, which is not what a normal visitor would do. )

And now it seems the nurse has been disciplined by NUH.

What message does THAT convey?!

Discussion

2009-10-11T17:41:00.006+08:00

Thank you to An Old Friend, who contributed this topic suggestion.

"Hi moderators, wondering if we could have a discussion on The Practice of Medicine (eg Parson's Sick Law) vs Service Quality and Standards (eg ISO) vs cost and the conflicts they present?

Personally I feel that the delivery of medicine is not the same as the delivery of service in other industries, eg hospitality or airlines.

Secondly, the expectations and cost factors.

For example, while there is always this drive towards "service excellence" in every organization, the quality of the service is different depending on the price you pay for that service. However the management do not look at it that way. They look into every complaint in the same way in every organization. It seems to be left to the customer to decide what his expectations will be (sometimes this can be tempered if he is paying a low price). But it seems that in healthcare, free seems to be the price everyone wants to pay so no luck having any pared down expectations subsidized or not.

Case in point. How do the management of SIA and Singhealth weigh their quality standards? I bet they both want "service quality excellence". I don't see SIA rates being cheap though. Same with ShangRi-La Hotels.

It is extremely difficult if the government does not control the expectations of the people when it comes to subsidized healthcare, and yet want to control cost. The system is extremely taxing on the staff who provide the service. They are sandwiched between trying to give "world class service excellence", but keeping costs low."

spacefan

I will post my reply first. Perhaps the rest of the panel can add their comments by editing this entry.

I fully agree that healthcare in Singapore has a distinct slant towards service provision, and that patient expectations aren't being managed sufficiently.

Conversations with people from the United States, Canada, Australia and the United Kingdom reveal a very different mentality - they understand the constraints of the public healthcare system based on how much less it costs the consumer.

The ER is a common discussion point - partly because I'm an ER physician. I recall a Canadian couple who recounted an 8-hour wait to consult a doctor about an elderly mother's hip fracture. When I told them an 8-hour wait in our ERs will guarantee a major riot - not to mention a reprimand from MOH, followed by interventional measures - they looked shocked and described this as "grossly unreasonable", especially after I told them we see an average of 400 cases a day, about twice the ER attendances in these countries.

The same goes for Americans and Brits. They know what to expect and usually kick up a fuss only if mismanagement is involved.

One might argue that since the Canadian and UK governments provide free healthcare for its citizens, patients have no cause for complaint.

But Singaporeans also receive substantial subsidies, and have easy access to tertiary hospitals where high-quality medical expertise and technology are readily available ( unlike rural areas in larger nations ).

Even a B2-class patient can be listed for an elective operation within weeks, compared to someone in the UK who waits an average of 12 months for a routine hernia repair or cholecystectomy.

The definition of "service excellence" varies according to the individual. For some, waiting time is a huge factor ( and one of the most important key performance indicators across the board ), while others may pay more attention to, say, the staff's demeanour.

But there's no denying that few subscribe to the idea that "the quality of the service is different depending on the price you pay for that service". In my 10 years within the public sector, I've encountered numerous patients ( and relatives ) who demand a level of service which is better accomodated in a private institution. But when I suggest they seek an opinion at such hospitals, they retort, "Why should I pay more?"

They want immediate scopes, cardiac scans, MRIs, consults with senior specialists. They criticize our "ridiculous policies" of arranging early clinic appointments, even for clearly non-urgent conditions. They start screaming bloody murder when they don't get sent to the ward within 2 hours, even when we explain that the hospital is full and beds can only be emptied when patients are discharged.

Is it because the government isn't controlling the people's expectations? Perhaps, to some extent, this is true, and is reflected by how MOH prioritizes its list of KPIs. After all, waiting times do nothing for a doctor's frazzled psyche, and only serve to pacify and impress the consumer.

The media also plays a part, regularly churning out statistics comparing one hospital / polyclinic with another. Let's not forget the dreaded Forum Page, which every HOD / CEO pores through first thing in the morning, hoping s/he won't see his/her department or institution fingered in a complaint letter which may / may not contain reliable facts.

The evolution of healthcare towards a service industry was probably also accelerated by marketing efforts that trumpet Singapore as THE centre for world-class medical care, including public hospitals in the mix. How much this has affected local perceptions, however, is hard to say.

I wouldn't go so far as to state that "in healthcare, free seems to be the price everyone wants to pay so no luck having any pared down expectations subsidized or not." I do ( occasionally ) meet patients who demonstrate a good understanding of our limitations - and it's no coincidence that many hail from the older age and lower income groups.

Based on personal experience, the majority of those who voice dissatisfaction are the well-educated, more affluent and younger people. I'm especially wary of those who come armed with information from the Internet or "a doctor friend / relative" or "a friend / relative who also has this condition or knows someone who does".

Another contributor to unreasonable expectations? Whether it's deliberate or not, I've had GP referrals asking me to arrange scopes / MRI scans / consults with specialists the very same day the patient comes to the ER.
You can see how this causes problems when the patient thinks I'm trying to pull a fast one, since his/her family physician of XX years, whom s/he trusts whole-heartedly and who can do no wrong, is being contradicted by this idiot of an ER physician.

Anyway, I'm nowhere as good as Angry Doc and Gigamole where in-depth analysis is concerned. Just offering a view from the trenches.

angry doc

This is not really a 'medical' issue, so I can't claim that my analysis is an accurate one...

There are a few issues being brought up here, from the question of cost and affordability, to quality of "service", and also timeliness of access to care. People want "Better, Faster, Cheaper", and it seems that no one is willing to tell them that they can't have all three.

Good healthcare requires considerable resources, and since resources are limited, healthcare must be rationed. Longtime readers of my blog will know that I used to be an advocate for rationing by needs and not means, but over the years I have changed my views on the topic.

My current views on the topic are set out in the comments section of this earlier post.

Put simply, subsidised healthcare not backed by the moral courage to demand accountability from patients distorts the true value of healthcare and is ultimately destructive to the morale of its providers. We are in the state we are in today because the public thinks they can dictate what resources they wish to consume from the system based solely on the fact that they hold a ballot, and no one tells them otherwise.

Many doctors remain within the public system because they have no choice - they are either bonded or under traineeship - and others remain because the public sector offers them things of value which they cannot obtain in the private sector, such as research or teaching opportunities. No one, however, chooses to stay so they can be told how to do their jobs by laymen. Whatever the reason, as long as we choose to remain in a subsidised healthcare system where laymen's "concerns" are allowed to override our clinical opinions, we are helping to perpetuate it.

I will end by repeating the quote I posted in the earlier thread:

"I observed that in all the discussions that preceded the enslavement of medicine, men discussed everything—except the desires of the doctors. Men considered only the 'welfare' of the patients, with no thought for those who were to provide it. That a doctor should have any right, desire or choice in the matter, was regarded as irrelevant selfishness; his is not to choose, they said, only 'to serve.' That a man who's willing to work under compulsion is too dangerous a brute to entrust with a job in the stockyards—never occurred to those who proposed to help the sick by making life impossible for the healthy.

I have often wondered at the smugness with which people assert their right to enslave me, to control my work, to force my will, to violate my conscience, to stifle my mind—yet what is it that they expect to depend on, when they lie on an operating table under my hands? Their moral code has taught them to believe that it is safe to rely on the virtue of their victims. Well, that is the virtue I have withdrawn. Let them discover the kind of doctors that their system will now produce. Let them discover, in their operating rooms and hospital wards, that it is not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of man who resents it—and still less safe, if he is the sort who doesn't."

Interaction

2009-10-09T19:53:00.002+08:00

We've seen a surge in the number of visitors to this blog these past few weeks, mainly the result of lively discussions of hot topics close to readers' hearts.

Thank you for sharing your views with us, and especially with regard to the residency programme issue, I hope all concerns expressed have reached those with the power to do something about them.

Singapore MD was launched only 5 months ago, but thanks to an outspoken panel of contributors, an increasing number of followers, and referrals from other traffic-heavy websites, it appears we're gaining a good momentum.

For me at least, comments from readers motivate me to post more entries. And my fellow writers' choices of current and occasionally controversial subjects keep things very interesting.

On this note, I'd like to make a suggestion to our readers: if you have any topics you'd like to have discussed on this blog, or any burning questions to ask its contributors, feel free to leave a comment or drop us an email. If you choose to contact us via the latter route, please rest assured that your identity will be kept in the strictest confidence.

Bear in mind, of course, the disclaimer posted on the left.

I look forward to seeing what happens. :)

Bravo

2009-10-06T20:59:00.003+08:00

I would like to thank Dr. Chong Yeh Woei and Prof. Goh Lee Gan for their eloquent Forum Page rebuttals to Ms. Salma Khalik's recent editorial in The Straits Times.

This isn't the first time a journalist - usually from ST - has written a piece like this. It seems doctor-slamming rears its ugly head from time to time, especially after an epidemic has died down ( another good example: SARS ).

Lack of other newsworthy topics?
Part of some incomprehensible ST protocol that gets recycled every few months?
Or a certain senior correspondent's compulsive need to assert journalistic power by making sweeping statements about something she knows little about?

Treating High Profile Patients

2009-10-04T18:54:00.003+08:00

An excellent article by Dr. Cuthbert Teo in the September issue of the SMA News.

I'm sure many of us have encountered "special" patients at some point in our career, and that our experiences range from pleasant to downright harrowing.

I personally find the vast differences in how people handle fame and power interesting.

Most recently, I heard how a certain not-that-well-known F1 driver displayed quite the attitude at the ER, causing those who recounted the event to grimace.

Compare this to another driver who ranks much higher on the list of championship contenders, whom I had the pleasure of meeting during his visit to the ER, and who charmed us all with his respectful demeanour and beautiful manners.

Local celebs have also passed through on and off. Again, there're those who want to be treated like normal civilians -- I once treated an elderly man who's related to a very nice actress from the TV series Growing Up -- and those who kick up a major ruckus and make a scene so their demands will be entertained ( a certain TV show host who's a household name in our country ).

Politicians, however, are the true VVIPs.

Every time there's an international meeting for whatever reason, a certain hospital is assigned for emergency medical coverage purposes.

I can understand the need to expedite care for these delegates, but question the prudence of fast-tracking a stable patient and using up a resus panel, when a much sicker case needs more urgent attention.

The number of senior specialists, nursing officers and public relations personnel swarming around the ER when a VIP / VVIP arrives also makes me wonder how much more efficiently the system could function if we cared as much for our many "lower-profile" patients.

Also, let's not forget that in the event of a major disaster, it's very likely that resources will be prioritized such that VIPs / VVIPs will receive medical care in a more timely fashion compared to other mere mortals.

A small price to pay for their invaluable contributions to society? Maybe it's just me, but I think the right thing for a VIP / VVIP to do would be to decline such special treatment at a public hospital, especially when resources are being stretched. Surely being managed at a private hospital would be considered acceptable and perhaps more appropriate?

Last but not least, the fact that a certain ER's staff are on standby 24/7 to make non-urgent house calls to a retired politician's home, even during busy night shifts when manpower is minimal, is something that should be looked into, and preferably stopped.

Residency - From Down Below

2009-10-01T21:47:00.003+08:00

Lots of hoo-ha has been going around about the residency program ever since the news broke, and it seems like the murmurings are getting louder. Being from the most recent graduating batch, ie the sandwich year, yours truly is keenly interested in the developments, as are her classmates. Many in her class have been straining their ears to find out more, but as of now, there seems to be some gaps in the information being provided to us. Worse still for those in the regional hospitals, because we have had no briefings/roadshows held for us, so all we hear are drips and drabs of info culled from various sources.

So yours truly, being stuck in one corner of the island, has been trying to sniff out information on her own. What she found, however, sounds like fodder for a Saturday Night Live episode. Take for example this:

11. What are the restrictions of duty hours, what do they mean?
The ACGME mandates a limitation to duty hours to ensure that there is sufficient rest for the residents. The idea is that if the residents are too tired, they will not be able to learn.

Some rules:

Residents cannot work for more than 80 hours per week on average.
After 24 hours of continuous work, they must not see any new patients.
There should be at least 10 hours of rest in between 2 duty periods.
In a period of 7 days, one day must be completely devoted to rest.

The ACGME takes all the above very seriously. Failure to comply will result in citation of the program.

Cue ripples of laughter.

Maybe my poor houseman brain is too tired from taking bloods and setting plugs all day, but yours truly honestly can't figure out how an 80-hour work week and a 24 hour day including call can ever be in existence with our current manpower. I mean, I can't even take post calls sometimes (even when postcalls are supposed to be "protected" in a medical posting) so will the 24 hour day ever arrive? And the next thing that comes to mind is even scarier - if residents are truly to be "protected", then it means all scut would have to be borne by people like me - the MOs next year who have not declared their specialty. According to the website, the accreditation visit will be in July 2010, and "we should get most if not all things ready by then", so it sounds to me that I will turn MO next year - and return to doing HO work.

Speaking to seniors (including people who are somewhat involved in this exercise) has not yielded much result. The advantage, I am told, is that a trainee would have the same supervisor for the entire period of training and the supervisor is entirely responsible for the structure and exposure that the trainee gets, which sounds good because the current system does not allow close follow up of trainees. But to do so, the trainee must decide not only on a specialty, but also on a subspecialty, because if, for instance, the trainee is interested in cardiology, he or she would be assigned a cardiologist senior as a mentor right from the start and given opportunities at every turn to develop skills required by the specialty. Deciding on an area of specialisation so early is only possible with the US system, where students are the equivalent of HOs, and are rotated through the work in many departments and hence would have had a pretty good idea of the actual work each specialty does. Most of us here are completely clueless even after HOship, so it is pretty difficult (and unfair) to decide so early on.

But while yours truly is whining about this, she is also thinking of her juniors who, in addition to losing sleep/hair/weight over the upcoming MBBS, now have to concern themselves with portfolios and interviews. I don't envy them at all.

(Just a few cents' worth from a very junior and very tired doctor.)

Residency Part III

2009-09-30T23:00:00.001+08:00

Read: The Hobbit's Galactic Guide To Training

Residency Part II

2009-09-20T05:30:00.004+08:00

After reading a local final year medical student's comments to the original "Residency" post, I think it deserves to be reproduced as a separate entry:

"Hi, i am a final year student at YLLSOM and i have a few comments on this issue.

We have brought up quite a few of the questions that spacefan has mentioned today at a NUHS briefing on the residency program. The answers we were given were rather vague, with the higher powers knowing little/unwilling to commit as they too have no idea what the finalized plans by the DMS are.

This puts us in an extremely tight spot, as we were informed of this new program only 2months ago, and are now given ONE month to decide and make up our mind and subsequently submit a portfolio in October and go for interviews in January, on top of studying for the final MBBS.

The whole process has been rushed through with little thought given to the current batch of graduating students, with the reasoning being that with us being guinea pigs and that the kinks that we encounter will be ironed out in time to come.

However, this is OUR future we are placing on the line, not theirs.

With regards to the trainee not performing up to expectations, the panel of program directors assured us that it will NOT happen, as we will be very closely monitored and supervised every step of the way(hand-holding). I have serious doubts about that, but they declined to elaborate further with a sweeping statement of if we fail, the sponsoring institution will suffer and the program directors face the sack, hence we will NOT fail.

This whole residency thing benefits those who have made up their minds about their future, and in a short 5 years most will become associate consultants equivalents,(attending physicians). In fact, most will hit reg levels in 3years, which is a boon for them.

However, those of us who are still undecided are "forced" to make a less informed decision of signing up with a residency program, or for that matter ANY residency program if we do not want to be left behind. I say this because even though they have repeatedly stressed the option of a transitional year to look around and decide, we will be severely disadvantaged as the number of places allocated for that particular year will have been almost, if not totally filled, hence we might have to start from the postgradyear1 again in that particular residency should we decide AND get accepted.

The process of the interviews is also a hot topic of discussion, primarily because we have very little to present to the interviewers, who will now scrutinize our medical school grades, down to our anatomy grades in year1 and that biochemistry TEST in CA2. Many of us are caught off guard, as we were time and again told by our seniors and many junior doctors to just pass all the tests and exams in med school, even the MBBS. As long as we pass, our application for speciality training will be based on our performance as a HO/MO.

But now it's a whole new ball game, and many of us are on a wrong footing.

Lastly, all three clusters are scrambling to give us talks on the residency program the past few weeks, treating us as hot commodities and trying to sell their department/programme as the better one.

So do we now choose a particular hospital because say, the programme director was extremely charismatic and eloquent? Or that they gave us more freebies, a better tea session and promises to treat us BETTER than the other hospitals?

If, for example i have been posted to the surgery department in SGH surgery for my third year rotations in medical school, i will almost certainly choose it over the TTSH department as i will have no clue on how their department operates. But will i be making an informed decision? I highly doubt so. Of course if SGH rejects me and i put TTSH surgery as my 2nd choice i might not get it compared to someone who placed it as his 1st choice.

Dear seniors, if you were in our shoes, what will you do?"

It is my hope that putting this comment up will spur the powers-that-be to tackle this issue head-on. I wasn't at the abovementioned briefing, so I have no idea whether any MOH official was present, but I do know that Singapore MD is monitored by MOH, so perhaps this poor M5's S.O.S. will filter through to the DMS.

That said, I'd also like to point out that since emergency medicine is one of the disciplines that has been earmarked for this residency programme, patients can look forward to having fresh med school graduates in our ERs. And I don't mean "look forward to" in a good way.

Back in my medical officer days, ERs were staffed with a good number of medical / surgical trainees, and only 2nd-year or more senior medical officers were allowed to rotate through.

Over the past decade, there's been a huge paradigm shift such that 1st year non-trainee MOs ( and 1st posting MOs especially ) now throng ERs all over the country, with a significant portion of these hailing from overseas ( i.e. returning to Singapore after completing their housemanship in Australia / the UK, etc. ).

Even with 12 months of internship behind them, most 1st year MOs are ill-equipped to handle the stress of ER work, which involves constant multi-tasking, rapid and accurate clinical decision-making, and the difficult job of handling anxious / hysterical / violent patients and relatives.

While I make room for the possibility of fresh graduates mastering the art of communication and public relations quickly, clinical skills is an entirely different kettle of fish. We already face problems monitoring our current MOs. Imagine having a group of even more inexperienced junior doctors added to the mix.

Did this new programme get any coverage in the local news? Don't remember reading anything, and was away during the 1st half of September. Is the public aware of any of this?