Running on Empty

This is a difficult post to write. Simply because it attempts to address issues that are raw and painful to a segment of the medical profession – the junior doctors, i.e. the house and medical officers, residents etc.

There have been many instances of reporting of junior doctors finding life unbearable now in the public institutions. Many have purportedly quit or are in the process of quitting. Apparently, dissatisfaction is at an all-time high and about to get worse.

This Hobbit has provided links to articles on this topic found in the mainstream media at the end of this post. But this is only from the mainstream media. If you go beyond this, there are many more stuff found in blogs, memes etc.

What is the profession’s response to this? At the risk of stereotyping, the profession’s response can be divided into two groups. One group of doctors are those that share the view that things are really bad. Another group just thinks that well, today’s younger doctors are soft and just can’t hack it and things were far worse last time.

This hobbit will not go into whether things are better or worse now. For one thing, the Covid-19 pandemic has upended many things in the practice of medicine. PPEs cannot be that comfortable, especially with global warming. Taking consent now is a labourious affair. Unlike my time, you can’t just find a houseman to stuff a consent form into a patient’s face and instruct him gruffly in Hokkien or Cantonese, “Uncle, we have to operate on you, sign this form”.

Things are also better now, because you don’t have to give IVs and contend with performing 120-second hypocounts. And of course everyone gets paid decent money for doing calls.

So there are pluses and minuses between the past and present. It is pointless to debate ad nauseam whether things are better or worse between the present and the past from a material point of view. Of course if money is the solution, it would be simple for MOH to pump more money and pay junior doctors more. After all, MOH has the largest budget allocated this year by the Government, at some S18B, even larger than MINDEF. So paying the junior doctors say a bit more won’t really put a big dent in the budget. But life is more complicated than that. Of course, more money also helps, but money is not the cure-all or be-all.

It may be fruitful to look at abstract issues that drive morale. What is clear to this hobbit is that life in the past was bad too. But we had one thing that perhaps young doctors today don’t have very much – hope.

We knew that life will get better when we became specialists or when we serve out our 5-year local undergraduate bond. We knew there was an end to all this and things will get better. I am not so sure if young doctors have this optimism today.

Let’s take the example of being a specialty “trainee” (the old term for “resident”). We knew that when we completed specialty trainee, we will be appointed Senior Registrar or Associate Consultant. Senior Registrar was the term used when the Specialist Accreditation Board (SAB) and Specialist Register had not come into being yet. There will always be a job in a public hospital for you after exit. And on top of that, you know you are well-trained, having seen and managed many, many patients. That black name-tag (signifying you were a ‘senior’ doctor with at least a master’s degree or fellowship, i.e. at least Registrar) that was hanging off your chest or stethoscope gave you hope, satisfaction and a spring in your step.

Now associate consultants, let alone residents or senior residents, do not have this aura of positiveness around them. In fact, residents do not have any assurance of any job security when they exit. All this came about because a few geniuses in MOH decided to Americanize our specialty training system more than 10 years ago with ACGME-I Residency. The idea was that being a more structured system, the residency can produce more specialists faster. A good summary of this is that some geniuses thought they can produce more specialists like how the Clone Army was produced on the planet Kamino (Star Wars Episode 2), vis a vis the old system of apprenticeship, like Jedi (or Sith) training.

To this old coot, residency is a term used by Celine Dion when she is contracted to sing at a casino in Las Vegas for 2 years after Titanic. But like the Titanic, our young doctors are sinking in residency.

It starts with this ill-informed idea that training can be delinked from employment. This can be acceptable in a large country like the USA, where you can train in a Los Angeles hospital and after that the LA hospital may not offer you a job but you can get a job in a hospital in the state of Montana. America is a big country and life goes on. This cannot be so in a small place like Singapore. If you exit training in NUHS and don’t get a job offer from NUHS, the chances are you can’t get a job in the other two clusters as well. It is simply unwise to delink training from employment in Singapore. MOH should disabuse public healthcare clusters and hospitals of the idea that they can recruit many residents (i.e. cheap labour) and then hope someone else will hire them later on when they exit.

This is especially so because most residencies are confined to the same cluster and other clusters’ clinical leadership do not know the resident. This is different from the past when MOH controlled the postings centrally. Trainees rotated between different hospitals across the country and he has a chance of being hired by different hospitals after exit.

We then move on to what happens after one exits and cannot get a job in where he trained.

If nobody hires them as associate consultants then legally speaking, they can still set up shop in the private sector and practise as specialists in private hospitals, albeit somewhat lacking in experience and exposure.

But as of recently and in a practical sense, they cannot.

There are only a few private hospital operators in Singapore. Recently the largest private hospital group issued a policy stating that they will only accredit new specialists if they have been registered specialists for at least 5 years, of which at least 3 years must be of consultant grade (note: consultant, not associate consultant) in a public hospital. If you were promoted to consultant from associate consultant after 3 years and not 2, effectively you have to hold a specialist position in a public hospital for at least 6 years and not 5. Another private hospital has also followed suit with this policy.

Now back to these new specialists who cannot get a job in a public hospital. What are they going to do? Theoretically,  they can practise as specialists in the private sector with no practising and admission rights in at least 5 (some of the largest) private hospitals in Singapore. What kind of prospect is that? This may be OK if you are a dermatologist or psychiatrist but definitely not OK if you are in almost all other specialties that require a hospital setting.

In other words, from the start of residency to the time a specialist is able to gain practising rights in most private hospitals in Singapore, he needs to be employed for at least 10 years (5 years of residency + 5 years as AC and Consultant) if not more in the same public hospital that trained the resident. Yet, the young doctors are not getting any assurance it will be so from some public healthcare clusters and hospitals. Of course there are good residents and not so good residents, and nobody owes anyone a living for 10 years, especially if the resident doesn’t perform. Nonetheless, this kind of uncertainty is very unsettling for young doctors today, and a source of unhappiness that in our time many years ago, under the old traineeship system, simply did not exist. In the past, if a trainee was very bad, the hospital simply did not sign him up for exit. This is unlike today when we over-recruited, under-trained our residents and under-employed them after exit.

In the past, once you are a trainee in a certain department in a hospital, you are practically family. Of course, every family had its problems, but you are still part of the family.

The powers that are have recently addressed this by drastically decreasing the number of training positions offered in some specialties. This in turn has created another source of unhappiness. Newer batches of medical graduates now wonder why there are so few residency positions available when compared to their seniors. This is the typical sort of deep unhappiness and frustration that accompanies boom and bust, feast and famine cycles. And in this case, they are man-made, avoidable cycles.

Perhaps the only bright area for young doctors is in family medicine and this explains why its popularity as a training program is rising. Once you exit you are not at the mercy of private hospitals’ accreditation requirements. And with the emphasis on prevention, everyone having a regular family physician and Healthier SG, the future of family medicine looks reasonably bright.

There are certain things that are beyond our control, such as the demands of infection control and patient load brought on by the pandemic. But many things can be managed. Are we managing public expectations and patient expectations? Or are we content to just accept the inexorable climb in these expectations, and let the young doctors (and nurses) bear the brunt of it? Some expectations are reasonable and should be met but are all expectations reasonable? What are hospital administrators and MOH doing to buffer our frontline healthcare workers from some of these unreasonable expectations?

Another common phenomenon which is seldom addressed is that when every hospital and department attempts to manage their risks (a euphemism for covering backside), then invariably new and more complex policies are written which in turn lead to more work being created downstream for the junior staff like medical officers and staff nurses. Has anyone thought of saying “Hospital management will take this risk so that we don’t pile more work on the medical and house officers”? No. The usual answer is “we will implement a new policy to address this problem/risk”. Which almost always translates into more work for the poor guys at the ward or clinic floor.

The lack of opportunity for career advancement and the lack of certainty in career prospects have a pernicious effect on morale and undermines hope. Aggravating this situation is the junior doctor often has to bear the full brunt of unreasonable public expectations as well as get bogged down by an every-increasing array of administrative and policy requirements that are perceived to increase the survivability of hospital management but not that of the junior doctor.

Is it therefore any surprise that our junior doctors are feel they are running on empty?

Links to writings about junior doctors’ plight in mainstream media:

https://www.straitstimes.com/singapore/health/long-call-hours-teach-time-management-but-not-best-way-to-learn-medicine-say-junior-doctors

https://www.channelnewsasia.com/singapore/review-junior-doctors-work-hours-among-steps-improve-healthcare-workers-well-being-2551376

The Elephant in the Room

Recently, there was a report in mainstream media about how an Integrated Shield Plan (IP) provider refused to provide cover for a patient who was suffering from cholangiocarcinoma. The reason given was that the immunotherapy drug was normally used for breast cancer and not for cholangiocarcinoma. The use for cholangiocarcinoma was “off-label”. (Cancer patient ends up with $33,000 bill after insurer refuses to pay for drug).

Two letters from members of the public (both doctors) were published in The Straits Times Forum on 24 April 22 and then MOH and Life Insurance Association (LIA) subsequently weighed in with letters on 25 April 22.

Military colleges often teach that a country fights a war for usually two reasons:

  • It thinks it can win the war, thereby achieving the objectives it has set out for the war, so it fights, or
  • If it doesn’t fight the war, the country, culture and society as they know, will be destroyed and it may well cease to exist. i.e. the conflict poses an existential threat to the country.

For example, in the current Russian invasion of Ukraine, Putin is claiming the second reason, but his calculus for starting the war was probably that of the first. Ukraine on the other hand, is fighting obviously based on the second reason.

While the arguments put forth by LIA and MOH are not invalid – cancer drugs can be frightfully expensive and their use needs to be controlled in some way, the elephant in the room in this case is that the patient is alive, and appears to be having a decent quality of life. In other words, the immunotherapy drug Pertuzumab worked.

This is quite remarkable given that cholangiocarcinoma patients often live for several months only and the patient is alive and walking around 22 months after diagnosis. The other salient point is that Pertuzumab was not given callously. It was only given after two other conventional drugs had failed.

The last point that should be noted was that we are arguing over $33,000 for something that worked and gave someone a decent quality of life for many months. Not exactly a sum that will sink the system in Singapore, even though it may be a lot to an individual. Putting a patient on a ventilator in ICU for about a week often costs that much if not more, and as we know, many a time the patient ends up not making out of the ICU alive.

It is true that there is scant evidence that Pertuzumab works for cholangiocarcinoma. But we need to remember that clinical evidence is based on inferential statistics – the science of probabilities based on assumed distribution of values (e.g. the bell-shaped curve of a normal distribution).

Let us now return to this patient at hand, Ms Koh Ee Miang. Probability-based and evidence-based medicine mean little to her. Only one thing matters – either she lives on, or she doesn’t. And at only 45 years old with a teenaged daughter, the will to fight for her right to live on (and again this hobbit stresses – with  a decent quality of life), must be very strong. She will fight. She has to fight. She is fighting based on the aforesaid second reason – if she ceases to fight, death will beckon quickly and she will cease to exist.

And indeed, this is exactly what has happened. She has gone to the press so that her plight gets highlighted. And really, the answers and replies so far from the establishment aren’t exactly useful to her or her oncologist.

What does the oncologist do now? Stop the medicine? Should she not have even given her Pertuzumab in the first place? Just let her be overwhelmed by the cancer after the two conventional drugs failed? She’s 45, not 85…..

And then there’s the issue of off label and on label use. The letter from LIA makes it sound like off label use is always an undesirable thing. But that is simply not true. Whether something is considered off label or on label use may be just a commercial consideration.

Let’s take the example of Sildenafil – what is now commercially known as Viagra. Viagra is now famous for being a drug used to treat erectile dysfunction. But Sildenafil was originally put on clinical trial for use as a drug to treat pulmonary hypertension. However, it was then serendipitously discovered that many trial (male) subjects had erections and viola, Viagra was born.

As far as this hobbit knows, the use of Viagra in Singapore for erectile dysfunction is on label but not pulmonary hypertension. It is not because Viagra is not effective against pulmonary hypertension. After all that is what it was intended for and there is clinical evidence to support this. The drug company just didn’t apply for it with the drug regulation authorities for reasons best known to itself. It could be the market for pulmonary hypertension is much smaller than erectile dysfunction and also because of risk management. When a drug is used off label, the doctor and hospital bears the risk. When it is on label use, that risk is shared with the drug company. Since the market for treating erectile dysfunction is such a big and lucrative one, why should a company take on the additional risk of it being used as a pulmonary hypertension drug?

Whatever the case may be, whatever is on label is at the discretion of the drug company when it puts up the drug for registration with the authorities. The authorities can reject the application because of lack of scientific evidence, but they have no powers to ascribe something as on label if that is not applied for by the drug company.

It is noteworthy that the MOH letter to The Straits Times Forum did not mention on label or off label use. It talked about scientific evidence. Because on label or off label use is not quite the gold standard of appropriate use it has been made out to be. There are many drugs that are being used off label in both private and public sector healthcare settings. It doesn’t mean that off label use is always imprudent or unsafe.

Let us now return to the patient. Since missing Pertuzumab for one session in January, her cancer markers have shot up by about 50%. In fact, it was reported that the oncologist may have to change to another even more expensive HER-2 drug because the effects of Pertuzumab are “waning”.

As Dr Jeremy Lim implied in his letter in The Straits Times Forum on 24 April 22, in the age of precision medicine, (e.g. immunotherapy), some finesse is needed. In evidence-based medicine, all of us have been taught that the 95% confidence interval and p<0.05 are sacrosanct. But 95% is not 100% and what about the remaining 5%? What if somehow something that falls outside the 95% actually works for this individual, do we deny this person care? Especially when we are pretty sure that this denial will lead to a quick and premature death?

This hobbit would like to see if some IP providers will think out of the box to address these issues instead of drawing a line in the sand about on or off label use. For example, it could have covered the treatment for just two to three months to see if the treatment works. If the treatment doesn’t work then by all means withdraw cover. But if the treatment works then it should continue cover but the coverage would be subject to reimbursement caps that are stated upfront.

Personally speaking, I would have thought that the IP provider should have just paid out the $33,000 for a treatment that manifestly worked for their policyholder, a living human being. All IP providers profess to care about their policyholders in their marketing materials and public communications. But here again, this hobbit is reminded that insurance companies are business entities designed to maximise shareholders’ value. Bad press, public opinion or the almost certain prospect of an unnecessarily premature death matter little when their bottom line is hit by about $33,000.

March Musings

On the day after the Budget was delivered by the Finance Minister (19 Feb 2022), an important infographic appeared in The Straits Times. It showed something that this hobbit didn’t think he will see in this lifetime.

It showed that MOH now had the biggest budget in the government – S$19.29B, even higher than MINDEF, which traditionally had the biggest budget all these years. For the coming government Financial Year, MINDEF’s budget was $16.36B. In third place was Ministry of Education (MOE) at $13.6B. Traditionally, MINDEF and MOE always had the biggest and second biggest budgets in government.

MOH’s budget is going to grow by 4.7% from last year and takes up 18.8% of Total Expenditure (estimated to be $102.41B). This $102.41B is carved up by 15 ministries as well as Organs of State and the Prime Minister’s Office making a total of 17 buckets. But MOH’s bucket alone takes up 18.8%, almost a fifth of total expenditure.

One can say that well, we are in the middle of a pandemic and everyone is spending a lot on health, which is true. But there is no denying that even without the pandemic, MOH budgets over that 15 years or so have been growing very quickly. In 2007, government healthcare expenditure was 2.283B1; by 2019 (the last year before Covid-19 struck) this had risen to 11.147B. In other words, between 2007 and 2019, a period of 12 years, government healthcare expenditure grew 4.9 times. Put in the effect of Covid-19 and over a longer period (from 2007 to 2022), government healthcare expenditure is expected to grow by 8.4 times in these 15 years!

Some of this growth along the way can also be attributed to a change in strategy for healthcare funding. In 2013, the government decided to raise its share of total healthcare expenditure from 30% to 40%, which was the correct thing to do as the population aged rapidly.

So it is of little surprise that the Health Minister announced MOH’s strategy for the next 10 years in this year’s Budget – Healthier SG

He outlined the five pillars of Healthier SG –

  • Activate Family Physicians (FP) Networks – Everyone should have a FP
  • Everyone Should Have a Care Plan with heavy emphasis on prevention
  • Community Partnerships
  • And if the above three are in place, then everyone can take part in a National Healthier SG Enrolment Programme
  • Structures and policies to support healthcare reform, e.g. Manpower, IT, Finance

A White Paper will be presented in Parliament to debate Healthier SG. The need for Healthier SG can be reduced to two main factors – a fast ageing population, as well as a population that is getting unhealthier. To underscore this second point, he said pithily in Mandarin, “what should be high is not high, and what should be low is not low”. (Somehow when this is said in English, there’s no kick)

Also indicated in not so big print is that with the National Healthier SG Enrol Programme, capitation can be explored and that each cluster can enrol up to 1.5M patients.

Chope. Wait. Tunggu. 等。

Capitation. A four syllable word that can trigger some serious action potentials in many a doctor’s neurons.

It would seem we are moving from paying for workload to capitation. And we have heard some horror stories about capitation from overseas examples. These would include, just to name a few:

  • Hospitals avoiding expensive, complicated cases and pushing the work to other providers. For example, how would national specialty centres be funded for the management of complicated cases and provision of tertiary care?
  • Hospitals running out of money before the funding cycle is up. For example in some places, when there is no more money, public hospitals then stop total knee reconstruction surgeries in the last two to three months of the year.
  • Insufficient funding for cutting edge medicine as hospitals thereby leading to erosion of excellence.
  • While clusters are paid by capitation, how would healthcare workers, especially specialists be paid? Will they be incentivised to see more patients or not under a capitation system?
  • Will patient choice be limited? Currently, a patient can theoretically go to a NHG Polyclinic in the morning, go to a Specialist Outpatient Clinic in a Singhealth hospital in the afternoon and then to a NUHS Hospital A&E at night. If patient choice is not limited, how will capitation work under such circumstances? Can better efficiencies be realised without limiting patient choice?

These questions are not new and have been asked in other countries that have adopted a capitation financing model. The truth is there are pros and cons, strengths and weaknesses to both capitation and pay-for-volume models. Some have avoided the worst and adopted the best of both models and lived to tell the tale. But not many. How will we fare? This hobbit wishes the best for those policy wonks working in the White Building; the folks that have to come up with the White Paper. Incidentally, the last time MOH has published a While Paper was in 1993: “Affordable Health Care” White Paper. Yup, it’s so long ago “health care” was spelt in two words and not one word, i.e. “healthcare”. Anyone with any memory of contributing to this White Paper in MOH would have taken their CPF or pension by now…

Of particular local interest is how will patients be split among the three clusters. The minister has said that each cluster can enrol up to 1.5M patients. But the truth is one cluster is significantly larger than the other two. How will the work and financing be split?

Putting the issue of capitation aside, this hobbit is most heartened that prevention is put front and centre. It remains to be seen how GPs and Polyclinics will be funded to achieve better disease prevention for all. As we all know, results of these efforts will not manifest early. It may be years before a healthier Singapore materialises. So it is important for politicians and policymakers to stay the course even when early and interim outcomes are not encouraging.

Onto another aspect of the Budget debates. NMP aka SMA President Dr Tan Yia Swam asked what was MOH’s position with regard to managing or regulating Third Party Administrators (TPA). The answer given was “We are monitoring the situation”. Turns out that that was the same answer given 6 years ago to essentially the same question. Ooops. Monitor so long, still monitoring? What has been monitored and what is the outcome of this very long monitoring? Anyway, Dr Tan’s suggestion to this long-term monitoring is that maybe it is time for MOH to be more “proactive” than just monitoring. This hobbit cannot agree more.

Actually to this hobbit, the whole thing is quite simple. When you have a problem, you have to regulate all major parties such they have skin in the regulatory game. Take gambling – you have a regulatory framework that covers the problem gambler, the legal gambling providers, including casinos, Singapore Pools etc and includes punitive and enforcement action against illegal or unlicensed gambling providers as well. Similarly, for smoking, you regulate the folks that import and sell cigarettes and the smokers and even the potential future smokers (i.e. the young adults and teenagers).

But when it comes to TPAs and their commercial arrangements with doctors and their corporate customers, only the doctor is subject to any regulation (through the SMC). It would seem that ONLY doctors have the responsibility and obligation to ensure the system stays ethical and clean. The TPAs have no such responsibility or legal obligation whatsoever. In many regulatory regimes, a good regulatory approach is often cited as “multi-pronged”, “comprehensive” etc. But when it comes to managing TPAs, it is uni-pronged and one-sided – Just regulate the doctors and everything will be fine. That’s wishful thinking isn’t it?

You will NEVER solve the problem with this one-sided approach even if you monitor the situation to kingdom come. In fact, the current TPA milieu may just impede the smooth implementation of programmes and policies that are necessary for a Healthier SG.

Finally, a follow up on the last post “A Tale of Two Cities”. Since that was posted, things have gotten rapidly worse for Hong Kong, unfortunately. How bad?

On 1 March 2022, both places had roughly the same number of Covid-19 deaths. Singapore by then had recorded a cumulative total of 1030 deaths; HK had a total 1013 deaths from public hospitals (according to the Hospital Authority). There are probably more deaths than 1013 since a small number of deaths occurred outside of HK public hospitals, but let’s just stick to a discounted number of 1013 for now.

14 days later, as of 15 March, Singapore has 1153 deaths while HK has recorded a staggering total of 4568 deaths. HK has a population of 7.6M, which is 36% larger than Singapore’s 5.6M. For the purpose of comparison with HK, lets add another 36% to Singapore’s 1153 deaths to give a weighted total of 1568 deaths. In other words, we assume that had Singapore had a population of 7.6m (Similar to HK), it would have recorded a total of 1568 deaths on 15 March 2022.

There is nothing to indicate that HK’s hospitals and doctors and nurses are any inferior to Singapore’s. The age group distribution profiles of the two places are roughly similar. In the period of 14 days, HK has logged an excess of 3000 deaths (4568-1568=3000) over Singapore’s weighted number of 1568 deaths.  That’s an excess of 214 deaths a day over 14 days. This difference can be largely attributed to the fact that they had a much lower vaccination rate for their elderly and for residents of nursing and elderly homes. This point was admitted to by Chief Executive Carrie Lam herself when she said the efforts to get the elderly vaccinated were “not enough” and the vaccination rates for these groups were lower than “China, Singapore and certain European countries” just a few days ago. The difference between vaccination rates for HK and Singapore’s elderly is best represented by the charts in this article2 which in turn was first published in the Financial Times.

Sometimes the human mind cannot quite fathom what exponential growth is. To give an example, on 1 March it was reported in Bloomberg that according to an updated forecast from the Laboratory of Data Discovery for Health and the University of Hong Kong’s WHO Collaborating Centre for Infectious Disease Epidemiology and Control, “the cumulative number of deaths by the end of April (emphasis mine) could be around 4,645″. (Hong Kong’s Covid Death Rate is Now One of the World’s Highest, Bloomberg, 1 March 2022) Well, its the middle of March, and we are already at 4,568.

The hobbit is NOT highlighting the mistakes that HK may have made in their pandemic fight for the sake of making Singapore look good or HK look bad, but rather to make the point to all these rabid anti-vaxxers out there in Singapore (and there are still quite a number lurking around) that had the government and people of Singapore listened to their anti-vaccination rhetoric, then we may well have more than 4000 Covid-19 deaths by now as well. The hobbit derives no joy at all from what is happening to HK, a place he happens to like very much, but unfortunately there are quite a few tragic lessons that HK has in store for us now which we must learn from. Every death is tragic, let alone 3000 excess deaths.

1https://www.moh.gov.sg/resources-statistics/singapore-health-facts/government-health-expenditure-and-healthcare-financing (accessed 12 March, with link to excel spreadsheet)

2https://yourlocalepidemiologist.substack.com/p/state-of-affairs-march-14

A Tale of Two Cities

And just like that, we are now into March 2022. Quite a few things happened in February 2022.

A little known fact is sometime in late February (around 27 Feb 22), we crossed the fateful number of 1000 Covid-19 deaths in Singapore, some 25 months after the first case landed here. This hobbit suspects that we are now at the peak or near the peak of the Omicron wave. We are now chalking up 15,000 to 26,000 cases a day and daily deaths number from the teens to the twenties. Based on these rough numbers, the case fatality rates of Omicron can be estimated to be about 0.1% in Singapore, approximating that of the seasonal flu. There are two caveats to this number of 0.1%:

  • fatalities usually lag behind case number by two to four weeks, we could yet see a rise in fatalities in the coming weeks
  • the number of cases is probably an underestimate as many cases now go unreported under Protocol 2: the infected self-test and stay at home for 3 to 7 days without being captured by official data collection methods.

The number of ICU cases have also remained relatively stable, in the range of 40 to 50 cases a day. We have about 350 to 400 ICU beds in the system and the strain imposed on ICU beds by Covid-19 patients is largely bearable. The real issue is at the primary care and A&E level where doctors are swarmed by many patients, many of which have no or mild symptoms.

Meanwhile in Hong Kong (HK), a city that Singapore is often compared with for anything ranging from property prices to wanton noodles, the situation is getting grimmer by the day.

On 2 March 2022, HK has already chalked up 1168 deaths1, surpassing that of Singapore (1030 deaths as of 1 Mar 2022)2. This in itself is not surprising because HK has a larger population than Singapore. But the momentum of this current wave is just simply all-consuming. Up till 2 March, HK logged a very respectable total of 293,730 cases, but just for the last four days (27 Feb, 28 Feb, 1 Mar and 2 Mar) the case numbers were 26,026; 34,466, 32,597 and 55,353 respectively, making a total of 93,090 cases. The daily deaths in the last three days were 83, 87, 117 and 116, making a total of 403 cases. In other words, 34.5% of Covid-19 deaths and 39% of Covid-19 cases occurred in the last four days. If that isn’t frightening, I don’t know what is.

It is interesting to note that Singapore has 748,504 cases as of 1 March, about three times that of HK, but the number of deaths are about the same in both places. In other words, ignoring the underdiagnosing of cases in both places, the case fatality rate in HK is three times that of Singapore.

One reason to explain the difference could be that in 2020, large numbers of young healthy foreign workers were infected in Singapore. Very few of them died and this would lead to a lower overall case-fatality rate in Singapore. But this cannot explain the difference entirely.

Another reason could be that it is a well-known fact that when hospital systems are overwhelmed, fatality rates increase. That could be happening in HK now, and that is why we see mainland China rushing in resources to help HK cope.

The other very important factor is that vaccination rates in HK are pretty low among the elderly. About 77% of those eligible have received at least two doses of vaccination. A good number, but not as high as the corresponding figure of 94% for Singapore.

What is really problematic is that it is estimated that at least 40% of those 70 and older have NOT received two vaccination doses. In other words, the folks who are the most vulnerable, who need vaccination most are also the people least likely to have received any or adequate vaccination. Only 30% of those above 80 have received 2 doses and 59% of those aged between 70 and 79 have received 2 doses. The corresponding numbers for Singapore for these two age groups are 94% and 96% respectively

This has been a walking timebomb ever since vaccination was offered in early 2021 in HK. And now this timebomb has exploded.

The principles of communicable disease control remain the same even as pathogens change. These principles are destroying the source of pathogen, breaking transmission, treating and isolating the infected and protecting the susceptible, i.e. vaccination. Breaking transmission such as social distancing, wearing of masks etc worked well in the early phases of the pandemic because the original Covid-19 virus was not as transmissible as the later variants. The basic reproduction number R0 was estimated to be about 2.7 for the original variant. That number increased to 5 for the Delta variant. For the Omicron, it is estimated to be at least 7. In other words, one Omicron patient is estimated to infect at least 7 other persons.

For perspective, the R0 for seasonal flu is 1.2; for smallpox it was 3; polio: 4 to 6. Very infectious diseases such as mumps and chickenpox will have a R0 of 10 to 12 and measles 12 to 18. Another way to look at it is the doubling time. The doubling time for the original variant is about 7 days, while for Omicron, it is down to 2 to 3 days.

The doubling time and R0 numbers for Omicron suggest that it is far more infectious than the original variant of early 2020 or even Delta. What that means is that the old strategy of breaking transmission by wearing masks, handwashing and social distancing etc will become more and more ineffective in stopping Omicron vis a vis older variants.

Another way to look at it is that in order for transmission to be effectively broken, the costs of doing so will become more and more prohibitive for Omicron when compared to earlier variants, i.e. with a R0 of 7 compared to 2.7, one would need more and more draconian policies and measures to be put in place to break transmission.

But this need not be so if a higher vaccination rate is achieved. While it is true that higher vaccination rates do not prevent infections in many cases with the current Omicron wave, the truth is it does reduce the number of infections significantly. And it certainly dramatically reduces the number of seriously ill or ICU cases. Because of our high vaccination rates among all age groups including the elderly, this hobbit will wager that Singapore is not going to see 100 deaths a day in this round of pandemic with the Omicron variant. It is also very unlikely that we will reach 50,000 cases a day, but this hobbit won’t rule that out completely for now.

So to all those anti-vaxxers out there who still insist vaccination is a bad thing, just observe what is going on in Hong Kong now. They already have a high vaccination rate, but they are still being hit badly now. The vaccination rate just wasn’t high enough amongst the most susceptible – the elderly. The lesson here is every shot makes a difference and it all adds up, especially for the susceptible groups.

My prayers go out to HKers, especially to our fellow healthcare workers there who are in for the fight of their lives. HKers are a resilient bunch and this hobbit knows that they will rise from the ashes of this crisis stronger. As for us, it ain’t over yet. But even as daily numbers hit more than 20,000 cases, there is no need to press the panic button yet.

1https://chp-dashboard.geodata.gov.hk/covid-19/en.html (Accessed 2 Mar 2022)

2https://covidsitrep.moh.gov.sg/ (Accessed 2 Mar 2022)

Hobbit Awards 2022

A Happy New Year to the readers of this ridiculously irrelevant column. 2021 has been a year of shattered hope (that we would have gotten the pandemic under control) and realised fears. Delta and Omicron bookended 2021 and the world spent another year in a surreally sad state of ( albeit milder) lockdowns, social distancing and masks.

We now look back at the year that has passed and we dish out various awards to folks who gave colour to 2021, through the eyes of a halfling who is stuffed with beer and suffused with melancholy….

First World to Third Award

Recently, it was reported that close contacts of patients who had contracted the Omicron virus were quarantined in hotel rooms. Many of them were made to share room with complete strangers. Seriously, after spending billions on disease control for the pandemic, we have to save on such stuff? We have to bear in mind this is more than a one-night stand and complete strangers are made to share rooms for several nights. Maybe folks such as Singaporean boys who have done NS and slept in army bunks can accept this, but how about other folks?

Sharing a room with family members and friends is probably OK. But complete strangers?Whoever thought of this needs to get his mind checked (to see if any brain is present in the first place). The foreign press took us to town for this and perhaps justifiably so.

Best Cultural Advancement Award

For centuries, humankind has frowned on nose-digging, especially in public, as a uncouth, distasteful act. Now we have to do it twice weekly in the form of regular ART tests. Now, it is not only public but if you return from VTL flights, it is supervised nose-digging. Trust this hobbit, most people can dig their nose pretty well, with their fingers or with a swab. They don’t need supervision. I actually think these chaps have a strange job – all they do is watch people dig their nose, day-in, day-out…..

No Reality Check Award

This goes to the unknown genius that believed that KTV lounges/clubs etc will willingly pivot to become food establishments without any hanky-panky business. This of course we know became the KTV cluster later on. This is made all the more incredulous when it was discovered that many of these “pivoted” food establishments do not have kitchens to do any serious cooking.

Fat Cats Award

In 2020, Integrated Shield Plan (IP) providers collectively made S103.75M. This hobbit thinks 2021 will likewise be a bumper year for them. Will they pass any of these earnings to the policy holders? Will premiums not rise as such? Will they stop threatening to raise premiums at every call for increasing doctor panel size or improving reimbursement rates for doctors? This hobbit is not holding his breath for this. They are the big winners of this year’s Fat Cats Award.

Stealth Award

This goes to the Life Insurance Association (LIA) of Singapore. For years they have been singing the familiar tune that private healthcare costs are increasing unsustainably because patients are overconsuming and healthcare providers are overservicing and overcharging. This will lead to premiums likewise increasing at an unsustainable rate.

Well, it turns out that for the Integrated Shield Plan (IP) sector, from 2016 TO 2019, Gross Premiums (i.e. total premiums collected) went up by a compounded annual growth rate (CAGR) of 10%; while Gross Claims (money paid out to policyholders who made claims) increased by 11%, while Management Costs went up by 16% and Commissions by 15%!

In other words, the main causes of unsustainability is that the amount of money these IP providers are paying themselves is increasing at a far faster rate than that of premium growth! And all this while, nobody really noticed until recently.

LIA wins the Stealth Award (quietly and invisibly)

Circular King Award

Current DMS wins this award for the second time running. 244 circulars were issued in 2020. 192 circulars were issued in 2021, slightly fewer. But this hobbit thinks that 192 may be an underestimate because a new practice may have emerged. Quite a few circulars were re-issued with updates and amendments and given an alphabet suffix; e.g. Circular 188A/2021 and so on. So the actual number may be around 200 or so.

Not all circulars apply to all doctors. But let’s say we halve that number – to 100 circulars. That would mean that an average of 2 circulars a week require my complete understanding and compliance. That’s pretty scary isn’t it?

Common Sense is Uncommon Award

We allow passengers to take public transport (such as buses MRT trains) with practically no social distancing. But till now, we continue to have alternate urinals and wash basins taped up so that no one can use them.

In some toilets, we even see every other toilet cubicle with full-height partitions likewise adorned with signs that state they cannot be used in order to maintain adequate social distancing.

Do the folks who implement this realise Covid-19 cannot spread through full height partitions, and also one spends considerably less time at a wash basin or a urinal (unless you have serious prostate problems) than in a bus or train ride?

The persistence of such practices reflects what my professor taught me long ago, “common sense is uncommon”.

Complexity Award

Up till early Oct 21, before the introduction of the simplified 3 Protocols, the country’s policies and regulations on Covid-19 quarantine, treatment and recovery were so complex it was really impossible to understand, let alone remember. This was best encapsulated in a flow diagram published in Lianhe Zaobao on 4 Oct 21. You don’t have to understand any Chinese, just look at the diagram. Adjectives such as “bewildering” and “befuddling” are but euphemisms in this instance:

https://www.zaobao.com.sg/news/singapore/story20211004-1199797

Kudos to the folks who contributed to the vast array of policies and regulations that controlled our lives for a few weeks. Even bigger kudos to the Zaobao team for understanding them and compressing all that into one single expansive flow diagram. They are the deserved winners of this year’s Complexity Award.

Road to Endemicity Award

This goes to the Delta variant for breaching our defences at the Jurong Fish Port shortly after the KTV cluster. After these two clusters there was no turning back for us. We were truly well on the road to endemicity…..

Clueless Award

Online commentator Calvin Cheng on 22 May 21 posted, “What are GPs? They are general practitioners who got a degree in medicine, who then either chose not to specialise in a certain field, or were not good enough to be chosen to be specialists. So they became GENERALISTS. They look after small every day illnesses, and once an illness or disease is too complex for them, they refer them to the real experts, a specialist”

Enough said about this guy. He likes to be heard I guess. Even for the worst reasons. He gets this year’s Clueless Award hands down.

Contrast this to what the Prime Minister said at the recent celebrations of CFPS’ 50th Anniversary on 3 Dec 21:-

“As family physicians, you are specialists in your own right. Hospital specialists see patients for a specific condition, but you see patients holistically as a person, across their range of conditions”.

The Facepalm Award

This is a new award category. It is given to the folks who make the most ridiculously embarrassing actions in the previous year. The inaugural award goes to a small bunch of anti-vaxxers who do the silliest things. There was one chap who claimed on social media that he can be contacted via DMS. That was another one who threatened to sue people, including the DMS, the prime minister’s wife and a prominent infectious disease specialist.

By all means, be an anti-vaxxer if you so choose. But don’t do or claim things that make you look stupid or even looney. This is no way to heal any divide….

The Grinch Award

This hobbit thinks Omicron is like the character Grinch in Dr Seuss’s book – How the Grinch stole Christmas. It appeared in November and literally took out the festive spirit in December, just when many people all over the world believed we had the Delta strain under control, and were prepared to travel for holidays and take part in end of year festivities. Maybe we should rename Omicron as the Grinch variant.

November Ruminations

Before we know it, the nation is ambling towards the end of 2021. If you ask this hobbit, 2021 was even stranger than 2020. There wasn’t the shock and awe that inevitably accompanied the advent of a new pandemic. The fear is still there, but fear, like a fixed cost, sort of diminishes with time and vaccinations, replaced by an all suffocating sense of morosity, vexation and weariness.

Anyway, speaking of vexation, recently, there was a report about how a doctor was vexed when a 99-year old Covid positive patient died at home and the family experienced problems with procuring undertaking services immediately after the death. (The Straits Times, 1 Nov 21). A director from the MOH in charge of Aged Care Services replied that it need not have been so, “our (MOH?) processes allowed him to be conveyed to the mortuary but the undertakers were reluctant to do so”. He further said that “Many of our undertakers have undergone infection control training by the National Centre for Infectious Diseases, many may still be concerned about managing those who die of Covid-19”. (6 Nov, ST Forum)

In a rare case of factual rebuttal, the Secretary of Association of Funeral Directors Singapore wrote in the same ST Forum the next day, “Funeral directors, as of now, are permitted to handle bodies of Covid-19 patients only at hospital mortuaries. Even the casketing of the body has to be done on the mortuary services. The regulations do not allow funeral directors to do this anywhere else”. He added, “In Mr Teo’s (i.e. the deceased) case, the funeral director who was asked to assist but did not was complying with regulations set out by MOH. The funeral director would run afoul of the law if he had proceeded to move Mr Teo away from the residence”. He then stated the obvious, “If we are to allow persons with Covid-19 to undergo home recovery, we need to accept that some people will die at home”.

Ouch.

To-date, this hobbit is not aware that MOH has published any reply to this letter from the Association of Funerals Directors Singapore yet.

If only the dead could talk, maybe we should ask them about how they feel about this whole affair.

Going past the irony and pathos of the whole situation, this hobbit notes than 171 circulars have been issued so far. Actually, probably more than 171 circulars have been issued because nowadays MOH may issue “secondary” releases of circular on the same subject matter with an alphabetical suffix. E.g. In addition to Circular 170, there could be 170A and 170B and so on.

In 2020, 244 circulars were issued. In other words, probably 400 circulars have been issued since the pandemic began and Singapore saw its first case of Covid-19 infection on Jan 2020 till now. Of course, not all circulars are Covid-related, but the majority of them certainly are.

I guess with time, even the people who drafted these circulars and the issuers of these circulars may have forgotten about the content of earlier circulars. After all, events of a year ago seem a lifetime away. Alert readers of this blog may recall that it was on 28 Dec 2020 (i.e. Phase 3), that folks were allowed to dine in up to a group size of 8.  11 months later, eating in a group size of 8 seems like something so remote that it almost sounds bizarre.

The other possibility is that the whole thing has gotten so complex that different stakeholders may not be aware of what other stakeholders are doing. For example, the disease control folks have a set of concerns that could be quite different from the aged care people.

So this hobbit is not surprised one bit when the Director of Aged Care Services doesn’t seem to be aware of the MOH-issued prohibition on funeral directors to handle the bodies of Covid-19 patients outside of hospital mortuaries.

We now move on to the other big happening of November 2021, which is the announcement on 9 Nov 21 by MOH of the setting up of the Clinical Claims Resolution Process (CCRP) platform to resolve disputes among Integrated Shield Plan (IP) policyholders, IP providers and doctors. Tandem with this announcement is the commitment declared by IP providers to increase the size of their preferred provider (i.e. doctors) panels.

The CCRP is essentially a mediation platform. When disputes are filed and the stakeholders agree to go through CCRP for mediation, a CCRP Panel consisting of two medical director representatives from IP insurers and three relevant specialists chosen by the Academy of Medicine Singapore (AMS) and a non-voting representative from Consumers Association of Singapore (CASE) is formed to assess the case.

The hobbit thinks this is a significant development in both the patient’s and doctor’s favour as they seek a more level playing ground against the mighty IP providers. For one, hitherto to this, clinical issues really have nowhere to be addressed expeditiously unless one has the resources and tenacity to mount a law suit. The overarching insurance regulator, MAS, appears to be only interested in the financial viability of IP providers. MAS is either not equipped or has not shown any desire to be equipped with the knowledge and skills to deal with the clinical aspects of IPs. MOH, on the other hand, is also not the appointed administrator of legislation that directly oversees insurance company regulation. So clinical matters, such as whether a procedure should be reimbursed or not on clinical grounds, is really in no man’s land until now.

The other big development in the IP milieu is that IP providers have committed themselves to increasing the size of their doctor panels. At the beginning of this year, all IP providers, other than Raffles Health Insurance have panel size in the region of 300 to 400. By the end of 2021, these same IP providers are committed to having panel sizes of between 450 to 600. This is a step in the right direction. But there is still much room for improvement.

According to The Straits Times report “Give patients in Singapore better choice by having insurers share a common pool of panel specialists”, there are 1,235 specialists in the private sector who are eligible for empanelling. Since practically no one buys IP from more than one IP insurer, it means any policyholder only has less than half of eligible specialists available to him at any time should he need care to be covered by his IP.

Nonetheless, both the CCRP and the increase in doctor panel size are positive developments. It is therefore important to ask how have these positive developments come about and why.

Even before Covid-19 hit our shores, many private sector doctors have expressed disappointment with how some IP providers were conducting their IP business in terms of pre-authorisation processes, reimbursement rates and doctor empanelling. As far as this hobbit knows, all this came to naught as the doctors’ grievances fell on deaf years and were met with stonewalling.

Things only started to move after the 61st Council of SMA decided enough was enough and crossed the Rubicon on 25th March 2021 by issuing a Position Statement on “Troubled Integrated Shield Plans”.

This Position Statement

  • Described the historical context and development of IPs from the 90s till present, and explained how many of the problems faced by IPs were really of their own doing, when they, on their own volition, introduced IPs that were badly designed, e.g. as-charged plans, first dollar riders that did away with deductibles and co-payment etc.
  • Highlighted how IP providers misinterpreted and misapplied some of the recommendations of the Health Insurance Task Force (HITF) with highly exclusive panels (21% of eligible specialists), opacity in the selection criteria for panel doctors, and only respecting the lower-end of the MOH Fee Benchmarks
  • Questioned the sustainability of the entire IP sector; IP insurers were being indirectly and heavily subsidised by the government through this unique phenomenon of “voluntary downgraders”
  • Drew attention to the cost control efforts (or the lack thereof) of IP providers – the Statement referred to a Report published by the Singapore Actuarial Society (SAS) that shown IP providers’ management costs and commission costs grew much faster between 2016 and 2019 than gross premiums and gross claims. The SAS Report revealed that only 75% of premiums collected went to payment of claims.

There was intense public and media attention on the IP sector in the wake of the publishing of the SMA Position Statement. Just three weeks after the publishing of the SMA Position Statement, on 14 April 21, MOH announced the formation of the Multilateral Health Insurance Committee (MHIC) which comprised representatives from major stakeholders in the IP sector. According to The Straits Times, the changes that came about: CCRP and increase in doctor panel size were attributable to the recommendations made “by the MHIC which was set up by the Government in April to reshape the private health insurance market”. (“More specialists on IP insurance panels: What this means for you”; 9 Nov 21)

One can reasonably speculate that without the SMA Position Statement, the MHIC would not have been formed so quickly or even formed at all. And without the MHIC, there would have been no recommendations to set up the CCRP or to increase doctor panel size.

So let’s give the 61st Council of SMA a clap – without them and their Position Statement in March 2021, we may still be stuck in the trenches and facing stonewall after stonewall every time we tried to get a better deal for patients and doctors.

Clarification: First Note Republished

This evening (4 Oct 21) I was forwarded an opinion piece written by The Straits Times Senior Health Correspondent Ms Salma Khalik, “Covid 19: When there’s confusion. it’s tough to pull together against a common enemy”. It was posted on the ST website at about 2240hrs.

The article stated that “The Singapore Medical Association runs an opinion blog called hobbitsma, penned by an anonymous author”.

I guess the “anonymous author” means me.

The article by Ms Khalik makes many noteworthy points which I encourage you to read. However, I just want to make one important clarification. This blog is run by me. The Singapore Medical Association does NOT run this blog. It may choose to republish some of the posts from time to time with my permission, that’s about it.

The confusion may have arisen because of how my life began. I began as an occasional columnist in the SMA News some 20+ years ago. Then I left the SMA News in 2011 but SMA set up a Facebook account for me and long-term readers will remember that before I used WordPress, my posts were long Facebook posts. However in late 2015 , the Facebook account was discontinued and so even the last vestige of link with SMA has been cut and I now blog on the WordPress platform.

For the last 10 years I have been on my own. A “ronin” hobbit of sorts, not in service of any daimyo and answerable to any editor or editorial board. Completely independent.

This fact can be seen in the “First Post” on Facebook, which I reproduce here in full (first published on July 2011): https://wordpress.com/post/hobbitsma.blog/133

Dear Friends and Colleagues

Yes, the SMA Hobbit is back. But on a different forum from the SMA News.

Even an old coot like this hobbit has to keep up with the times and social media simply cannot be ignored.

The social media offers several advantages from an established hardcopy print medium like the SMA News. For one, there is no printing press deadline to meet. The SMA news goes to print every month and this hobbit has strived hard to meet these deadlines and come up with articles with some regularity in the past. There is no such requirement with the social media such as a blog or a post on Facebook. I can post every few days or every few months.

Secondly, hobbit columns in the past in the SMA News have to conform to rough expectations of print space, i.e. about two pages or about 1300 words. With the social media, there is no such expectation. A post can be just several words or a few hundred words or even more than the usual 1300 words.

Thirdly, there is no editing or censorship by the SMA News Editorial Board. What I post on Facebook is entirely my personal business. There are pluses and minuses to this new arrangement. The main plus is that I am not subject to the Editorial Board’s decisions on what to print and what not to print. The minus is that I am entirely on my own here. Don’t get me wrong, I respect the role and responsibility of the SMA News Editorial Board. They are volunteers and they have a job to do. Having said that, that doesn’t mean I necessarily agree with their decisions even though I must respect them when I contribute to SMA News. So when the differences came to a head over a certain article, I exercised my right to retire from the SMA News as a columnist. To be absolutely clear, there were many important reasons that led me to my retirement from the News about half a year back, including the demands of work, family, but the decision of the SMA News Editorial Board not to print a certain article was also a big contributory factor.

Enough of the past, back to the present. Since this is my first long post here, I need to stress that whatever is posted here does NOT represent in any way the official position of the SMA on any issue. The folks in SMA have kindly set up this Facebook account for me to continue my nonsensical and personal ramblings in Cyberspace. I appreciate this opportunity and new forum and I hope you will continue to support me here virtually as you have had in the past in print.

As you are well aware, the Hobbit lives in a mythical parallel universe called Middle Earth. Unless otherwise and specifically stated, events and personalities referred to in this Facebook account are completely fictitious and belong to the realm of utter fantasy. If you do suspect that I am referring to anyone or any event that you think may have occurred on planet Earth (i.e. 3rd Rock from the Sun, and NOT middle-earth), then let me again reassure you your suspicions are totally unfounded and without any basis.

For the avoidance of doubt and to be absolutely clear – all future writings and opinions expressed here on this Facebook account are un-researched, untrue and cannot be substantiated. So read at your own risk, folks.

The Meandering Undead

What Now:- The Undead Phase?

We are now in uncharted territory. We have gone where no human, hobbit, Klingon has gone before.

This hobbit is not even sure what phase we are in anymore. There were terms like Dorscon Orange, circuit breaker, phase 2 and 3, heightened alert, preparatory phase, transition phase etc that were invented by wordsmiths. Apparently, we may be now in the “stabilisation” phase.

I would like to think we may be in the necromantic “undead” phase. We will trudge on. Till when? To where? Nobody really knows.

I remember I had this discussion with a war historian many years back about why Germany lost World War 2. Man for man, equipment-wise, the German army was equal if not better than any other army at the beginning of the war. By 1941, Germany had conquered almost all of Western Europe. Those that were unconquered were allies of Germany or neutral. After the conquest of Western Europe, the Germans were mainly fighting the British (and later the Americans as well) in North Africa.

But they were defeated because they then chose to fight on two fronts in 1941 to 1942 when Hitler chose to invade Russia in the middle of 1941. Having failed to take Moscow in the winter of 1941, they decided to go for the oilfields in Caucasus in South Russia, which wasn’t a bad idea. The original plan was to just destroy the industrial capacity of Stalingrad and to capture the oilfields. But then Adolf Hitler decided that he wanted to occupy Stalingrad as well, which really was sort of a “vanity project”, as the city is named after his arch-nemesis Stalin.

As history showed, the main bulk of the German forces in the Battle of Stalingrad, the 6th Army, was wiped out in an encirclement by the Russian Army in the winter of 1942.

The German Army never quite recovered from the disaster in Stalingrad and so lost the war in the Eastern front. In the end, they also lost the war in North Africa because too much resources had been devoted and lost in Russia and the African front was hopelessly under-resourced. This led to the allies invading Sicily in 1943 and Normandy in 1944 while the Russians continued to push westwards and recovering all its lost territory. The war in Europe ended in May 1945 when Germany was defeated by the allies sweeping eastwards and the Russians marching westwards into Berlin.

Fighting on two fronts

When it comes to resources, it is really quite a finite zero-sum game, at least in the short run. Testing of asymptomatic cases, even when self-conducted, is not resource-free on the healthcare system. Testing involves the redeployment of resources and which could have been utilised elsewhere.  

This hobbit is not so sure what we are trying to achieve here. We seem to be going to something akin to a heightened alert phase when the number of cases rise. Then when cases drop, we relax a bit. Which in turn will probably lead to a rise in cases again as social interaction increases, and then we reflexively clamp down again.

Two questions need to be asked:

  • Are we in an interminable loop of relaxing/50% to work/5 to dine and restricting/WFH/HBL/2 to dine? Even though 82% have been fully vaccinated and another 3% more due to be fully vaccinated?
  • What exactly is this country pursuing as an overarching strategy? Are we pursuing a zero-case strategy like China, Taiwan, New Zealand etc? Or are we going for endemicity, i.e. living with the virus exit strategy?

The answer proffered is that we need to stabilise the situation in the hospitals. For one thing, the situation for those in ICU and those that need oxygen seems rather stable. But there are actually more than 1000 patients admitted for Covid-19. Are our admission criteria too lax? By now we should have enough data to know what are the patient profile characteristics that will give a good prognosis and those that we know will not do well later on. This data should be carefully analysed and translated into better clinical practice so that we do not admit excessively and take up too many beds. At present, out of all patients diagnosed, 1.8% require oxygen, 0.2% are in ICU and the rest are either asymptomatic or mildly ill. Given our extensive experience in the last 20 months treating Covid-19 patients, can we extract more efficiency out of the system in terms of hospitalisations of asymptomatic and mildly ill patients?

On one hand, we say we are resolute on opening up and living with the virus. On the other hand, when we test almost everyone under the sun, we seem to be also going for a zero-case disease elimination strategy. As one public health expert put it, it is like asking each and every person caught in a downpour, “Are you wet?”

Another expert put it more starkly, “the pain of transition is made worse by being stuck in applying disease elimination measures to deal with an endemic disease. Much of what is being done in the name of disease prevention is counter-productive”.

Social media groups involving doctors are rife with comments questioning our strategy of testing asymptomatic folks. And many of these folks are respected experts in the medical community – public health physicians, infectious disease specialists etc.  

We may have some of the best healthcare workers (HCWs) in the world. But we are really tired of fighting on two fronts, supporting policies that apparently are aimed at moving towards endemicity and another set of practices that are aimed at disease elimination. Such a schizophrenic approach quickly tires out people both physically and mentally.

The Costs of Abundant Caution

It is easy to say we must do things “out of an abundance of caution”, which is probably one of the most overused phrases in recent times. But this hobbit feels these folks do not adequately address two important facets of a so-called cautious approach (even though 82% of population have been fully vaccinated):

  • The economic cost and livelihoods lost, migrant workers’ well-being, children’s need for social interaction, mental health etc.
  • While we say we want to protect healthcare and HCWs, some of these policies ignore the fact that many policies make provision of healthcare so much harder: the 2x weekly swabs, stay home orders for HCWs who are well and vaccinated, confusion among the public so that their only recourse are GPs (who are equally confused) and the already excessively crowded A&Es.

Home Recovery: Policy is Implementation

The next issue that has caught the attention of the medical profession is that of our Home Recovery strategy, which has been declared as the “default care management model” for Covid-19 patients. In itself, this strategy is absolutely correct and in-line with our stated strategy of living with the virus. But the implementation was (out of an abundance of euphemism) in a word – suboptimal. Which is rather interesting, because our transiting into endemicity was not a sudden thing. It has been discussed publicly for months. Other countries have also done it; there are both positive and negative examples of this that we can learn from. Yes when the rubber eventually did meet the road, we were found wanting.

The famous World War 2 American general, George S Patton said “Good tactics can save even the worst strategy. Bad tactics will destroy the best strategy”.

Surely, if this was intended to be a “default” model, then small-scale trials could have been run earlier to spot potential problems in communication and implementation? For example, when a new and important software system is introduced in a big company, there is always User-Acceptance Testing (UAT) performed before the system is rolled out, so that teething problems can be identified and ironed-out. Was there any trial or UAT done before our Home Recovery care management model was implemented? A past Head of Civil Service once said “Policy is implementation”. Unfortunately, some folks obviously didn’t read his memo.

New NS Vocation: Patient Buddy

That leads us to the issue of operations planning and implementation. We are now 20 months into having Covid-19 infections on our shores. If there is one thing that appears to be obviously lacking, it is our capability to plan and implement operations on a large scale quickly and well. And each time, the SAF is called in to save our butts. This is troubling to this hobbit. In many other countries, the armed forces are called in to help out in sudden emergencies and disasters, such as earthquakes and typhoons. In Singapore, they are now called in to answer phone calls and be patient buddies after the country has battled the same Covid-19 virus for 20 months. Chew on that.

An insider commented to this hobbit, “It really goes back to the reward system. If the system rewards those that can best write beautiful policy papers, then the system will produce the best policy paper writers and presenters. If the system rewards those that can do the “sai-kang” (literal Hokkien translation – faecal work; i.e. grunt work) best, then the system will produce the best operators”.

As Mr Brown, the “blogfather” recently inferred in a post (“Kim Huat and the somewhat endemic phase”)  – stop dishing out all these complicated flowcharts that most people have difficulty understanding. In fact, this hobbit has some advice for these flowchart exponents – send your beautiful flowcharts to the most junior person in your department, such as the administrative assistant or receptionist. If they understand it, then it is a good flowchart. If these junior or lesser educated folks don’t understand it, it’s a lousy flowchart. Go back and redesign the workflow and flowchart until it is understood by junior staff before it can be allowed to be circulated. Because if they don’t understand it, chances are not many people out there will.

The Magic Number of 143

Going on to the subject of boosters. On 14 Sep 21, GPs were informed by AIC that boosters can be given for those 60 and above if they had received their two doses at least 6 months (or 180 days) ago. On 17 Sep 21, this was revised to 5 months (or 150 days). That’s fine. Then on 24 Sep 21, another (third) email was sent by AIC (on behalf of MOH) to yet again change the criteria to 143 days and if the person had received an SMS from MOH to take their booster shot.

Do the folks who craft and send out such emails in rapid succession think GPs have nothing to do but read their emails and circulars? Why 143 days? Why not 144 or 142? And why must it be accompanied by the SMS invitation? A nice number like 150 days or 5 months is very good. Thank you. Please don’t load us with more bureaucratic instructions that consumes more memory space. I have a small brain with limited memory space. This hobbit would like to suggest that bureaucrats should be given a KPI that states “Have you made HCWs’ life easier with less bureaucracy?” in their annual performance assessments. I think many will fail this KPI miserably.

So very, very sick of it

A GP working in the Queenstown area said it well in his FB post dated 20 Sep 21,

Every day MOH sends us a bunch of new directives; there’s so much that my free 5gb mailbox is actually almost full! One day they say one thing, one day we read it in the papers before we get informed.

It’s now 5pm and I wanted to go home at 2 and have a nap, instead I’m clearing all the *@# from just now. And I might as well just stay here since we start again at 6 anyway. I am sooooo sick of having to rush to see and jump queue for pts with a cold, and doing all the paperwork involved in swabbing them. I am so sick of having to trace results every night and calling the pts to tell them that it’s negative. Am so sick of having to learn one new thing after another, and reading about new policies which are not clearly thought out, in the newspaper… quarantine yourself, and then after 3 days gradual return to activities. What the heck is a “gradual return”?

So very, very sick of it”.

It is apparent that to this GP, all the many and periodic expressions of appreciation and gratitude by politicians mean little to frontline HCWs like him when the bureaucrats just insensitively shovel out loads of instructions that make no sense or make life unnecessarily complicated. Pleasantries unsupported by action can only do so much.

What We Need Now

What we need now is hope, not the dreary prospect of interminably oscillating between opening up and shutting down activities, when we already have one of the highest vaccination rates in the world.

What we also need now is unity of purpose to rally the people and the HCWs. This in turn requires clarity of thought.

Hope, clarity of thought and unity of purpose. To achieve these three, we have to first settle on a communications message that is consistent, cogent and concise. This message must then be delivered with great conviction. We then have to develop and implement operations that cohere with this message.

If not, we will just be meandering around like undead zombies in search of both disease elimination and endemicity and finding neither.

September Ramblings

2021 seems to be flying past even faster than 2020. Before we know it, we are now down to the last one-third of the year. Gone even faster is the immunity protection afforded by vaccination with Covid-19 vaccines. The government has officially announced that those aged 60 or above, living in aged-care institutions or above and those that are moderately or severely immunocompromised should go for their booster shots.

This hobbit is wondering why healthcare workers (HCWs) are omitted in this first batch of booster-eligible people. After all, HCWs are working in high-risk environments and pose a significant risk to the people they care for should breakthrough infections occur. Also, HCWs are the earliest folks to be vaccinated. Many HCWs were vaccinated even before senior citizens at the beginning of this year. This hobbit hopes HCWs will get their booster shots soon.

We now move on to something that is rather confusing to this hobbit. This hobbit must state that the confusion may probably have arisen because this Hobbit is completely untrained and insufficiently informed in matters concerning the law.

An anaesthetist/pain specialist was recently acquitted of molest by the State Courts of Singapore when the prosecution, i.e. Attorney-General Chambers (AGC) withdrew the charges. However the AGC apparently subsequently disagreed with some things that the doctor’s lawyer did or said and then released two press statements in as many days. In both statements, the way in which the molest was alleged to have taken place were described in quite graphic detail, including how the molester touched the victim’s hips, cupped her breasts and how high the arms of the victim were raised. Both statements strongly suggested that the AGC believed the victim/complainant did not lie.

And yet, the charges were withdrawn, because apparently there were inconsistencies in the evidence garnered from various sources and that from the AGC’s perspective, the high threshold necessary to secure a conviction could not be reached.

Let us first view this from the victim’s perspective. If the molestation did take place, then, we could well have an honest, molest victim out there whose case has been dropped by the AGC due to technical points of the law that few lay people would really understand. This would be a double blow, tragedy upon tragedy for the victim. One cannot imagine the mental devastation that this person has to go through, first to be molested, and then to have the case withdrawn by the public prosecutor because of legal technicalities. There is no closure, and there will probably be life-long and deep emotional scars in this victim’s psyche. It would not be surprising if she would need long-term professional psychological support. My heart goes out to her if she was indeed molested and yet her case was dropped, especially when (according to AGC) there is no evidence to show she lied.

On the other hand, if the accused was innocent and accordingly acquitted, this hobbit can imagine that the first thing the accused wants is to get on with his life, especially when he and his family had in the preceding four years suffered so much indignity and emotional upheaval. Yet, he now sees press statements describing his alleged molestation in detail being made because of some dispute between the AGC and his lawyer. At the emotional level, there is probably no closure for him as well, even though he has been acquitted.

They say the truth shall set you free but frankly, to this legally-ignorant and legally-untrained hobbit, both of the above scenarios come off as rather confusing if not unsatisfying. 

Let’s finally move on to some good news.

The latest SMC Annual Report was released to the profession on 30 Aug 2021. It is a fine document with purported efficacy against insomnia and/or constipation. Anecdotal experience also suggests that reading the case reports of SMC Disciplinary Tribunal outcomes can suffuse the reader with a surreal sense of misplaced schadenfreude.

Fear not, this Hobbit will summarise the Report so that you can have more time during the Pandemic to purse your Covid-related hobbies, such as and baking sourdough and pottery (i.e. baking mud).

First the good news. The number of complaints lodged with the SMC has plunged. While many may ascribe this to Covid-19, the fact is the numbers have been steadily falling since 2016. The last year merely accelerated this trend. The numbers don’t lie:

YearNumber
2016242
2017206
2018200
2019173
2020118

This decline in absolute numbers, more than half, is made all the more remarkable when you consider that the number of doctors has increased significantly over the same period (from 13478 to 15430, an increase of 1952 doctors or 14.5%). The complaints rate has declined from 18.0 per 1000 doctors in 2016 to 7.6 per 1000 in 2020.

Somehow, this hobbit doesn’t think the mainstream media will report this very encouraging trend.

From 2018 to 2020, the five commonest categories of complaints were (in order of descending number of complaints)

  • Rudeness/Attitude/ Communication Issues
  • Unnecessary/Inappropriate Treatment
  • Professional Negligence/Incompetence
  • Misdiagnosis
  • Consent-Related Issues

2020 also marks the year that the number of doctors exceeded 15,000 for the first time in Singapore. About one-third of these work in the private sector and about 39% are specialists.

Over the last five years, it is noteworthy that the number of new provisional registrations (i.e. housemen) have risen from the low 500s to almost 600 a year. About 150 are foreign graduates while the remainder come from the three local medical schools.

For the specialists, it is interesting to note that the five fastest-growing specialties from 2016 to 2020 in terms of percentage growth were:

SpecialtyPercentage Increase
Emergency Medicine43.6
Geriatric Medicine41.9
Orthopaedics37.6
Rehab Medicine30.0
Urology29.9

The five fastest growing specialties in terms of absolute numbers for the same period are:

SpecialtyIncrease In Number
Orthopaedics82
Paediatrics76
Anaesthesia73
Diagnostic Radiology71
Emergency Medicine/General SurgeryBoth specialties 68

Looking at these numbers, one must really ask – is the growth in both percentage and absolute number of doctors and specialists sustainable? While we are in the middle of the Pandemic, we certainly want as many doctors as can get our hands on. But when life settles down in a post-Covid world, can we keep up with this growth rate?

In 2020, the number of doctors who did not renew their practising certificates was 81. The nett increase in doctors was 554 for 2020, 542 for 2019 and 390 in 2018. It remains to be seen if the recent cutback in the number of medical schools recognised by SMC will have an appreciable effect on the number of foreign trained doctors returning or coming back to work in Singapore in the coming years. But if the current trends continue, we are talking about a nett increase of a thousand doctors every two to three years.