Dragon Flatus

The Year of the Dragon is off to a very blazing start in terms of juicy news and scandals. For once, Singapore may be outdoing our neighbours to the north on this front. Of course, local healthcare cannot be seen to be left out on the cold either. We have our fair share of dragon flatus, some of harmlessly odorous, while others are plain noxious.


Let’s start with the harmlessly odorous – the case of the new Parkway hospital located at Novena, just a few metres away from the Ministry of Home Affairs (which some wise guy has quipped should be renamed simply as Ministry of Affairs) headquarters. Controversy has erupted with it being renamed as Mount Elizabeth Hospital@Novena. Some doctors in the Mount Elizabeth@Mount Elizabeth are unhappy with this and are even considering taking legal action. This Hobbit thinks this is unnecessary. In fact given the exodus of specialists from the public sector (which the Lianhe Zaobao in a recent report has wisely attributed to the residency programme, among other things) as well as this naming precedent set, we can have a slew of new names for existing private hospitals: TTSH GS@Mount Elizabeth, KKH@Thomson, SGH Colorectal@Adam et Paragon etc. The possibilities are endless. We can even have a facility called Nobody@Residency in time to come.


More on the residency. It has come to light that some poor ASTs (Advanced Specialty Trainees aka Registrars aka Always Screwed Trainees) and BSTs (Basic Specialty Trainees aka Basically Screwed Trainees) are now forced to pay for and take Residency-related exams. The reason is that by making them pay, they will try their level best to pass the exams. Also, there is claim that they need to take these American exams because the UK exams have changed so much they are no longer good. This logic is astounding. It’s like making a GCE “A” Level student pay for IB exams so that they have a vested interest in passing the IB Exams. Or getting motorists to pay ERP charges even when they have chosen a route from Point A to Point B that hasn’t got any ERP gantries. Or charging hotel guests for room service they didn’t order so that they will order room service anyway. I believe if this was the commercial world where common sense and the law applied, it’s illegal. You cannot charge a person for a good or service he doesn’t need or want. And the geniuses who came up with this really believe that the UK exams aren’t good enough, that’s just too bad. You don’t change things mid-stream and make people pay for it. It’s not the money, it’s the principle. Can you imagine Ministry of Education telling students and parents “Hey, we let you enroll in the GCE system but now it’s not good enough. So now, you have to pay for the IB exams so that you will try to pass it and at the same time, you still have to pass the A levels?” If you messed up by offering a system that is now not good enough, that’s your business. Don’t mess with people in mid-stream. And people only pay for and take exams out of their pockets because they are relevant. Making them pay for the exams matters little to outcome if the exams are irrelevant. In any case, these BSTs and ASTs are already given a raw deal – they have to train junior residents and have heavier workloads to cover up for the residency system. Please don’t make it any worse


More disturbing is actually how much hands-on will these residents get. My old Professor of Surgery (arguably the most respected clinical teacher for Surgery in the last 30 years) said quietly to me that he was deeply troubled. He said residents only got to perform simple operations like hemorrhiodectomy as a Year 3 resident and they become qualified specialist surgeons after Year 4 residency! This professor is of the age that he probably won’t ever be operated on by a product of the residency programme. But there is no escape for the rest of us. I think chaps who are promoting the residency programme as a wonderful thing should stand up and be counted and state that they will only be operated on by surgeons who are trained in the residency system. Put your liver/gall bladder/stomach/colon/rectum where your mouth is. That’s intellectual honesty. In case you are wondering, this Hobbit has nothing against residents- these are poor chaps stuck in a situation that offers no way out besides quitting. They are stuck as victims of a cruel monopoly introduced by people with motives best known to themselves.


As you are well aware, the SMC has given us a nice New Year present by announcing on 4 Jan 2012 it is raising our annual subscription fees from $300 to $400, because it has been under-recovering and operating at deficit. These are seemingly standard and plausible reasons. For one thing, although SMC is run on our subscriptions, the accounts have never been shown in the SMC Annual Report. There is almost complete opaqueness in terms of SMC’s financial situation to the countless and nameless doctors working on the ground and paying subscriptions to keep SMC afloat.


There are two main functions of the SMC – maintaining a registry of doctors (including CME records) and the costs of running investigations and disciplinary actions against allegedly errant doctors.


We shall start with the first – maintaining a registry. Anyone who has run something similar to a registry or an association or a club will tell you that it’s all about scale. Except for initial processing costs, unit costs drop dramatically when the size of the membership increases rapidly. And considering that the number of doctors registered in SMC has increased dramatically in the last 6 years, one wonders how come costs have actually gone up for each member. In Dec 2005, when fees were last raised, there were 6748 doctors on full or conditional registrations. Be end of 2010, this number has increased to about 8600, an increase 27%, according the relevant SMC Annual Reports. By now the figure should be about 30%. That’s a lot of doctors in 6 years and a lot of fees paid. Maybe the SMC should why briefly explain why the principle of economy of scale doesn’t apply to the SMC registry.


The next big SMC function is that of investigations and disciplinary actions. We don’t have access to SMC records in this area but this Hobbit will hazard a guess that the biggest “customer” of SMC is actually MOH – in other words, MOH is the biggest referral source of cases to SMC. Some of these cases are obviously necessary and the doctor gets disciplined. But one must wonder – how many of these cases could have been unnecessary, in which the doctor is found not guilty? While SMC funds should be used to fund to process complaints from individuals, one must ask should these funds be used to fund complaints from MOH, especially when MOH is so well-funded? Shouldn’t MOH share the costs of such cases, especially for the ones when doctors are not found guilty?


Lastly, we really have to look at SMC operating costs. Especially at manpower, which probably forms the largest chunk of costs. One example will illuminate this concern.


There are now two executive secretaries in SMC- (link: http://www.sgdi.gov.sg/; accessed on 24 Feb 2012). Executive Secretaries are very senior doctors and they do not come cheap. Let us look at Section 10 of the MRA – “The Medical Council may appoint an executive secretary and such other employees on such terms and conditions as the Medical Council may determine”. That means Section 10 of the MRA states there is only ONE executive secretary at any one time, together with an indeterminate number of other staff. Let’s leave it to Attorney General’s Chambers to advise on the legality of this arrangement of having two executive secretaries since we doctors know nuts about such legal stuff and also the AG Chambers is the government’s legal advisors, but surely this duplication of posts and manpower must lead to increase in costs? Why have two when the law provides for one? No doubt the bureaucrats in MOH will advise the politicians to amend the MRA on this aspect and it will probably be done, but the point is, who is really looking at costs?


In case you are wondering if “a” or “an” can mean more than one – Let’s look at the law again – the Medical Registration Act (MRA) that provides for the existence of SMC. Section 18 (1) and (2) of the Act states that “For the purposes of this Act, there shall be a Registrar of the Medical Council. The Director of Medical Services shall be the Registrar of the Medical Council”


That means there is ONE DMS and ONE Registrar at any one time and they are one and the same person. Of course, there can be an Acting DMS or Registrar when the DMS is on leave etc. But at any one time, there is only one person holding (and presumably paid for) the two jobs on a long-term basis. In this case, it’s our very esteemed and well-loved Prof K Satku. No one has any problems here with this arrangement or assumes there can be more than one Registrar or one DMS, this Hobbit included. So how can it be that there are two executive secretaries? By the way, if you do go to the online government directory (as given above), in addition to 2 executive secretaries, there are about 36 other staff that of executive level and higher, including one legal counsel. That’s some serious manpower there.


This is enough flatus already for 400 bucks. It’s getting kind of hard to breathe in our little shire hut. Gotta go out and get some fresh air. Bye for now.

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