When is an orthopaedic surgeon NOT a registered specialist in orthopaedic surgery?

July is an important month for our healthcare system. It is so because it is the month of Primary 1 registration and stressed out parents of 6 year-old kids need some kind of psychiatric counseling. No, seriously, it is the month of America’s Independence Day and given the Americanisation of our medical training system, we should make all our residents swear an allegiance to the American President and hope that one day, our residents too will get to work in an environment where 18% of GDP is spent on healthcare and not 4%.


But here is the catch, notwithstanding our voluntary allegiance to the American Residency system, our products, i.e. residents are not recognized in America when they complete their residency. It is a one-sided love affair of the strange kind, like a moth’s fondness for the flame. In fact, as one wise guy pointed out, our residency training is not even recognized in JB or Batam, let alone anywhere else.


Which leads us to the next point – our traditional reservoir of medical talent – Malaysia. Many Malaysian doctors have come to Singapore to undergo specialist training in the past. This is because our training system is based on the British postgraduate system etc which Singapore’s system used to prepare our trainees for are recognized in Malaysia. With 5 years of postgraduate experience, these Malaysians can often return to Malaysia to practice in the private sector without working in the public sector. But with our residency system, one is not so sure anymore. The result is that Malaysian doctors no longer see Singapore as the first choice destination in medical training, notwithstanding the cultural similarities of the two countries. One medical specialty department lost an entire bunch of Malaysian medical officers because these chaps wisely know that if they want to retain the option of easily returning to Malaysia to practice as specialists, the Singapore’s American residency system is not the best option for them.


Of course, some of them may still stay in Singapore to train and even remain permanently. Why, they may even think they can become the DMS one day.


In any case, this should not be a matter of grave concern because this Hobbit is given to understand that there is a surplus of non-procedural medical specialists such as geriatricians etc. This Hobbit is also given to understand that Earth is flat and the Moon is inhabited by a lone Chinese woman and her pet rabbit.


Speaking of DMS. Our beloved DMS has around for quite some time. Unsubstantiated rumors abound about his desire to step down. In any case, finding a successor will be tough. He has done a monumental job and these are big shoes to fill. There are few jobs tougher than the job of DMS – like the Mayor of Fukushima, foreign minister of Syria or CEO of SMRT. Maybe we can have our version of the Hunger Games and each public hospital can offer one or two “tributes” to the Games and the winner will become the next DMS. The only problem is that the tributes may, unlike the original story, actually want to commit suicide rather than kill each other and survive.


The next big thing in July is that we had the mother of all healthcare IPOs in Singapore with the listing of IHH as well as the launch of the Mount Elizabeth @ Novena Hospital, which is not to be confused with Tan Tock Seng @ Novena Hospital or the Renci @ Novena Hospital. If you think this is confusing, spare a thought for the poor taxi driver.


Speaking of TTSH, the latest joke going around is “why did the TTSH doctor cross the road?” The answer is “because he wanted to see hospital room where the daily charge is more than his month salary, i.e. the Mount Elizabeth @ Novena Hospital Chairman Suite.”. We are of course talking about the $13,000 (Singapore dollars) a day suite in the newly opened hospital. I think policy makers must understand the doctor’s psyche better so that they can draft better talent retention policies. Key to understanding the doctor’s psyche is that


a)      They like to be better paid (at least on a hourly basis) than their children’s tutors

b)      They need to take every free drug pen there is to be taken

c)      They find it particularly depressing when their take-home monthly salary is less than the daily ward charge of a hospital suite in a country which is smaller than 700 square miles.


The other joke going around is that with the way things are going, poor Singaporeans will be mainly seeing only foreign doctors and rich foreigners will be the only ones seeing Singaporean doctors.


I wonder if the 13,000 a day suite comes with gold taps and a nice view of NKF?


Meanwhile, the Family Physician Register is being rolled out with all the finesse and grace of a herd of on-heat pigs thrashing in mud. Take the decision to bar the use of the word “family” in clinic names, even in clinics that had used the word “family” for decades – this is bizarre, to say the least. The logic of this may well remind you of some of rationale behind the decisions that were made during the Cultural Revolution or the reign of Stalin.


And then there is the SMC website. Every registered medical practitioner who is NOT on the Family Physician Register has now an additional data field entry which states clearly “This person is not on the Register of Family Physicians”. This may sound reasonable until you realize that this also applies to specialists who already have their specialty or subspecialty listed next to the comically superfluous but Orwellian-sounding declaration “This person is not on the Register of Family Physicians”. It’s like you have a bunch of hairy guys starting out at the London Olympics 100M race all wearing a tank-top that says “I am not a woman”. Isn’t this obvious? We all know, for example, that the Dean of Medicine or the DMS is “not in the Register of Family Physicians” because they are specialists. Maybe the geniuses who of thought of having this useless declaration should be made to wear headbands that proudly declare the equally obvious – “I am not clever”. This is one of those Jar Jar Binks moment that we are encountering with every more frequency nowadays.


But at least, this is at most a harmless but irritating remark. The next bit is far more perniciously divisive. This is Jabba the Hutt stuff.


Suppose we have an orthopaedic surgeon who graduated from our local medical school and subsequently trained at one of the most eminent local public hospitals in the land. He obtains all the requisite clinical training and passes all the exams, like M.Med, FRCS etc. The quality of his basic and postgraduate training is unquestionably good. His performance as a trainee is also good. He then becomes recognized and registered as a specialist in the specialty of orthopaedic surgery. He then maybe takes a few years off (e.g. 5 years), maybe as clergymen or missionary, to get a PhD in research, to enter into politics full-time etc. It doesn’t matter except for the fact that he wasn’t practicing orthopaedic surgery for a couple of years. He becomes maybe out of touch. He then wants to return to orthopaedic surgery. What happens? Of course, for the duration of the period he wasn’t practicing surgery, he still remained on the specialist register. But because he is trained and qualified as a orthopaedic surgeon and is on the register, all he needs is for the medical council to require him to practice under the supervision of an orthopaedic surgeon for a short period of time, say a year or two. In other words, while he is not “current” in his practice, he is not deemed “incompetent”. At the end of the supervised period of practice, the supervising surgeon will assess and recommend (or otherwise) that this surgeon be restored his full and independent practice rights as an orthopaedic surgeon.


Now, we will plunge in the crucible of discontent that surrounds the Family Medicine register. We have people who had practiced as a family physician for years, have completed all the training and passed all the family medicine postgraduate qualifications NUS and College of Family Physicians Singapore have to offer and yet, they don’t qualify to be on the Register of Family Physicians! The main reason being that their place of work does not happen to be a “recognized” place of practice. In fact, only GP clinics and polyclinics unconditionally qualify as places of recognised practice. Even time spent and work done in homecare and community hospitals have to be assessed on a points system and a case by case basis. This case of confused thinking may be befitting incarceration in Arkham Asylum.


There are two concepts here – competency and currency of practice. But with the Family Medicine Register, there is a confused confluence of the two concepts. If the person has completed training and passed M.Med, DGFM, M.Med, FCFP etc he should logically be deemed qualified as a Family Physician and registered as such. He can be put on an “inactive” list if he is deemed not to be current in his practice (for example, he may be working as an administrator in a hospital or a statutory board etc, just like the example given above for orthopaedic surgery). If he wishes to return to practice full time as a family physician in a polyclinic etc, again, he can be placed under supervision in the polyclinic and if he satisfies certain criteria, his “inactive” status can then be changed to “active” to reflect that his skills and knowledge are now “current”.


But what the people administering the Register are doing now is that they are denying well trained and qualified family physicians any place on the Register. This doesn’t make sense no matter how one makes of it. It also doesn’t help when JCFMS (Joint Committee on Family Medicine Singapore) is chaired not even by a family physician but by an anaesthetist. This hobbit has nothing against anaesthetists but if even a FCFP doctor(highest qualification conferred by CFPS) cannot qualify to be on Register of Family Physicians, how can an anaesthetist be qualified to chair such a powerful committee on training of family physicians?


So let us return to the question that this column started out with – When is an orthopaedic surgeon NOT a registered specialist in orthopaedic surgery?


This Hobbit’s answer is “When a family medicine trained and qualified doctor is NOT allowed to be on the Register of Family Physicians.

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