Moody May Ramblings

May is usually a very complicated month in a doctor’s life.This is mainly due to the fact that in May, we have a bunch of houseman and medical officers starting work in our public hospitals. It is even more complicated now because unlike the days of yore, these young folks expect tohave a life, which as we old coots all know, is a completely unrealistic and unreasonable expectation in medicine. Medicine cannot co-exist with life.Junior doctors have no life, hence the Hippocratic aphorism of “ars longa, vitabrevis” which literally means in Latin if your butt is long, wear briefs.*

But even more disturbing that the issue of new housemen and medical officers is the twin plague of mid-year exams and Mother’s Day in May.The juxtaposition of these two events must be a cruel joke designed by the most diabolical mind of our times. First, we have Mother’s Day, where fathers and children are coerced by TV, radio, newspapers and Ironman to perform acts of kindness to mothers. These acts of kindness include queuing and paying an arm and a leg for bad food at restaurants offering rip-off set menus and buying gifts that contribute to global warming. That’s the easy part. While fathers are paying and children are trying to be kind – remember, the mid-year exams are just around the corner – that means Tiger mums are now at their worst trying to whip their kids into shape through all manner of torture and threats– which include denial of access to the really important things in life: –sleep, the toilet and access to any gadget with a name that is prefixed by the letter “i”. All this while, the father is caught in the middle of the wife/mother going berserk and kids taking cover in trenches and guess what, he still has to organise, plan and pay for an expensive and tasteless Mother’s Day meal – and also convince the kids that they still need to be nice to mum.

Honestly, on days like this, don’t you just wish instead of staying at home and hanging around your wife and kids, you were in the hospital looking at a patient’s large, smelly, festering wound? So May is a tough month by any measure. But by the looks of things, this year’s May will be even worse.

For one, we are in the middle of a Mother of All Dengue Outbreaks, which in all likelihood will peak around Mother’s Day. With more than 500 cases a week being reported (and many more probably unreported), this year’s dengue epidemic will be BIG. The control of dengue lies in prevention and not us doctors. But it does mean more business for doctors and hospitals. Recently, I came across a private hospital bill that stated the charges for transfusing a pint of platelet was about a thousand bucks! Not bad business for giving a product that is supposed to be free in this country, other than processing charges by HSA. I wonder how much HSA charges for processing a pint of platelet? It must be a fraction of a thousand dollars?

Recently, there was this bizarre newspaper report of a guy going around polyclinics sedating patients who were waiting to see their doctors and then stealing stuff from them. This Hobbit thinks all this is frankly unnecessary. Come on, there are some poor fellows waiting so long to see their doctors in the polyclinics they are already in rigor mortis! They don’t need any sedation – you can just walk up and take whatever you want from them.

In the first week of May, some of us may have received an important letter from MOH. The letter states that by the powers vested in themfrom Section 12 of the Private Hospitals and Medical Clinics (PHMC) Act, if you happen to perform treadmill tests in your clinic, you are to submit 6 months’worth of patients (of those who had undergone treadmill tests between 1 July to31 Dec 2012) data to them so that they can select patient records for audit.This data include not just simple biodata but stuff like reasons for ordering treadmill as well.

The first thing you should note is that when a section of any Act is quoted, you have to obey. This is the law and no one is in any mood for bargaining. If you happen to be a busy cardiologist and you order two to four treadmills a day, it may well mean that 500 to 1000 of your patients have undergone treadmills in the stated 6-month period. It also means that you, or your clinic assistants/nurses now have to comb through these records (assuming you even know who these patients are) and extract the required information from each and every relevant patient record. And if you think this sounds like a nightmare, para. 3 of the letter states “For a start, we would appreciate it ifthe following information could be forwarded to us by 31 May 2013”.  This is ONLY “for a start”, bro. It means they may well ask for more information which you, the doctor, HAS to comply under the provisions of Section 12 of the PHMC Act.

This Hobbit doesn’t offer treadmills in his clinic. Whew. For the rest of you who do, all this Hobbit can offer is to quote what his Orthopaedic Professor is found so oft to say – “Good luck, chum”.

But even as we have to comply with the law, one can still question aloud why treadmills are chosen for audits? One usually audits procedures and investigations that are expensive, open to abuse or high-risk. And the treadmill test does not fall under any of these considerations. And even if one orders the unnecessary treadmill once in a while, that could easily be accounted for by the fact that the doctor is erring on the side of caution. Generally speaking, a doctor or a patient (or anyone) would like to err on the side of caution when it comes to the subject of heart attacks.

There are better things to do than auditing treadmills. “For a start” (yes, this Hobbit is a fast learner), one can audit all elective PTCAs that involve putting in 4 or more stents (i.e. what cardiologist call “full metal jackets”). Now, wouldn’t that be more interesting than treadmills?

Finally, for moody May, there is a very interesting letter in the latest issue of the Annals of Medicine, published by the Academy of Medicine Singapore. This letter is titled “Will the Local ACGME-trained Surgeon be Adequately Prepared? An Estimate of the Impact of Duty Hour Restrictions on Operative Experience” (April 2013, Vol 42 No. 4, pages 203 to 206). This letter compared the number of operative hours a first year General Surgery registrar under the old AST system will get compared to that of a 4th year resident that would have met the ACGME (new American-style residency system) requirements. (Note: a first year registrar is roughly equivalent to that of aYear 4 resident in terms of experience and training).

The results were, to put it mildly, disturbing. The letter studied three registrars’ training records and concluded that had these three registrars been trained under the new ACGME system, they would have experienced 12% to 22% less operative time for that year. If you think this sounds OK, here comes the sucker punch – registrars under the old AST system go through FOUR years of being registrar and TWO years as MO/BST – a total of SIX years. The ACGME resident only goes through FOUR years of training in TOTAL: two years rotating through various disciplines like a BST, and TWO years “advanced training” (similar to a registrar) instead of FOUR.

According to this Hobbit’s very rough ball-park estimates, ACGME residents may only undergo 40% of what the old ASTs went through in terms of operative time before they are signed up as Specialist General Surgeons by our Special Accreditation Board (SAB).

The letter’s authors opined, “While we fully acknowledged that the numbers presented here are but rough and somewhat simplified estimations, the fact that there will be a significant and substantial change in the amount of operative experience obtained by the products of the ACGME system is indisputable”.

The authors concluded that “while the new ACGME-accredited residency programme is an attempt to innovate the national specialist training landscape, the results presented here show that there will be an inevitable decrease in clinical and operative exposure, brought upon by the inherent reduction in the duration of the training programme and further exacerbated by restrictions placed on duty hours…. and the question of whether or not “specialist” graduates of this system will be adequately prepared for the clinical responsibilities of a full-fledged practitioner……must receive serious consideration in order to ensure an adequately trained and adequately prepared healthcare force for the challenges ahead”. Well said.

This Hobbit takes his hat off to this letter’s authors fortheir courage in submitting the letter to the Annals and also to the people who decided to publish this for public record. Some people will get very defensive and upset about this, but that is to be expected.  Veritas odium parit.**

*Actually the phrase means the art is long, but life is short

** Truth begets hatred

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