Festering February

The Year of the Monkey is upon us. And it is not looking good. For one, the first casualty in the Year of the Monkey is not bananas but fish. The ubiquitous raw ikan parang or salmon found in “yusheng” during Lunar New Year has been replaced by all kinds of stuff such as abalone, jelly fish, and even truffles. “Yusheng” which means raw fish is now replaced by “Yusi” (dead fish) or “Yujia” (fake fish).

What is the connection between raw fish and jelly fish is really beyond me, let alone truffles. Maybe they will serve starfish next. What the fish.

But the real question we medically-trained people need to ask is why is the usual raw fish unsafe to eat now? We have eaten the stuff for decades and until recently, no one has lost an arm or a leg, let alone his life. Why now? An important point to note is that the spate of tragic cases cannot be traced to any food outlet. They occur randomly across the country after eating Chinese-style raw Toman and Song fish (fresh water) from many different food outlets. The infection can be traced to Group B strep infection but no one food outlet has been linked to a multitude of these infections. They are literally “all over the place”. In other words, the problem does not lie with food handling at any particular food outlet such as a hawker stall or restaurant etc. Which is why till now, the authorities haven’t charged any hawker or restaurant etc.

AVA and NEA have said that contamination could have occurred in the food supply chain. This Hobbit agrees with this observation. But these fish are mainly farmed fish. In fact, most of the fish we eat today, cooked or otherwise, freshwater or seawater, are farmed. The imagery of your friendly fisherman at the kelong or rowing his fishing boat into the sea and fishing with a net or casting a line against the splendor of the morning sun is really a thing of the past. Move over, Ernest Hemingway. Fish, like cows, lambs, chickens, pigs, orcs and frogs – are farmed. Has anything gone wrong with the farming process? Is anyone studying the farming processes since these fish are farmed around and near us?

The other thing about this issue is that of food regulation. In some countries, food regulation comes under one department or ministry; example: USA: Food and Drug Administration (FDA). A single agency approach also applies to Korea, Japan and Hong Kong, to name a few. In Singapore, food regulation comes under at least three agencies spanning three ministries. AVA (under Ministry of National Development) which supervises the importation and sale of raw food; NEA (under Ministry of Environment) which regulate food outlets such as restaurants, hawker centres and coffeeshops; MOH which looks at control of communicable disease outbreaks linked to food. And this excludes other agencies such as HPB which looks at promotion of healthy eating habits and HSA which oversees regulation of food supplements.

As anyone can see, this is rather complex. Unnecessary complexity is never a good thing. Which is why it took a rather long time before the conditional ban on selling of raw fish came into effect. And till now, there has been no further news on food chain contamination.

Shouldn’t we put everything under one roof, much like how the regulation of media and telecommunication industries now come one statutory board? Food for thought indeed….

We move onto SGH. The mother and cradle of medicine in Singapore (Although TTSH may disagree). This is where it all began. No, I am not talking about the first dialysis or renal transplant or separation of conjoint twins in Singapore. I am talking about faculty practice and 200% professional fee surcharges. (TTSH will NOT disagree)

Just kidding.

It was exciting to see our Prime Minister unveiling the SGH Masterplan. In all likelihood, when the Masterplan is completely executed in 20 years’ time, only the elves will be around. Nonetheless, it looks like a good plan. But this Hobbit would like to offer one teeny-weeny bit of feedback to the master-planers now if they don’t mind – please WIDEN the pathetic SINGLE-lane two-way roads and build MORE carparks!!!!!

I know there is this national agenda to make Singapore car-light and promote public transport but we are talking about sick people and their caregivers. If these sick people can take public transport or walk or cycle, they don’t need to be in SGH. I know of people who borrow cars from relatives and friends so that they can bring their loved ones to public hospitals on the day of the patient’s appointment. Please EXEMPT public hospitals from any well-meaning but erroneous car-light and walking-heavy transport plan.

And then there is staff parking too. For example, there is no parking space in a huge building such as The Academia. It must be the largest building in Singapore without parking. Seriously folks, what is the use of studying so hard to get into medical school so as to be able to afford a car if you can’t get parking in SGH? What is worse, you know the kind of stress that many of our medical students go through nowadays? Many of them have rich parents who buy them Porsches and BMWs to drive to public hospitals and these public hospitals do not provide parking. Spare a thought for these poor/rich medical students – they need parking lots too. They cannot handle such stress any more than they can handle 30-hour houseman shifts when they graduate (which is why we have 12 hour shifts now).

So if you see a Porsche in a public hospital circling around looking for parking, it is probably not owned by patients, visitor or senior consultants, the Porsche belongs to the medical student. The senior consultant can only afford a Volvo at best. If the senior consultant owns a BMW or Merc, he is probably moonlighting as a Uber limousine driver at night. Or he is from SGH, is on the faculty practice scheme or can slap on a 200% surcharge. (I can hear TTSH groaning)

So in a nutshell – more carparks in the Masterplan please. In any case, carparks make money, unlike proton therapy, cyclotrons and other swanky stuff. Car parks pay for themselves. And definitely not another huge building like The Academia where floors of offices remain largely empty during office hours. They should be converted into office hour parking lots accessible by car lifts. The genius who decided that the Academia didn’t need carparks should be brought onto the helicopter field behind MOH and hung at sunrise. Of course not, we must be more humane; he should do community service by being a valet in SGH campus for 30 days without the use of valet-designated lots. Or we can make him run back and forth from the multi-storey carpark behind MOH (i.e. further than Siberia) to Blocks 1,2 and 3 of SGH ten times a day. His cardiovascular health will improve even as he comes to the realisation that The Academia needs parking lots.

Finally, we move on to Managed Care. There has been a lot of discomfort and grumblings on the ground about Managed Care. They are certainly getting more aggressive. And they remain unregulated, unlike the humble hawker trying to eke out an honest living by selling raw Song Fish salad. Recently, they have even become third-party administrators (TPA) for established insurance companies offering Integrated Shield Plans (ISPs). Be careful when you sign up as a doctor with these Managed Care companies. You may think the relationship is confined to one aspect of this practice but you may be blindsided. You may suddenly find that your ISP patient who signed up for an “as-charged” ISP will not pay you “as-charged”. What has happened is that the ISP insurance company has also signed up with the Managed Care company as a TPA. The Managed Care company now will impose on you their schedule of prices for the services you rendered to your ISP patient who is supposed to pay you “as-charged”. On top of that, the Managed Care company will levy a 10 to 20% surcharge on you as “admin fees” – this amount is automatically deducted “at source” when the insurance company pays you.

In other words, you think you have two independent relations – one with the Managed Care company which is independent from the second relationship with the ISP insurance provider. Well, the Managed Care has conflated the two and imposed the terms of the Managed Care contract onto the ISP insurance company relationship because they have been appointed as TPA by the insurance company. And what is more, if you look closely, in the terms and conditions of the Managed Care contract, they have a clause that states they can change and alter the terms of the relationship anytime and unilaterally. So things can only conceivably get worse.

While these practices are linked to just one or two Managed Care companies now, if these companies succeed, others will probably follow suit.

After all, it is monkey see, monkey do…..



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