Bigger than War on Diabetes

It finally happened.

As it surely must. What we had expected has come to pass.

I am not talking about the sequels to X-men, Captain America or even Chen Shao Mao challenging Low Thia Khiang to be the leader of the Worker’s Party. I am not even talking about the arrival of the Zika virus in Singapore.

Speaking of the Zika virus, I must say that, like our taxation regime, it is a “progressive” virus, (i.e. affects the rich more than the poor). This can be seen by the fact that the virus came through a permanent resident living in the posh Watten Estate area, after he had spent some 6 weeks in Sao Paolo, Brazil. This permanent resident is probably rich to be living in Watten Estate, can afford to spend 6 weeks in faraway Brazil and also sought medical attention with a specialist working in a private hospital.

The bus captain living in a Punggol 4-room HDB flat cannot afford to go to Brazil for 6 weeks or see a private sector specialist.

But this hobbit digresses. What has come to pass is common sense prevailing. For some strange reason, this hobbit has suspected that some folks in Ministry of Health are waging a secret war that is even bigger than the War on Diabetes – the War on Treadmill. I think these folks may have a fetish to see treadmill testing eliminated in this country.

To me, treadmills are a relatively cheap and safe test to investigate a potentially and frequently fatal disease – Ischaemic Heart Disease. But some folks want to regulate it to death, as opposed to using it to prevent death. MOH issued a circular on 14 Dec 2015 saying hat it has finalised the “Guidelines on Provision of Electrocardiography Stress Testing (EST)”. It further said the Guidelines would take effect on 1 May 2016.

The circular and the appended Guidelines are very interesting in at least 3 aspects:

  1. It said it had consulted respective professional bodies and has finalised the Guidelines. As far as this Hobbit knows, consultation indeed happened. But there probably wasn’t agreement. So while it gives a veneer of concurrence because it “consulted”, there probably wasn’t real agreement. This can be seen by the next two points –
  2. Under Paragraph 3 or Section III of the Guidelines, “Patient Selection”, it is stated that should a patient who does not fall under the indicated criteria for a treadmill be offered one, he needs to be given “a cooling-off period of 7 days to consider whether to proceed”. I am not making this up. This hobbit will bet his last pint of beer that the requirement for a cooling-off period of 7 days for a treadmill cannot have come from a person who actually practises clinical medicine or any of the aforesaid unnamed professional bodies.
  3. Lastly, while the circular is titled “Guidelines on Provision of Electrocardiography Stress Testing”, the next page shows the list of people who are purported to be responsible for these Guidelines and the page was headlined “Treadmill Services Workgroup”.

These are incredible times. An 18 year-old girl can get an abortion legally in a licensed clinic in Singapore on the same morning but a purported healthy guy needs a seven-day cooling period to get a treadmill. Where is the sense of proportionality here?

By the way, real doctors call a treadmill test, “A treadmill”, not electrocardiography stress testing, for crying out loud. And even if you do it call by that dreadfully long name, then do not call the workgroup “Treadmill Services Workgroup”. If you want to be annoying, please be consistently annoying.

This hobbit still doesn’t understand what is the fuss about ordering an un-indicated treadmill for a healthy person. What is the big downside? Did anyone get hurt? Yes, the doctor made an extra buck along the way. We may even discover the occasional asymptomatic IHD patient who claims to be very healthy and prevent a sudden death. So why this obsession to regulate a relatively cheap and safe investigation modality to oblivion? Don’t we have better things to do like examine why are people getting 8 to 10 stents inserted into their coronaries electively? Or look into why are people charging $10,000 or more for a colonoscopy? Or as this hobbit has said recently, regulate the Wild, Wild West that is managed care and all the kickbacks, fee-splitting and commission paying that is happening there rampantly?

But some folks just want to have their little private war and make the humble treadmill the Jose Mourinho of medicine. (The Special One). Can’t we just make it The Normal One (like Jurgen Klopp) instead?

Instead of doing real meaningful regulatory work, these geniuses want to stamp out unnecessary treadmills as if the treadmill posed a real great danger to our already battered healthcare system. It’s like trying to stamp out littering and jaywalking in war-torn Syria now. Seriously folks, if you have too much time, go to Watten Estate to swat mosquitoes.

So it is with great satisfaction that on 26 April 2016, an email was sent out to all licensees of clinics with an appended circular that the implementation of the Guidelines, originally slated for 1 May 2016, has been deferred till further notice. For the uninitiated, defer till further notice is the equivalent of  “a Prata” (Singlish).

But even here, the act of informing all licensees could be done far better. ALL the licensees’ email addresses are listed on the “cc:” section of the email in hyperlink mode. This is terrible email etiquette. The least the sender could have done is to put the licensees’ email addresses on the “bcc:” section so that the licensees’ email addresses are not exposed in a long list to everyone on the mailing list. I had to scroll down for what seemed an eternity just to get to the message proper and then open the appended files. Moreover, just because the government is not subject to the PDPA requirements does not give a civil servant the moral authority to share my email address with a few hundred other clinic licensees and vice-versa. What if the entire list of addresses was passed on to some pesky internet marketer or internet conman etc?

A wise wizard once told me that the most dangerous people to hang around are those that are diligently stupid. People who are lazily stupid actually do less harm. I guess this case qualifies….

Anyway, since this hobbit doesn’t offer treadmill services in his clinic, it’s really of little concern to me other than that his email address has been made known to a few hundred other clinic licensees. Time to go to Pek Kio hawker centre to get my prawn mee after the big clean-up so as to celebrate The End of The War on Treadmill (hopefully).


5 thoughts on “Bigger than War on Diabetes

  1. Among elves , men, wizards and hobbits, i think the hobbit is probably the most naive and choose to only dwell on his own likes and dislikes, rather than consider the big picture. A hobbit who goes for health screening would be very happy if his doctor offers to throw in a treadmill for him at marginal cost . Perhaps when the test suggests that he would need to undergo further coronary angiography he will also gladly take it up without question and pay a bit more money to enjoy the whole process, because he thinks he is well taken care of. Perhaps the hobbit would be happiest when his doctor then inserts a stent into his otherwise normal coronary artery but tells him that it would help protect him from future coronary event for a further fee. Maybe the hobbit is irch from selling vegetables grown in his garden so he does not mind paying the doctor for doing so much for him, or maybe he, like all hobbits do, is just out to please his doctor and help him earn a few more bucks. Makes sense to you? Not to me though cos i am a Man, not a hobbit. And i hope the hobbit’s doctor is also a hobbit serving only hobbits, cos i seriously do not wish to have such a hobbit doctor serving Men.


    1. I wonder if you are a doctor or a healthcare worker. Perhaps you are not. But if you are a healthcare worker, you will know that medicine is fraught with uncertainty. Especially in the area of heart diseases and especially heart attacks. Doctors and nurses have all seen people die unexpectedly from heart attacks and treadmills are a good and cheap screening test to find out if a patient has such problems before the unthinkable happens.

      The point you are making is that there are a lot of unnecessary elective (non-emergency) angiograms and stents going on, which is the point I am making too. The point of regulation is to know what and when to regulate given that you have limited resources – therefore it is far better to audit treadmills that lead to angiograms and then follow through to see how many angiograms and stents are unnecessary, not prevent “unnecessary” treadmills. Treadmills are relatively cheap and safe, vs angiograms and stents. Instead of regulating angiograms and stents strictly, we regulate treadmills, which doesnt make sense.

      With limited resources, you should regulate expensive and high-risk procedures, not the cheap and safe ones. Obviously, the latest MOH circular recognises this point as well which is why the implementation of the guidelines has been deferred till further notice – This is the big picture.

      Yes, I am naive. That’s why I am writing after all these years.


  2. I am not a doctor nor a healthcare worker. Just a housewife.
    I have to agree with the Hobbit. Why regulate same relatively cheap procedures that can actually save lives? I had a friend who worked with a healthcare company. He was asked to try out their new treadmill machine then. His colleagues were shocked at the results.. he went on to receive a triple bypass. He was one of those who will die from silent heart attacks without prior symptoms. There are many cases like that. I know 2 others who were symptom-free but detected by the treadmill and saved from heart attacks/death.

    But yes, MOH, what really needs regulation are the Drs who order angiograms and angioplasty unnecessarily – where the real cost and ethical concerns are.

    Targeting treadmills is easy. But where is the impact you want? It is akin to regulating/limiting x-ray usage instead of PET/Gamma where the big costs concerns are.


    1. I come from the corporate sector and have seen many clinics advertising screening packages containing treadmill. Price can go up to more than a thousand dollars. Is that necessary? Just thinking that while you are right that there is a greater need to regulate more expensive services, as a consumer I would think very hard if a doctor wants to do some big expensive procedure on me, but I might just go along with a treadmill without much thought and if I am kiasu a bit. Question is are doctors allowed to just sell any tests without considering whether a patient needs it or not? Aren’t there supposed to be some guidelines for doctors on what kind of tests should or should not be done, at least for normal people doing health screening? Is treadmill really harmless and in fact useful for everyone, which seems to be what you are suggesting?


      1. A treadmill should not cost $1000 or more. Maybe 200 to 400. A doctor should not “sell” any tests. But I would think that any person above 40 should be able to get a treadmill. A treadmill is usually quite harmless. Of course, he get may experience chest pain or even heart attack while doing a treadmill. The doctor should be able to handle that in a properly equipped clinic. Better for that to happen in a clinic than in some other place


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