Scattered Thoughts of July

July has been a very rough month for Singapore. No. We are not talking about DBS, Stanchart or UBS being inadvertently involved in suspected money-laundering activities. We are not even talking about the multiple murders that took place. We are talking about the fury over the first Singapore Edition of the Michelin Guide. Imagine a bak chor mee stall getting one star. Seriously folks, we should get Eric Khoo to do a sequel to his 1995 hit with “Mee Pok Man 2” – with a Michelin/healthcare twist. It can feature a legendary obsessive-compulsive mee pok man who goes into depression and ends up in IMH after he overcooks his mee pok for the Michelin inspectors (How hard is it to spot a few angmohs eating meepok at a hawker centre??).

Speaking of stars, this hobbit understands that Managed Care (MC) and Third Party Administrators (TPA) have also started to rate or rank doctors. Nothing wrong with that in-principle. Not all doctors are equal. But ranking should be based on facts and objective measures.

For example, recently, certain doctors were preferred by a certain MC company because these doctors were purported to be experienced with good clinical outcomes and their clinics were equipped with good clinical facilities. Maybe this is true. Maybe this is not. On what basis are these doctors deemed to be experienced or well-equipped? Isn’t this kind of laudatory? And while it is not self-laudatory ostensibly, by allowing such practices to continue in the MC and TPA industry, aren’t we allowing the SMC Ethical Code to be circumvented and hence making the Code nugatory?

Is anyone in power doing anything about this? Probably not. Because the market has frequently triumphed over ethics for healthcare in this country, this Hobbit is not hopeful.

Speaking of rankings and lists, here’s another one. A website which describes itself as “an Ego-Stroking Men’s Lifestyle Portal focusing on empowering Men with the latest updates and news relating to Fashion, Business, Health & Grooming, Lifestyle, Technology and Current Affairs” has just published a list of “Ten GoodLooking Doctors in Singapore”. The list includes both male and female doctors. It’s really quite hilarious and if I were on the list, I would have volunteered to be quartered slowly by a bunch of trolls riding on giant worms. Just in case you are wondering, “good looking” is also laudatory but this Hobbit will let this pass. We live in an increasingly miserable world and everyone needs some comic relief.

We move on to something that is more that affects everyone in the medical profession. This is really important, unlike most of the stuff that goes on in this column. In last month’s column, the Hobbit speculated that the Court of Three Judges overturned the SMC Disciplinary Tribunal’s (DT) judgment on the case of the orthopaedic surgeon giving only two days MC to a foreign worker after fixing his fractured wrist was maybe because the DT had erroneously concluded that it had to find intent on the surgeon’s part before it could find him guilty.

Guess what? This hobbit’s speculation was largely correct. (gloating like Smaug this hobbit is….) No, this hobbit is definitely not legally trained. SMC cases and ethics is still about a lot of common sense and listening to how your conscience speaks and not so much “legalese”, unlike what some what the previous bigshots said in the Ivory Building (note: not Tower) on College Road.

But there is a very important development in this case that EVERY doctor must know. And this is the point regarding how the Three Judges gave a suspension of six months while the SMC lawyers only asked for four. This is quite unprecedented.

The ground for decision for the abovementioned case have just been released and on page 48, under the section “Recalibration in Sentencing Benchmarks”, the learned judges felt the need to deviate from sentencing precedents and give harsher punishments because current conditions are different and warrant more severe punishments. It said that there were several SMC cases where sentencing was inadequate in the past.

This is so important that the relevant paragraph (para. 117) is reproduced here:

“As can be seen from Lee Kim Kwong and Kwan Kah Yee, we have on at least one previous occasion referred to and, on another, exercised our discretion to depart from precedents that do not reflect the prevailing circumstances and state of medical practice. In our judgment, public interest considerations weigh heavily in imposing deterrent sentences on errant doctors who are found guilty of professional misconduct. In this regard, we expressed at the hearing that we found the sentences imposed in the Dr K case, Dr L case and Dr Amaldoss case (“the Relevant Precedents”) to be lenient. We observed without reservation that these sentences should have in fact been longer. We highlighted to the parties that this court has given fair notice of its intention to recalibrate sentences across professional misconduct cases, and would do so in the present case.”

Doctors have to know that the final powers of interpreting legislation passed by Parliament lie in the Courts, and not SMC or even MOH. In this case, the relevant legislation is the Medical Registration Act (MRA) which provides for the existence of SMC and empowers the SMC to punish doctors. While the courts cannot give out punishment that is more severe than what the legislation specifically allows for, it certainly can decide on how severe the punishment should be as long as the punishment is within the limits provided for by the relevant legislation.

So here, the “this court” has, in the name of public interest, interpreted the relevant part of the MRA and within its powers, decided that the surgeon deserves six months of suspension instead of the four asked for by SMC. More importantly, this is not a once-off decision as “this court has given fair notice of its intention to recalibrate sentences across professional misconduct cases….”. “This court” which consists of the Chief Justice and two Judges of Appeal, is for all intents and purposes, the highest court in the land with regard to SMC appeal cases. There is no higher court. Repeat: this is a new development that is not once-off.

All doctors are hereby warned.

You know, just when you thought things are getting so depressing here, it can’t get any worse? Well, it sure can.

Recently, this Hobbit heard of a resident who on realising there is no specialist job available for him upon completion of residency, quit residency with less than a year left to go. He has since joined a bank, I am told. The lack of jobs upon completing residency is now commonplace.

The sort of long-term Confucian relationship between a department and their residents and between the boss and his juniors is now truly gone. Gone by shortsightedness and a utilitarian approach to manpower planning. And it’s about to get worse down the line with the large number of undergraduates we are producing locally and those returning from abroad after getting their MBBS. For those of us not in the know, the three medical schools are now taking in more than 500 students a year. Where are they going to find training and long term jobs beyond their bond period nobody knows.

The public healthcare system thinks it needs a lot of junior medical staff to run the public healthcare system. (undoubtedly exacerbated by the low-efficiency residency system), but it doesn’t know what to do with all these junior doctors beyond the first few years. We need to change direction soon but everyone is mired in policy inertia, much like how our population policy was still stuck in the “Stop At Two” phase when our birth rates had long declined to justify such an anachronistic position.

The legal profession is more responsive and cleverer than us. They clamped down on the list of overseas law schools recognised locally recently as soon as they realised that a glut looked imminent. As for the medical profession, we now have residents with no jobs after finishing residency but nobody is clamping down on nothing.

Maybe in the years to come, we will have another one-star Mee Pok Man; one with MBBS, MRCS. His surgical training is probably more relevant to cooking than to being a banker.

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