The Reopening

Give yourselves a clap. We have successfully emerged from a tight CB period. In case you have forgotten, it was the Prime Minister no less who announced the “tighter CB period” on 21 April 2020 which would last until 1 June 2020 (inclusive).

The gov.sg website actually stated,

“PM Lee on 21 April 2020 announced tighter measures to the Circuit Breaker period, to further reduce the transmission of COVID-19. He also announced that the Circuit Breaker period will be extended by another 4 weeks until 1 June 2020 (inclusive)”.

This hobbit was thinking to himself on 21 Apr 20, “Wah. I thought the CB already very tight. Now even tighter and must be inclusive too”.

You really have to give it to those wordsmiths in the civil service and political leadership.

Anyway, we are now in Phase 1 of “The Reopening”. That’s when you realise nothing much more has reopened. Except the schools, car and air-con servicing, hairdressers and basic pet grooming. Interestingly, animal rehab and physio are allowed too.

That brings us to our pet peeve today (pun intended). What is allowed and what is not allowed in The Reopening: Phase 1. In medical school, when we construct a research study design and draw conclusions, we are told to make reality checks. These are called internal validity and external validity checks. Internal validity checks are checks that ensure the conclusions from the study drawn make sense within the aims and methodology of the study while external validity involves comparing study conclusions with what was already known in the external environment to also see if the conclusions make sense.

Policy-making is no different. There should be internal and external validity checks. Now let’s come to the subject of aesthetic medicine. These are largely banned. Aesthetic doctors are only allowed to treat organic diseases like acne and eczema. I suppose there is some internal validity when you compare aesthetic practices to what is allowed in the practice of Western Medicine. But when you think of what is allowed in other areas, then you will probably wonder where is the external validity?

Is aesthetic medicine less essential or more dangerous than basic pet grooming? Or complementary medicine such as TCM, Ayurvedic practice or chiropractic and osteopathy? Can we allow “basic” aesthetic medicine without allowing invasive or aerosol-generating aesthetic practices? So many questions arise when you look at the aesthetic medicine issue from an external validity angle.

To top it off, even HDB may be into the act of regulating aesthetic medicine. Apparently, a GP was told by a HDB officer that he had to close his HDB shop-lot clinic because it was named “XYZ Aesthetic Clinic” when all he was doing was just opening it to see common GP ailments and treat severe acne.

(For the avoidance of doubt, this hobbit has no pecuniary or physical interest in aesthetic medicine. He is an ugly, old coot who doesn’t practise the stuff and he hasn’t received any form of aesthetic treatment).

A whole-of-government to fighting the Covid-19 pandemic is largely a good thing. Because no single ministry has enough resources to do this alone. But from observation, this hobbit suspects that one of the problems of a whole-of-government approach could be what the age-old adage says, “When everyone is in charge, then no one is in charge”. The other problem with this approach is that when everyone in authority can make rules, then they indeed do, but no one is looking over their shoulder and having a helicopter view of what each and every department is doing. The result is that people on the ground are saddled, if not crushed by a mountain of regulations and requirements issued by a myriad of agencies.

An example is the construction industry. The BCA announced that construction workers in dorms can begin work again once they are tested. But I guess they didn’t check with MOH when they said this. Because none of the folks out there who provide testing, i.e. the polyclinics, PHPC clinics, hospitals, are allowed to offer Covid-19 testing to anyone unless there are clinical and/or epidemiological indications. I wish I could, but I cannot offer a swab to a billionaire even if he paid me $100,000 for a swab, unless he possessed some indication for swabbing. The same applies for construction workers. So many of us were swarmed with requests by construction industry bosses, supervisors last week in the first few days following end of CB for their workers in dormitories to be swabbed. All this angst, frustration and disappointment could have been simply avoided by coordination between MOH, BCA and MOM. They could have issued a joint statement in the last week of May that goes like “All construction workers would be allowed to start work again after CB if they are tested. However, please note that construction workers will be notified through their employers or dormitories by MOM/BCA/MOH as to where and when they should go for testing. In the meantime, please be patient”.

The same considerations apply to the Malaysian workers who are stranded here. The Malaysian government has said these returning Malaysians may avoid quarantine if they are tested negative for Covid-19 in Singapore. But again, there is no testing available here. Meanwhile some of them have had their pay cut or even retrenched. This has been reported in the mainstream media and this hobbit won’t elaborate here. But the point is, there have been many such requests and the PHPC GPs have to be the bearer of bad news to these stressed-out folks.

Instead, the various agencies had to run around and do service recovery. The 2nd Minister for National Development had to announce in Parliament on 5 June that BCA would be the one-stop agency for these workers and their employers to go to with their concerns and queries. He said “BCA will be the point-agency in Government or the one-stop shopfront for all matters regarding construction restart”. This could and should have been said before 1 June, before the end of CB, so as to avoid the chaos that ensued from 2 to 5 June. And of course front-line GPs and PHPC doctors had to manage the demand for testing when there was effectively zero supply at the frontline. As if though we don’t have enough problems of our own, huh?

Yet another example is the announcement of swab stations in the community, e.g. One Farrer Hotel about a week ago. Again, there was a small rush by some folks to be swabbed there when these places are meant only for people who need to be re-swabbed. Again, people at the frontline had to face irate members of the public.

The message is not getting through. In other words, the people must be told they will not be tested unless they meet specific MOH criteria, e.g. they are sick. Please do not just say we are ramping up testing capacity to many thousands a day. That is only one side of the story. There are ministerial speeches going on now every few days. Can one of the ministers say this out loud and clear that there is NO testing for the public unless they meet MOH criteria? Because there is great demand for testing from the public which healthcare providers cannot meet because of regulatory prohibition. We have to give the good news and the bad news to the public and manage expectations on this subject of testing. It will save the public and us healthcare workers a lot of grief. Thank you very much.

Even in MOH itself, it appears no one is taking a look at regulation from the end-user’s perspective. Today, if a 75-year-old patient comes into my PHPC clinic for flu, do you know how many forms I have to fill? I have to

  • Fill up the Flu Subsidy Scheme (FSS)  once a day for the clinic for all FSS patients, which in itself is a lot of work.
  • Fill up a swab form if I performed a swab or fill up the Swab Referral Form which is two pages-long per patient if I refer the patient elsewhere.
  • Fill up the Patient Risk Profile (PRP) form through the Patient Risk Profile Portal. Many of the fields in this PRP are already filled in the daily FSS submissions. It will save everyone a lot of work if MOH can merge the databases of FSS and PRP.

On top of filling up forms and making submissions up to my goggle-encased eyeballs, I have to remember a phalanx of policies like

  • What drugs are reimbursable under the FSS
  • Suspect Case definitions
  • Who to send for enhanced Swab and Send Home (SASH)
  • Advise irritated patients who are given 5-day MCs that the MC is essentially a 5-day Stay at Home Notice (SHN).
  • Social or physical distancing in my clinic

Another side but important point about enhanced SASH is that certain patients “should” go for swab if they qualify under certain conditions. But the key word is “should”. “Should” is not a “must” and many patients have refused to go for swabbing. What does a GP do? The PRP form does NOT have an option for this. No one seems to know the answer.

I suspect all these different requirements and regulations are issued independently by different departments within MOH and no one is putting themselves in the GP’s shoes and realising how collectively these demands will drive private sector doctors and their clinic support staff nuts.

I know if I take your money for FSS I must suck thumb and take all this. But can you just cut me a little slack?

There is a lot of fine-tuning of language in policies and circulars that frankly, the busy and tired doctor find difficulty in grasping. Put it simply, enhanced SASH should be mandatory and not a “should”. This pussyfooting is doing no one any good. Most doctors at first instance understood it to be mandatory anyway. It was only on second or third reading that they realised enhanced SASH was not a “must” but a “good to have”. There are no penalties for refusing enhanced SASH. Such nuancing creates difficulties on the ground. By now, doctors are so tired, we are long past the stage where we can perceive and appreciate linguistic finesse.

Another example is in the language used in some circulars. If we doctors were so good with language we would have become lawyers. In a MOH circular dated 19 May, it is stated in para. 3, “MOH proposed 2 phases for the resumption of more of the healthcare services”. In para 10 of the same circular, it stated “This circular is for your compliance”.

I don’t get it. If MOH “proposes” then maybe it is something that can be discussed? But if it is “for your compliance”, then there should be no discussion; we just get on with it. It’s like Mr Tan Ah Kow proposes to Ms Ong Ah Choo, but Ong Ah Choo must marry Tan Ah Kow.

This hobbit is stunned like vegetable.

Finally, as this pandemic wears on, the authorities must explain why certain policies are necessary and how they are effected in a fair and transparent way. For example, till today, people do not understand how the number of essential workers are arrived at in clinics. People also do not understand why aesthetic medicine is less essential than pet grooming, rehab and physio. People who do not understand why unlicensed and largely unregulated treatments like osteopathy and chiropractic have higher priority than certain treatments and interventions offered by doctors (and dentists too, I guess).

Sometimes things are so complicated that maybe even public institutions cannot keep up. According to a GP friend, he referred a 13-year old patient with ARI to be swabbed at the polyclinic. The parent reluctantly did bring the teenager there, only to be told they won’t perform a swab on the student. Another GP referred another teenager to polyclinic for a swab. She was accompanied by the grandparent. The polyclinic staff said the teenager must show her birth certificate as documentary proof. A student pass is not good enough. The clinic staff actually called up the polyclinic to double-check and confirmed that a birth certificate was necessary. Imagine what these GPs had to endure from the patients and their parent/grandparents consequently. With polyclinics like these, who needs pandemic-causing viruses?

In summary, this hobbit sees three areas that need to be dealt with:

Regulatory Fragmentation – e.g. the construction industry is pulled apart by different regulatory requirements by BCA, MOM and MOH; clinics regulated by MOH and MTI; polyclinics making up their own rules.

Regulatory Redundancy and Overlap – e.g. many forms and submissions for one single patient for one diagnosis, e.g. PRP form, FSS submission, SASH form

Regulatory Opacity – who decides and what is the criteria for decisions? Any external validity checks across ministries and agencies?

The sum of all these problem areas is

  • Confusion and bewilderment (directives and policies should be short, simple and clear. Avoid “coulds” and “shoulds” if possible; what do you do with a patient who declines enhanced SASH?)
  • Extra and unnecessary work is created (multiple form filling)
  • GPs and frontline healthcare workers are made to bear bad news (“I can’t test you”…..I have to give you 5-day MC…..)
  • The public and certain industry stakeholders aren’t happy
  • The doctors and their support staff aren’t happy

We all know we need to make sacrifices and endure pain in this pandemic. But let’s not make it more painful than what is absolutely necessary.

8 thoughts on “The Reopening

  1. 1) How many aesthetics procedures or consultations allow the patient to wear a mask throughout the procedure, and how many hairdressing/Chiro/osteopathic/PT/pet grooming/you get the idea treatments require the patient to NOT wear mask throughout? This should be intuitively obvious why aesthetics is high risk.

    2) PRP is not compulsory. My group is not using it yet.

    3) kids under 17years old for SASH MUST go to KK or NUH ED. This is made abundantly clear in the MOH circular. Polyclinic will not do it. SASH clinic has discretionary power if they feel confident to do it.

    4) pet grooming is not a beautification process only. It includes hair cutting and nail cutting. In case you don’t know, certain breeds can die of heat exhaustion if their coats are not cut at regular intervals. The natural shedding rate is not enough to overcome this in Singapore. Same for nail cutting. Sometimes you actually have to sedate the animal to cut properly and not all owners are competent in doing it. I personally have to bring to vet every 3 month just for nail cutting even though I’m tempted to just Piriton my dog.

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    • PRP will be compulsory from 15 June yes? In any case what is the point of having a form if the advocated position is NOT to fill it, which is what you are saying?

      Dogs have been around before humans. They weren’t groomed then. So it is very difficult to justify that the dog’s grooming needs outrank a human’s.

      Not ALL aesthetics are high risk. Those that aren’t should be allowed instead of a blanket ban

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    • Dear Derek

      On the point that you should only refer to KKH or NUH is patient is 17, that is only partially correct or partially wrong. The 17 cut off point applies if you assess him to require admission. If you dont think he requires admission, but still needs a swab according to MOH case definitions then the cut off page is 12. Above 12 can refer to PHPC and polyclinic.

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      • I agree the aesthetics part was handled badly. They should not have made special concessions for pigmentation and acne, but rather any condition where the patient can wear mask through should be allowed.

        Yes you are correct on the stable SASH for 12yo cut off.

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  2. Hi sir, i chanced upon your blog and i must say its really a delight to read! I would like to ask if there had been mature students that are accepted in residency (ie held jobs and went back to med school in 30s) and what are the issues in doing so(during post med school years in job application and ability to work with the team)? Thank you so much!

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  3. hello sir, I chanced upon your blog and its really insightful(alongside humorous) on the whole medical views and journey. Could I ask if you have worked with any older residents during your residency period? I am asking in context to people who have worked many years and decided to go back to med school. Was it significantly harder for them to obtain residency jobs and hard for them to assimilate into the healthcare team setting in hospitals? Thank you very much for taking time to answer this!

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    • Hi. I am so old there wasnt such a thing called residency. U didnt need any formal training to be a GP after graduation. But if you want to do medicine as an older person just remember medical training can be physically demanding. Some specialties are less so. Like radiology, public health, pathology..

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