Part 2: The “Perfect” Communicable Disease Outbreak

The first case of Covid-19 infection in Singapore was announced on 23 Jan 2020. We are now into the 4th week of the outbreak in Singapore.

The situation in China appears mixed. The number of new infections each day seemed to have peaked. But apparently those happier numbers were due to under-diagnosis. Yesterday the numbers hit the roof with another 15000 new infections and 254 deaths in China in one day. There are now almost 64,000 cases and 1400 deaths in China. The number cases in Hubei province, including Wuhan, continues to outnumber those in the rest of China by about 4:1. This implies that there is still rapid transmission of cases both within and without Hubei. You know the battle is far from won in China when they have just removed the bosses of Hubei Province and Wuhan City (their party secretaries).

We Haven’t Seen The Fat Lady Yet

The current state of affairs in China is such that we really do not know if the worst is over. But there are some folks out there who repeatedly lobby for a softer stance in the fight against Covid-19. They say this is no more harmful than the common flu, which kills a lot more people every year than any coronavirus outbreak.

This hobbit would like to be a bit more cautious. For one, while we know it’s less deadly than SARS or MERS, we just do not know how less deadly it is. Statistics so far suggests so. Outside of Hubei province, the Case Fatality (CF) Rate is below 0.5%. While for Hubei it’s about 3%.

Why is the CF Rate for Hubei (and it’s provincial capital of Wuhan) so much higher? Many theories have been proffered. For one, being the place of origin of where Covid-19 started, the outbreak went undetected for 2 to 3 cycles longer than other cities, which had heightened awareness and sensitivity to the novel disease. By the time the disease reached other Chinese cities, it had already taken root in Wuhan and its surrounding cities. So the number of infections there are much larger.

But this does not alone explain the higher CF Rate. It could be that hospitals there are overwhelmed and the hospital themselves have become great incubators and reservoirs of the virus. They are so because therein lies a great number of sick people with many comorbidities and their chances of dying are much higher than the average person in the street. This is not much different from SARS where hospitals and hospital staff and patients had a much higher chance of being afflicted with the disease.

This is this hobbit’s theory of why the CF Rate in Hubei is much higher than other parts of China. And therefore, it is vital that we do not let our hospitals get hit by Covid-19. But it is only a theory. The truth is, we really don’t know for sure why Hubei is doing so badly in terms of the CF Rate.

The other two important factors are that we do not have drugs that can definitively treat the disease (like Tamiflu for influenza) and a vaccine.

And so, until we know for sure why Hubei is different from the rest, or that we have a drug for definitive treatment or a vaccine, it is best we don’t throw in the towel by treating Covid-19 like the influenza virus.

And besides, it is early days yet. SARS infected 238 persons in Singapore and killed 33. We have about 67 cases and no fatalities for Covid-19. It is too early to give up the fight.

Another factor to be considered is that China is now returning to work after the Chinese New Year extended holidays. Will that lead to another round of infections as hundreds of millions of people go on the road again from their hometowns to their place of work? Only time will tell. It is true that we have effectively closed off China as a new source of infections since everyone that comes to Singapore from China must be given leave of absence for 14 days. But one can still get infected in other countries before coming to Singapore – an imported case, but not from China, so to speak.

So as the saying goes, “It ain’t over till the fat lady sings”. No one is quite sure if they have seen the fat lady yet…..let alone see her sing.

And so, that means we, the ground troops, must slog and plod on in our clinics and hospitals.

Logistic Fog of War

After three weeks, things are really getting a little edgy on the ground in the private sector, to put it mildly. If you are the grunt troops fighting in the trenches, after three weeks, you are going to be in pretty low morale if you have had only 5 warm meals and 3 changes of underwear and socks and you are down to your last 2 magazines of rounds. You are sick of eating combat rations, you have bad body odour and you are starting to get foot rot.

We have learnt from SARS that when we fight a communicable disease outbreak, we are really fighting on at least three fronts: medical, logistic and psychological.

For the front line troops in the private clinics and hospitals, we are failing quite badly on the logistic front, I am afraid. That is, until the Health Minister announced he was giving 1M masks to the private sector doctors 2 days ago. This hobbit reckons these 1M masks will last the private sector for about 3 to 4 weeks.

Simply put, private sector doctors have no visibility, let alone clarity or assurance, of the government’s resupply plans for them. How much of the National Stockpile of PPEs is meant for the private sector? Nobody knows and all of us in the private sector are fighting Covid-19 while blinded by this fog of war on the logistic side.

Let’s Do The Maths

Let’s take a recap. Up till now, assuming you have been on the ball as a GP securing your masks, here is what you would have gotten from “official channels”:

  • From SMA (they obtain their stocks from government): 3 boxes of N95 and 1 box of surgical masks.
  • From Zuellig Pharma (The government authorised dealer): 1 box of N95 and 2 boxes of surgical if you are a GP, 1 box of N95 and 1 box of surgical if you are a specialist

Which means the MAXIMUM amount of masks you could have gotten so far are 4 boxes (80 pcs) of N95 and 3 boxes (150pcs) of surgical masks after three weeks in the trenches.

Zuelling is selling another round of masks now, also along the same lines as the previous round. Assuming you are lucky and get what you want, you would have accumulated a total of 5 boxes of N95 (100pcs) and 5 surgical masks of N95s (250pcs) if you are a GP. And if you are a specialist, it’s a maximum of 100pcs of N95 and 150pcs of surgical masks after 20+days at the front lines.

Most folks out there do not achieve this maximum allocation of masks. And we haven’t even started talking about isolation gowns.

Strangely speaking, or maybe my memory is failing me in my old age, I can’t seem to recall we were so short of PPEs during SARS, other than for N95s. Certainly, we weren’t so short of surgical masks then.

A typical GP clinic will have 3 to 4 working persons, including the doctor. Assuming each mask lasts 6 hours, you will use up 2 masks a person or about 6 to 8 surgical masks a day. You are also required to put a mask on a person with fever or respiratory symptoms as per MOH requirements. That would easily take up 10 to 15 surgical masks. In other words, a small solo GP clinic working 3 shifts easily consumes 20 to 25 surgical masks in a day if not more. Now that we are in Dorscon Orange, a solo GP practice would use up to 4 N95s a day in addition to the surgical mask utilisation (One N95 for GP and one for triage nurse per shift, assuming 2 to 3 shifts a day, so 2×2 = 4 N95s a day. If you go for extended (stingy) use, then maybe 2N95s a day).

Assuming the GP works 6 days a week, the clinic will consume 120 to 150 surgical masks a week and another 12 to 24 N95s a week

But as the records show, in the last 3 weeks, we could only have received 80 pcs of N95s and 150 pcs of surgical masks with hopefully another 20 N95s and 100 pcs of surgical masks on the way from Zuellig. This is simply not enough to keep the GP and his clinic going.

It is understandable that we teach the public to limit the use of PPEs and to concentrate on efforts to improve hand and personal hygiene as well as to limit large group interaction. But it is another thing altogether when we try to squeeze the PPE supply to the private healthcare establishments and their staff, when they have to face people who are sick, i.e. a high risk segment of the population.

We Need An Integrated Approach to Making PPE-Related Policies

There is a fine line between conserving PPEs and keeping morale up, i.e. winning the psychological war. Ultimately when everyone does not know when the next batch of masks will come, morale will suffer. Just like troop morale will drop when they don’t know if they will be resupplied with food, water, clothing and ammunition. Everyone is thinking of getting or have been getting their masks from private suppliers. And prices are going up. A box of surgical masks (50pcs) have gone up from $3.50 to $4 before the outbreak to around $25! That is, if you can find them in the first place.

The truth is that PPE consumption rate is influenced by a few factors:

  1. The epidemiological features of the disease
  2. Dorscon status
  3. Case definitions of the disease
  4. PPE usage policy

We can’t do much about the natural epidemiological features of Covid-19. It is what it is. But case definitions are largely man-made. If your case definitions are too broad and too many persons fall under the suspect category, then the use of PPEs will shoot up. Likewise for Dorscon status. PPE usage policy also heavily influences usage, although admittedly this is also in turn determined by the epidemiological features of the disease. But whatever the case, the resupply operations must support what the case definitions and mask usage policies demand.

To the uninformed, it would appear that the 4 policies are governed by different groups of people working independently of each other. The resupply practices of 20 pcs of N95 and 100 pcs of surgical masks a week is not keeping up with the demands of the case definitions or the Dorscon status. It looks like the resupply guy is still in Dorscon Yellow while his colleagues in the other departments or ministries have moved on to Orange.

Talk about frustration.

What this Hobbit would like to see is that the authorities commit to a certain rate of resupply for GP and private sector community specialist clinics. E.g. 1 box of 20 N95s every two weeks, 3 boxes or 150pcs of surgical masks a week and 10 isolation gowns a week and maybe 2 bottles of sanitizers/hand rub. Then all of us doctors can concentrate on picking up new Covid-19 cases and treating other patients instead of constantly worrying about where their PPEs will come from. We will pay for the PPEs too, we don’t need freebies. And of course, community clinics with more than one doctor should appropriately receive more PPEs than the solo GP.

Public Health Preparedness Clinic (PHPC)

That brings us to what is listed as a MOH National Scheme called the Public Health Preparedness Clinic (PHPC). This Scheme “consolidates the primary care clinic response to public health emergencies such as influenza pandemic, haze and anthrax outbreak into a single scheme for better management”. (www.primarycarepages.sg/practice-management/moh-national-schemes/public-health-preparedness-clinic-(phpc)

For volunteering to be on this wonderful Scheme, MOH is supposed to provide you with “up to 12 weeks’ supply of PPE for staff at no cost”. This sounds great right now because I know some GPs who will pawn their grandmothers for 12 weeks of free PPEs.

But, according to a circular issued on 11 Feb 2020 by MOH, this Scheme hadn’t been activated yet. Therefore, no one has received any PPE free of charge under this Scheme either. Today it has been finally activated. Maybe it’s about tough love on Valentine’s Day.

Frankly, this hobbit cannot understand why the Covid-19 wasn’t considered a public health emergency until today. The Scheme was increasingly looking like a joke until a powerful necromancer decided to breathe some life into this cadaver of a national scheme today.

Come Down Hard On False Declarations

Doctors and other healthcare workers need to be protected with PPEs. But they also need to be protected against reckless and selfish people who put others, especially healthcare workers (HCWs) and healthcare establishments, at risk. Several people have already been punished for breaking quarantine. But this hobbit thinks there are far more people who give false declarations about the travel and contact history. I think practically all doctors out there know other doctors who have had seen irresponsible people after they had made false declarations, even if they had not met one themselves.

The authorities should protect the public and HCWs by taking these false declarers to task, and charge them under certain provisions of the Infectious Diseases Act. This would send a clear signal that false declarations will not be tolerated, and not just those that illegally break quarantine orders.

The New Battlefront: Private Hospitals

This Hobbit opined in Part 1 that Generals fail when they fight the last war. Generals often assume the new enemy is like the last enemy and they will win against this new kid on the block by bashing him/it the same way as they bashed the previous kid on the block. And they are often proven wrong when they do so.

The recent spate of cases whereby patients and staff have been exposed to confirmed cases underline this point. During SARS, the private hospitals were spared and the restructured hospitals bore the brunt of outbreak. This time is different. The first two hospitals to have unprotected staff exposed to confirmed patients were private hospitals. The first healthcare worker who contracted Covid- 19 was a private sector anaesthetist who was rumoured to have seen patients in more than one private hospital.

It is clear that the private hospitals are at as much risk as restructured hospitals for Covid-19. Some of these hospitals are running very short on PPEs. But this hobbit was told they are expected to source for them on their own. The Singaporean equivalent of the biblical Joseph guarding our National Stockpile should quickly beef up the dwindling stocks in the private hospitals. MOH should also ensure that private hospitals have the same standards of disease control as restructured ones, especially in terms of PPE usage, triage and limitation of doctor movement.

When stocks are running low, private hospitals and clinics have no choice but to make compromises on PPE usage, leading to suboptimal infection control. And we are only as strong as the weakest link, as the saying goes.

Research

Singapore has the most cases of Covid-19 after China. (Other than the cruise liner docked off Japan). It is interesting that Chinese, HK, USA, Germany have all published research papers in reputed research journals and Singapore hasn’t. That’s a shame, given our reputation as a medical hub with top-notch researchers and clinician scientists. What’s happening?

And so…..

Again, as this hobbit has said in Part 1, there will be many twists and turns to this blockbuster saga sequel to SARS. And we are now beginning to see some of these twists and turns.

As Winston Churchill said long ago while fighting another war, “Now this is not the end. It is not even the beginning of the end. But it is perhaps, the end of the beginning”.

Where the 2019-nCoV outbreak is heading….

The situation in China is getting grimmer by the day. Yesterday, some 2900+ new cases of 2019-nCoV infections were reported. With the total number of infected exceeding 17000, this ugly new virus has blew away SARS in this aspect. A record number of people (57) died yesterday, pushing the total number of deaths due to the disease to 361. More lives have been lost in China to 2019-nCoV than SARS. These are breath-taking numbers

Hence, hearing then Health Minister speak in Parliament today was reassuring. The Ministry is certainly working their butts off to try and prevent local transmission of the 2019-nCoV. It is also working out scenarios on how to manage the situation should the virus be found to be transmitting locally.

This novel 2019-nCoV is one mean SOB, you have to admit. It’s as mean if not meaner that SARS in at least 3 ways.

For one, it has been now established that a patient is infectious even during the incubation period. This was published in as a correspondence to the NEJM by German doctors a few days ago.

Secondly, about 80% of patients exhibit easily detectable symptoms or signs such as fever or cough. That means even with temperature screening, 1 in 5 patients may escape detection. This was published in The Lancet a few days ago too.

Thirdly, Chinese health officials suggest that a person may get re-infected with the virus. In other words, one is not off the hook as immunity may be fleeting. If that is the case, it would also suggest it may very difficult to develop an effective vaccine that confers lasting immunity.

Singapore has been gearing up to meet the threat of 2019-nCoV. It certainly warmed the heart of this hobbit to see our NSF boys packing surgical masks for distribution to every household in Singapore.

Since we are on the issue of masks. This hobbit would like to say a few words about our mask policy. The official message is, unless you are dealing with potential high risk patients, such as potential suspect patients, one doesn’t have to wear a mask.

But on the ground and when policies are actually rolled out, there is wide variation in interpretation. This can be observed on the 1 Feb 2020 print copy of The Straits Times. On one page was an article describing how during the ruling party PAP’s Meet-The-People Sessions (MPS), temperature screening is now being carried out. The same article also said that MPs and party activists should not be wearing masks (in line with the prevailing instructions of government then).

Several pages later, under reporting coverage for the recently held Chingay Festival, there was a large photograph showing masked-up temperature screeners checking on Chingay Festival attendees. I think the Chingay Festival is an event sanctioned by the government.

Personally for me, I think the logical thing to do in a gathering of normal-risk people, is NOT to conduct temperature screening and NOT to wear a mask, if we truly believe there is no local transmission of the disease. We should conduct temperature screening when there is a gathering of higher-risk persons, such as patients seeking care (and accompanying persons) in hospitals or clinics. In which case, temperature screeners should wear a surgical mask because they need to be protected in case a suspect case of 2019-nCoV turns up. Therefore, to forbid a screener from wearing a mask suggests that there is practically no chance of the screener meeting a suspect case, in which case, then why screen at all? Does this make sense? In other words, do not screen for fever at all. But if you do decide to conduct temperature screening, please let the screener wear a mask.

Another interesting feature is the definition of a suspect case. The current MOH definition of a suspect case of the 2019-nCoV infection (unchanged since 25 January) is:

a) A person with clinical signs and symptoms suggestive of pneumonia or severe respiratory infection with breathlessness AND travel to mainland China within 14 days before onset of illness; OR

b) A person with an acute respiratory illness of any degree of severity who, within 14 days before onset of illness had:

  • Been to Wuhan city or Hubei Province, China; OR
  • Been to a hospital in mainland China; OR
  • Had close contact with a case of 2019 novel coronavirus infection.

On 1 Feb 2020, Singapore moved to bar all recent travellers to China from entering Singapore (other than Singapore residents). This would suggest that the authorities have deemed that the risk of contracting 2019-nCoV is so high for the whole of China that it makes no sense to distinguish a person who has been to Hubei province from another person who has been to another part of Mainland China in terms of risk posed to Singapore.

As such, this hobbit thinks that the case definition of a suspect case should likewise not make any distinction between Wuhan, Hubei or a hospital in mainland China. I hope someone updates the case definition soon.

A third interesting feature in the latest list of notifiable diseases under Section 6 of the infectious Diseases Act, 2019-nCoV is NOT on the list as of today if you google it. But if you login through SingPass into the CD LENS system, it is there. Can someone please fix this discrepancy? Very confusing to simpleton hobbits.

Finally, back to Epicentre China. This week and over the next few days, Wuhan will be commissioning an additional 2600 beds to treat 2019-nCoV patients in its two coronavirus hospitals: Huoshenshan (fire god mountain) and Leishenshan (thunder god mountain) hospitals. Beijing has also brought out of mothball a SARS hospital with 1000 beds (Xiaotangshan hospital). This probably reflects what the Chinese leadership is thinking now about where the 2019-nCoV epidemic is heading. This is what we call a “lead indicator”, as opposed to lag indicators that tell us about things that have already happened. Health authorities build hospitals and commission beds in anticipation that they will mostly be filled. With such a huge number of beds put into circulation at such blinding speed, it suggests that the worst is yet to come and the outbreak has not been brought under control yet. The daily surging number of new infections and deaths also underscore this point.

This hobbit will be looking out if more such coronavirus hospitals will be built in China soon. If more are built, then it suggests that the epidemic is still growing quickly. If no new hospitals are built, then it may be that growth of the epidemic is slowing down or that the epidemic is being slowly brought under control. Or maybe the authorities have concluded isolating and treating these patients in new hospitals may be futile in controlling the epidemic and other measures need to be taken.

In the Napoleonic era, Prussian diplomat von Metternich said “When French sneezes, the whole of Europe catches a cold”. This was modified in the later half of the last century to “When America sneezes, the whole world catches a cold”, to underline America’s preeminent place in world affairs. Given the current state of the 2019-nCoV epidemic, it may not be out of place to say that “When China catches pneumonia, the whole of Asia is breathless”

We are in this for the long haul, folks.

 

 

 

 

 

 

 

The “Perfect” Communicable Disease Outbreak

Make no mistake, the 2019-nCOV virus is not a remake of SARS. It is a blockbuster sequel. Like Empire Strikes Back. And like all well-made sequels, there should be many surprising twists and turns to the plot. I call this a sequel because both SARS and 2019-nCOV belong to the coronavirus family of viruses.

For other old coots like me, we have fought and survived SARS. I wouldn’t call it a victory, but we survived. That’s enough for me because I know people who literally and physically did not survive SARS. The 2019-nCOV is the big test for the current young generation of healthcare workers.

Like most major and surprising developments, there is good news and then there is bad news.

First the good news. From a case-fatality (CF) rate perspective, the 2019-nCOV is less lethal than SARS. The CF rate for SARS was about 10% (10% of those infected died) while the CF rate for 2019-nCOV is hovering around 3%. The other good news is that the international healthcare community has developed very quickly diagnostic tests that can give you a result in about 24 hours, versus SARS when diagnostic tests took about 2 to 3 days to give a result and these tests were only developed late into the outbreak. But even so, we should remain guarded on this point because we are not sure when the tests can pick up the disease because we do not know for sure when the disease turns detectable. The third piece of good news is that this new disease is spread by droplets (and not airborne) like SARS and a good mask and universal precautions should be enough to break the transmission.

So much for the good news. Now for the bad news, of which there are many.

The 2019-nCOV outbreak (I wish someone in WHO or China will give this bug a more catchy name, like R2D2 or BB8 for example) is designed to perfection in several ways. First, it is perfect in timing. It blew up about a week before Chinese New Year in China, the busiest week of the year when hundreds of millions of Chinese are travelling back to their villages or for holidays, both within China or beyond China’s borders. The size of the travelling population in the week preceding Chinese New Year has been likened to the entire populations of France, Britain, Germany, Italy and Spain going on the road at the same time. Or the whole of USA moving. In other words, timing-wise, it is timed to perfection for maximum dissemination/propagation of the virus. And it is not done yet. These people now in their hometowns have to return back to their workplace – so a few hundred million people have to go on the road again soon in the next one or two weeks.

In comparison, SARS occurred post-Chinese New Year in 2003, in mid-spring, when Chinese New Year travelling had already been done and dusted.

Outbreak-wise, the 2019-nCOV is location-perfect. It has chosen Wuhan, the city right in the middle of the world’s most populous country with the most comprehensive network of high-speed trains, otherwise known as the High-Speed Rail (HSR). Wuhan is a bit like the Toa Payoh of Singapore in terms of location- smack in the middle. From Toa Payoh, you can easily travel to Jurong, Yishun, the CBD or Changi by a network of expressways. Similarly, from Wuhan, you can travel to the populous Sichuan province and Chongqing in the west, Beijing in the north, Shanghai in the east or Guangzhou and the Greater Bay area in the south within 4 to 6 hours by HSR.

Wuhan and its surrounding areas are so central that since ancient times, it has been a battlefield for different armies contesting for supremacy of China. This is especially evident in the Three Kingdoms period (at the end of the Han Dynasty in the third century) where the Three Kingdoms of Wei, Wu, and Shu fought around Wuhan and the nearby cities, such as Jingzhou. Wuhan is at the junction or confluent point of these three kingdoms, which underlies the centricity of it’s location. The biggest battle of the Three Kingdom period took place in Chibi or Red Cliff on a tributary of the Yangtze. It’s so famous that director John Woo made a two-part movie about it (Battle of Red Cliff) with a star-studded cast in 2008. Chibi is a stone’s throw from Wuhan and one of the first cities to be locked down together with Wuhan.

You cannot choose a better location than Wuhan in Hubei province to plant a disease outbreak in China. As they say, location, location, location. And Dr Evil couldn’t have chosen a better location even if he wanted to.

Next is the speed of transmission. In the past, a migrant worker may take up to four or five days to return to his kampong from centrally-placed Wuhan – You take a few slow trains, take a bus, hitch a ride and walk etc. Now with the HSR, you are home probably on the same day, within 24 hours, for 90% of China’s migrant working population. China’s HSR and road network is as good as any developed country in the world. That means the spread of 2019-nCOV is several times faster than the 2003 SARS, thanks to great travel infrastructure in 2019. In other words, in terms of coverage, 2019-nCOV beats SARS hands down.

Outside of China, the spread is also of many orders of magnitude faster and bigger than SARS, thanks to the huge number of Chinese travellers going overseas for holidays over the festive period. In 2003, SARS only came to Singapore because the virus travelled to Hong Kong and several Singaporeans caught the infection when they travelled to Hong Kong and stayed at the Metropole Hotel and brought the virus back to Singapore. That took time and quite a few people. Now in 2019, you can see that most countries have the infection introduced to them by people travelling from Wuhan directly to these countries. The number of travellers coming from Wuhan number in the tens of thousands in any given month to major cities in Asia. The number of Chinese travelling abroad in 2003 was a fraction of what we have in 2019. In 2003, we had to “import” SARS from HK, which in turn was imported from Guangdong, China. Now Wuhan has directly “exported” 2019-nCOV to Singapore and several other countries.

SARS lasted quite a few months in 2003. In the end there were about 8000 cases and 800 deaths. Contrast this to 2019-nCOV. Official investigations into this new disease started after the Chinese National Health Commission was alerted to the outbreak on 30 Dec 2019. It took only 4 weeks since then for this new disease to infect about 4000 people, half the total number of SARS patients. It is no surprise that the official (let alone the unofficial) statistics reflect the speed of the spread. This hobbit predicts that many more people will be infected with 2019-nCOV than SARS. Hopefully with a lower CF rate, and better facilities, therapeutic options now than in 2003, not too many people will perish. But I am not betting the farm on this hope…..

These are the hard truths. But there is more. The prospects may be grimmer than the above because of our imperfect understanding of the disease on two fronts:

• We do not know if the infected person is infectious during the incubation period or not
• Simple signs like fever may not be a reliable sign for the disease

These two points dramatically changes the game for us battling this new disease. SARS patients were not infectious during the incubation period and when they were infectious, they had fever. That gave us time and ease of detection. Outbreak fighters were given up to one incubation period (a minimum of ~7 days) to locate close contacts of SARS patients so that they could be quarantined and in doing so, break the chain of transmission. Now, if claims that a patient is infectious even during the incubation period is true, that one-week window of safety may no longer be there. There may be no time to find and round up close contacts. The Chinese believe this is so while local (Singapore) experts think this point is still debatable. We don’t have conclusive evidence on this one way or the other.

The next point is that fever may not be a reliable sign, although according to a study published in The Lancet on 24 Jan 2020 for a cohort of 41 patients, 40 out of 41 or 98% of patients developed a fever, though it was not stated if they developed the fever early or late into the course of the disease. Other reports cite that up to 30% of patients do not develop fever. The jury is still out for fever as a reliable sign. From a study design point of view, the power of a study based on a cohort size of 41 is debatable. We need bigger studies.

In Singapore, there is no evidence of community spread. Strictly speaking, there is no cause for panic. Or even N95 masks. So surgical masks should suffice for front line staff unless you are dealing with a suspect case, pending serological confirmation, in which case you need to get a N95. But if you are dealing with a suspect case, you are probably working in a restructured hospital, armed to the teeth with PPEs (Personal Protective Equipment) and as a SARS veteran yourself or a younger doctor supervised by a SARS veteran, you should be OK.

The problematic issues for now remain on two fronts

• Where do we get surgical masks (and other PPEs) in the private sector?
• How to risk stratify and what responses should we make to different risk levels

For folks in the private sector, surgical masks are getting increasingly if not impossible to get. Strangely, you can still get your box of N95s from SMA. But no one can promise you your supply of surgical masks beyond the odd box of 50 masks here or there. That is hardly reassuring to the GPs in the frontlines. This hobbit would like to think or hope that someone is sitting on a war-chest of surgical masks (and gowns) like Joseph hoarding grain in biblical times, now ready to unlock the supply that will be enough to feed Egypt in a famine lasting seven years. Or at least enough masks for seven weeks lah……

As for risk stratification, policy makers have made it clear that travel to China is a major risk factor.

Returning (from China) students and healthcare/eldercare workers are required to be quarantined. The selection of these groups reflects the thinking that these are people with the potential for spreading the disease to many people quickly, should they be infected.

A much more worrisome point is that it has now been reported that 2000 persons who are now in Singapore have been to Hubei recently. How many of these are already carrying the infection? What are the chances that community or local transmission will arise from these 2000 persons?

The next question we must ask is that how do we enforce a proper quarantine for these groups? Should they be monitored closely like in the past during SARS? Does home quarantine suffice, since fever may not be a reliable sign and they may be infectious during incubation and hence may spread the disease to family members? Should we think about hotel quarantine instead? (Since there are going to be quite a few empty hotel rooms soon, I guess)

There are many questions. But as with any novel disease outbreak, the answers are few. We need to buckle down, keep our morale up, and observe strict discipline in our infection control practices. These are obvious.

What is less obvious, and quite worrisome, is that we must avoid the mistake that many generals make – generals often fail or get defeated when they fight the last war.

These is a new enemy. A new war. We have to think new too.

Monkey See, Monkey Do?

It’s December and the season to wind down. But sometimes, they just won’t let you. You sense a grave disturbance in the Force. The Dark Side is lurking just down the corridors of power, and you hear it’s mocking snigger giving way slowly to cackling, evil laughter. Ready ever to exsanguinate and impose great pain on you.

We are of course talking about the Blood Suckers Group (BSG) (oops, I mean Blood Services Group) of the Highly Soporific Authority (HSA) (oops, I mean Health Science Authority) and its latest circular to all Hospital Transfusion Committee Chairs and Hospital Laboratory Managers titled “The Need for 2 Separately Drawn Samples for Pre-transfusion Testing w.e.f. 1 Jan 2020″.

The BSG has just decreed that for all new patients (without prior records of blood grouping) for what we mortals know as Group and Cross Match or (GXM) will now need to submit TWO separately drawn blood samples taken on SEPARATE occasions which are preferably drawn by TWO persons.

This is to “detect and prevent ‘Wrong Blood in Tube’ (WBIT) errors”.

This Hobbit is given to understand that this requirement does not apply to restructured hospitals because they have already implemented “an electronic patient identification system” that is used “verification of blood samples meant for pre-transfusion testing”. Again, in plain mortal-speak, it means restructured hospitals have IT systems that can print patient stickers with patient-specific bar-codes.

For a start, these geniuses can improve their communication skills by taking lessons from Chewbacca.

But apparently, no private hospital in the Middle-earth have these fantastic sticker-printers that can print bar codes. So now, whenever a patient in private hospital needs blood, he has to be poked twice by two different people.

When one changes policy or implements a policy, there are trade-offs in costs and benefits which must be looked into and in this day and age, and explained to the affected parties (because in this day and age, affected parties are not morons).

  • For example, how many WBIT incidents and near misses have there been in the last five years? What is the average number of incidents per year?
  • How many GXM requests are there in a year from private hospitals? What is the additional cost of doubling this number of blood group testing?

Internally, one has to also conduct a cost-benefit analysis of this proposed new policy of poking everyone twice.

  • Give an imputed value to the value of a life saved (health economists can do that) by taking blood twice from each person.
  • Give an imputed value to the pain suffered for the additional blood sample taken
  • Give an imputed value to the possible complications (e.g. hematoma, infection etc) of venipuncture (low risk is NOT no risk).
  • Work out the manpower and material cost (reagents, supplies, biohazard waste disposal etc) of this additional testing requirement

Then deduct the costs from the proposed benefit and ask -does this still make any sense or cents?

While patient safety is a laudable aim in healthcare policy-making, there is cost to additional patient safety once we have achieved an acceptably high level of patient safety. It is naïve to think that patient safety has to be pursued at all costs (no matter how catchy that sounds) because there is a limit to resources. If we have unlimited resources, we can pursue something at all costs. But alas, the inconvenient truth is we don’t have unlimited resources and the healthcare budget is the fastest growing budget in government in the last 10 years and healthcare expenditure likewise is growing rapidly.

There are examples in the crime fighting world as well as the IT world where real people deal with stuff like limited resources. Law enforcers will tell you privately it is always impossible to eradicate ALL crime in society and some low level “ambient” level of crime is quietly allowed to exist. Of course, the police will usually and vigorously pursue all violent or serious crime, such as murder, robbery, kidnapping etc. Petty crimes such as pickpocketing, illegal money lending and debt collection, littering, speeding etc, they all exist to varying extents in societies and are seldom completely eradicated. This is because the cost of bringing all criminals and lawbreakers to justice is usually too high, not just in dollars and cents, but also from the perspective of the general population’s loss of peace and privacy.

In the IT world, when we buy or deploy a new IT system, let’s say a hospital IT system – If we specify that the IT system’s availability is rated at 99% (i.e. downtime of 1%), it may cost, say, $10 million dollars. But if you want the same system to have an availability of 99.9%, the price may go up to $12 to 13 million. You are paying an extra 20 to 30% for just an increase of 0.9% in availability from 99%. This also demonstrates the principle of diminishing return.

This hobbit suspects (100% speculation) that we are going to incur a lot of costs and inflict a lot of physical pain just because some genius decided that WBIT incidents should be eradicated. The problem is, one is not even sure poking a patient twice (especially by the same person, which is permitted but not encouraged) is even effective in eradicating all WBIT errors. But this hobbit also suspects, in the mythical realm of Middle-earth that bureaucrats live in and when “patient safety” is mentioned, the consideration of limited resources does not exist at all. But the hard truth is, outside of Middle-earth, even for a sacrosanct issue like patient safety, limited resources in terms of money, people and time are very real considerations. This hobbit further suspects that because the public hospitals are not affected because they can print the fancy patient stickers, private sector concerns were not addressed before this new policy was declared.

On 4 Dec 2019, a major private hospital group issued its own circular to all doctors practicing in its hospitals stating that the requirement to take two specimens of blood stemmed from the fact that HSA’s BSG was accredited to this organisation called AABB (American Association of Blood Banks) and that AABB required its members to follow this practice so as to remain accredited with it.

This makes the waters even murkier and begs even more questions. Last I heard, Singapore is a sovereign state and we do many things differently, like driving on different sides of the road. We also spell “organisation” with an “s”, not a “z”. The last time we tried doing things the American Way in healthcare, like Residency, it didn’t turn out well. So, if it is indeed an AABB requirement, then Singapore healthcare stakeholders must ask – what are the benefits of being accredited to AABB? Versus the costs? Not just benefits to HSA BSG, but to ALL Singaporeans and Singapore. Is our situation similar to AABB? Maybe there are many WBIT incidents in USA. What is the number of incidents per, say, 1000 GXMs? I.e. the rate of WBIT in Singapore vis a vis USA and other first world countries?

So many questions, so few answers. If the private hospital circular is factually correct and the private sector is doubling the number of blood specimens taken for GXM just to satisfy some bureaucrat’s desire to fulfill some obscure American accreditation requirement, then it is yet another case of monkey see, monkey do.

Actually wait, this hobbit stands corrected. Monkeys are actually quite intelligent.

 

 

A Word About Locums

Locums are an important segment of the profession, particularly for those of us who work as GPs/Family Practitioners.

This hobbit used to do a lot of locums in his younger days. Mainly because he had mouths to feed and loans to pay. Old coots like me will reminiscence about the bad old days when we were paid as low as $40 an hour, saw 12 to 15 patients per hour etc.

Times have changed. From the chat groups I am in, I hear disturbing stuff about some locums. They may not represent the majority and it is unfair to tar all locums with the same brush. Apparently, there are locums that:

1. Refuse to see more than 4 to 5 patients an hour
2. Refuse to take blood (or perform any procedure) or give injections
3. Refuse to see female patients
4. Refuse to see children
5. Refuse to review lab and radiological reports (even if ordered by the locum)
6. Refuse to turn up the next day (although already booked for say, the entire week) unless you pay him more per hour because the clinic was busier than what the locum thought.

The last point is particularly galling because it is purely a point about lack of honour and professionalism bordering on blackmail. I wonder if our mammoth SMC ECEG covers such unbecoming behaviour.

There are one or two infamous locums in my time that are still circulating perilously in the market now as full-time locums which many GPs are afraid to engage. But most of these stories involve young doctors. They may be full-time or part-time locums.

But this is not another article by an old coot complaining about the state of young doctors and locums. Other than point 6 above, the other five points beg the question – what is the root cause? Is it just bad attitude? Maybe not.

My guess is that maybe it is also due to competency, experience, and risk-averseness.

One cannot but wonder with today’s residency and workload caps, are young doctors trained to cope with high workloads? Also the breadth of experience that the system affords. For example, other than in polyclinics and A&E, many young doctors never see kids after they graduate. In NHG for example, there is no paediatrics or O&G department. With the three clusters now firmly in place and cross-cluster movement of doctors not happening much if at all, how does one get broad-based training?

After all, it doesn’t take much to be a locum. All you need to be is to be fully registered with SMC. But being fully registered doesn’t mean you are comfortable seeing kids or women. The locum may never have been part of a structured training program if he wasn’t a resident.

The other possible explanation is that due to efforts to improve quality and risk-averseness in our public institutions, many things are pushed upwards to more and more senior people and younger people are less and less trained or exposed. This is not new and has been taking place for decades to be sure. In the past, a second year registrar can perform a gastrectomy himself competently. Now, I am not so sure even a second year Associate Consultant can do a gastrectomy all by himself. It’s not entirely a bad thing and its inevitable as society progresses.

But there is a downside when things are carried out too far. I have been told that some locums refuse to take blood because they are “not confident”. And these are not old doctors suffering from failing eyesight or hand tremors. Maybe, it is because many of these “simple” procedures are now carried out by technicians such as phlebotomists and hence the lack of confidence.

Many locums refuse to perform “risky” procedures now (such as H&L injections, ear syringing) because they are not paid adequately if at all to assume the higher risk. They are after all paid by the hour. This is understandable. If I was still locuming, I would maybe do likewise. But taking blood or giving injections and vaccinations are really, really bread and butter.

The point that really needs to be made is that GPs only hire locums because they want their patients to have continuity of care when they aren’t around and that the locums pay for themselves. Yes, the hard truth is that locums have to earn their keep. With locum rates at anywhere from $100 to $120 per hour, a locum has to generate at least $200 to $250 of revenue per hour for the clinic so that it makes hiring the locum worthwhile.

But if a locum refuses to do many things, or caps his work-rate to 4 or 6 patients an hour then it is kind of difficult to justify hiring him. It is really down to the locum’s productivity in dollar and cents. So if a locum wants to stay in the business of locuming (And it is possible to make a very good living by being a full-time locum), he needs to get repeat business from clinics. To achieve this, he has to make more for the clinic than what he takes. It’s that simple.

All of us agree that the quality of locums are really patchy. Sometimes, you really get a locum from hell, and sometimes you get a wonderful one, and all your clinic assistants tell you the locum gets things done with minimal fuss and is even a joy to work with.

Thinking aloud, maybe it is possible to accredit or certify trained locums on a voluntary basis. Maybe a responsible professional body like the College of Family Physicians Singapore can run courses for people to attend and certify these locums of certain competencies and skills. This training is not about the latest in medical science etc but skills every locum needs – common office procedures, like taking blood, ear syringing, I&D, T&S etc as well as certifying stuff like fitness to drive etc.

One may argue that what the locums really need is to attend the Graduate Diploma in Family Medicine (GDFM) course. But frankly, many locums do not have the opportunity to attend a full diploma course. Maybe a Locum Certificate course is all that he can afford for the time being.

I think many GPs in the market who use locums will welcome such a Locum Certificate course. At the very least, the holder of this Certificate cannot say he does not want to give injections or doesn’t know how to take blood and he may even be able to command a small premium in terms of his hourly locum rate.

This reminds me of an old story. Upon finishing his 5-year bond, a brilliant classmate of mine left town and went for his training in the United States as an internist. He is now professor and head of department in a big hospital there. He underwent training in one of the most famous hospitals there. One night while on call, a distressed nurse called him to inform him she could not insert the IV cannula and wanted to call the phlebotomist on-call (but who was not stationed in hospital). My friend said he will insert the IV cannula. At the bedside, the nurse had an ultrasound machine on standby (thinking that the doctor/resident will insert the IV cannula under ultrasound guidance)

He inserted it on the first try without any fuss, without ultrasound guidance, Singapore style. The nurse was extremely grateful. The next morning, his boss, in front of the entire ward team, clapped his back and congratulated him on his grand endeavour of inserting an IV cannula while on call.

I have a bad feeling Singapore medicine may be heading in this same direction.

A Scary Bedtime Story – the SSC Case

The appeal to the Court of Three Judges (C3J) on the psychiatrist Soo Shuenn Chiang (SSC) case had a familiar ring to it. This is evident right from the word go, as delivered by the Chief Justice in The Judgment of the case,

The opening paragraph of the Judgment states,

“For the second time within a short span, this court is faced with a potential miscarriage of justice in a case involving alleged medical misconduct. Once again, the Singapore Medical Council (“the SMC”), which is prosecuting the case, has changed its position from that which it maintained before the Disciplinary Tribunal (“the DT”); once again, the task of the DT was made more difficult by the decision of the respondent, on this occasion, Dr Soo Shuenn Chiang (“Dr Soo”), not to contest the charge or the facts upon which it was based; and once again, the DT failed to carefully consider all the relevant facts and circumstances before it pronounced the respondent guilty. On this occasion, the DT then meted out a sentence that was in excess of both that sought by the SMC and that submitted by Dr Soo. And once again, an outcry from the medical profession sparked a reaction from the SMC”. (emphasis mine in bold and italics)

This hobbit is not a halfling of letters, and with his limited language skills, has to resort to Hokkien to describe what he thinks was the Chief Justice’s mood when he delivered this – in one word – sian. Sian in Hokkien means tired, with more than a tinge of frustration perhaps.

Later on in para. 68 of the Judgment, it was stated, “We make this observation because it seems to us unsatisfactory that reliance has been placed on the medical profession’s propensity to protest loudly over the decisions of disciplinary tribunals and/or courts, with dire warnings of the spectre of defensive medicine, in order to secure in individual cases the result that is desired and/or perceived to be just. The doctor against whom a charge is brought also has a responsibility to look after his own interests. Dr Soo could have contested the case on liability, and subsequently, even after pleading guilty to the Charge, he could have appealed against at least the sentence imposed on him, but he chose to do neither. It is not unreasonable in such circumstances to hold that he ought to lie on the bed that he has chosen to make for himself”.

This hobbit begs to disagree with the learned and wise C3J on the point of a “spectre”. First, it is not a “spectre”, but reality. The consequences of the SMC DT’s judgment (before the C3J’s Judgment) on the Lim Lian Arn (LLA) H&L Case is an increase in both the practice of avoidance defensive medicine and a general rise in price for performing a H&L injection. This is not a spectre, but evidence documented through research and published in a peer-reviewed medical journal. Seventh Month has come and gone and it is now Halloween, but this hobbit hasn’t seen any Ghost of Defensive Medicine yet. If you ask me, it’s more like the Golem of Defensive Medicine, which is very hard to kill once it comes to life.

It is true that a doctor “has a responsibility to look after his own interests”. Unfortunately, “his interests” are also defined according to ‘his’ perspective – which in this case, seems to be Dr SSC wants to plead guilty, pay the fine and move on and get on with his own life. It is his prerogative and perspective, not anyone’s else. Just as we enshrine patient autonomy and patient-centric-ness in promulgating the Modified Montgomery (MM) Test, it should be argued that here, in disciplinary tribunal proceedings, a doctor’s interest has to be defined from a doctor-centric perspective, not public interest-centric or medical profession-centric.

And certainly, arising from such a basis, the doctor has “to lie on the bed that he has chosen to make for himself”. In fact, there is no strong evidence that Dr SSC was unwilling to lie in this bed he made for himself. We shall nominally name this the “SSC bed”.

But what about the other 15,000 or so doctors licensed to practise medicine in Singapore? In our English Common Law system based on legal precedents, it appears that we too have to possibly, if not probably, lie in the same bed, or at least a bed of similar proportions and design, with mattresses, bed sheets and blankets of similar specifications as the SSC bed, when faced with a situation similar to Dr SSC.

That, my friends, is the nub of the problem.

Many of us do not have “the propensity to protest loudly over the decisions of disciplinary tribunals and/or courts” because we felt Dr SSC was dealt unfairly by the DT. Yes, unfairness to Dr SSC is a starting point for dissatisfaction, but the crux of the matter is that the $50,000 fine or $100,000 fine (LLA case) could also apply to me. SSC’s bed can also become my bed. Other than anger, fear is also a very powerful motivator to “protest loudly”.

Legal minds may argue that there is a good chance that Dr SSC’s bed may not fit me when my case is argued in a DT or a court when the SSC legal precedent is tested in real life again. This hobbit always finds this sort of argument rather callous from a doctor’s perspective. After all, which doctor wants to be a “test case” for a legal principle? I would rather be a test case-patient for a new experimental surgery to remove my kidney than a test case in a court.

Therefore, we must assume that the bed made by Dr SSC for himself to lie in, should also apply to some 15000 other doctors as a legal precedent. Is there any other prudent way to look at it?

Even though the appeal from SMC to appeal against itself has succeeded and the case against Dr SSC has been thrown out, many other questions still remain.

Moving forward, the quality of the investigative work of SMC has to questioned. How much can a Complaints Committee (CC) and DT rely on the SMC investigators’ work when they come to their conclusions over a case? In this case, the “facts” were not verified, which led to wrong conclusions being made. As the saying goes- garbage in, garbage out.

Secondly, because the case was thrown out, the issue of sentencing became moot. But it would have been terribly interesting if the C3J had also looked into and commented on how the DT arrived at a fine of $50,000, which was well in excess of what both parties (the SMC lawyers and Dr SSC’s lawyers) asked for.

In other words, there are actually two SSC beds. The first is the bed of pleading guilty and conviction in SSC’s case; this bed had been dismantled and such an outcome therefore made looking at the bed of sentencing unnecessary. But in all probability, most doctors were most uncomfortable lying in the SSC bed of sentencing, not the other bed of pleading guilty.

Finally, a point of secondary importance that could be looked into would be to see if there was any deception or falsehood on the part of the complainant’s brother and husband in firstly asking for the memo from Dr SSC, and secondly in the statutory declaration made by both of them subsequently. If there was deception and falsehood, what further actions could be taken?

All in all, the SSC case has been a very scary incident for many of us, even though many of us didn’t see any ghosts, wraiths or spectres…..

 

A Final Many Words On The LLA Case

And so, it has come to pass, on appeal from SMC against its own Disciplinary Tribunal (DT), our wise Judges have ruled that Dr Lim Lian Arn (LLA) is not guilty of professional misconduct. Everybody has to pay their own costs, including Dr Lim and SMC’s lawyers. Other than the lawyers and the DT, everyone lived happily ever after. And so the story comes to a happy ending.

Not quite.

Learning Points from the C3J Judgment of the LLA Case

First, a few learning points can be gleaned from the Judgment that was issued on 24 July 2019 by the Court of Three Judges (C3J):

One key point was that the SMC’s position to call for a five-month suspension for Dr LLA was “wholly unwarranted” and that the “DT also fell into error by too readily accepting Dr LLA’s submission (made in response to the five-month suspension) that the maximum fine of $100,000 would be appropriate”. (para. 63). This hobbit couldn’t agree more. To me, it means that how a sentence is called for by SMC must be dependent on the specific facts of the case, and that the several calls (at least in four previous cases) before the LLA case by the Court of 3 Judges (C3J) for harsher sentences and sentence re-calibration against doctors must be taken in their specific contexts on these occasions and not to be interpreted as “general instruction” for all cases. This is helpful.

Personally speaking, the most helpful information in the Judgment is it makes our clearly how professional misconduct is to be proven (summarised for brevity and not necessarily for high fidelity):

  • Establish what is the applicable standard
  • Establish whether there is departure from this standard
  • Prove whether this departure is serious enough to constitute professional misconduct. With respect to negligence, it must be “serious negligence” and departure from standards must be “serious disregard” or “persistent failure” to meet the standards set out under the ECEG.

The Judges took effort to state that the lawyer for LLA “was mistaken” when he regarded that a breach of a “basic principle” in the ECEG amounted to professional misconduct. They also stated (para. 30 of Judgment) “there must be a threshold that separates relatively minor breaches and failures from the more serious ones that demand disciplinary action. Were it otherwise, doctors would find it impossible to practise in a reasonable way”. Hurray.

The extent and coverage of expert evidence was also elaborated on. The Judgment stated that it was not enough for an expert to merely state what he or she thinks how things should be done. The expert must also present “the underlying evidence and the analytical process by which the conclusion is reached” (para 43) for the expert opinion to hold sway.

On the subject of informed consent, the Judgment reiterated essentially the basic requirements of the Modified Montgomery (MM) Test:

  • Establish what is relevant and material information to the patient. Materiality of a risk or complication is generally determined by its severity and likelihood and “largely a matter of common sense” (para. 50).
  • Establish that the doctor possesses this information
  • Establish whether the doctor can justifiably withhold this information from the patient

On the subject of defensive medicine, the Judgment defined or described it as “the situation where a doctor takes a certain course of action in order to avoid legal liability rather than to secure the patient’s best interests”. The Judges said that it is a mistake to classify “information dumping” (i.e. doctors overwhelming patients with a deluge of information in order to protect themselves legally) on patients by doctors as defensive medicine because “giving too much information will not avoid legal liability” (para. 54)

Informed Consent

As this hobbit has said below, in our local context, “just follow law”. Whatever the Judges have said is case law and therefore has to be adhered to. But perhaps in my senescence and folly, please allow this old coot blabber a few irrelevant and immaterial things about three points – informed consent, defensive medicine and information dump

MM Test

The MM test is largely a matter of common sense. As my professor (now emeritus professor) once said to me when I was a medical student, “common sense is uncommon”. Were it not so, it would not have been necessary to introduce the Bolitho Addendum to the Bolam test. The Bolitho Addendum is essentially an addendum to require common sense when applying the Bolam test. The MM test essentially requires even more common sense than the Bolam-Bolitho (BB) test because it demands the doctor to establish what is material and relevant to the patient.

Don’t get me wrong, I think being patient-centric is good. How to achieve this is already cast in legal stone (Case law – MM Test) even though I am still trying to grapple with implementing this in my clinical practice. To this hobbit, essentially, the MM Test ignores a basic dimension of existence: time

For one, a three-step test doesn’t quite work for me when I see 40 patients a day and I prescribe hundreds of medications, investigations.

Secondly, what is relevant and material to the patient changes with time: – his circumstances changes and his memory fades. For the same procedure, what is of concern to him one month before the procedure can often be quite different when it is one week or the day before the procedure. And all this could be quite different one-month post-operation when his concerns are quite different from pre-op. As one doctor wisely said, “often the only relevant risk or complication is the one the patient develops post-op”.

Also, there are scientific studies to prove that a patient’s retention of information or advice given to him by the doctor is really quite limited and diminishes with time. You may have told him to your best effort what you think is relevant and material, but he may have forgotten or ignored what you said and he then turns around and sues you.

Another smaller issue about the MM test is the severity and likelihood matrix. As advocated, you should tell the patient the risk if it is more serious, even if it is unlikely). The most serious risk is of course death. Another doctor also said “once you mention “death”, the patient’s mind goes blank thereafter”. But the patient still signs the consent form and undergoes the procedure usually. And then he may also turn around and sue you later.

There is little doubt that the MM test brings increased uncertainty to the practice environment and doctors generally don’t like it. However, that doesn’t mean doctors are against being more patient-centric. It is an argument of false dichotomy to say that just because many doctors are uncomfortable with the MM test it suggests the medical profession is not supportive of being patient-centric.

Defensive Medicine

We now come to the difficult subject of defensive medicine.

Let us now return to the Judgment delivered on 12 May 2017 by CJ and four Judges of Appeal in the Hii Chii Kok vs London Lucien Ooi (a civil suit and NOT SMC case). This was when the MM test was introduced as case law. Here are excerpts from Paras 84, 85 and 87 “The argument for full retention (of Bolam and Bolitho)” (The portions I wish to emphasise are in italics and underlined)

84 What of the view that the Bolam test and Bolitho addendum should not be interfered with to any degree, even as regards advice? The strongest argument in favour of that view is the contention that if the Bolam test and Bolitho addendum were abandoned in favour of a standard that placed greater emphasis on the interests and perspective of the patient, it would spark an unacceptable increase in medical litigation. This would, it is said, have two deleterious effects: first, it would drive up the cost of medical malpractice insurance, and thus increase the costs of healthcare to the public, and second, it would increase the pressure on doctors to adopt what is commonly referred to as “defensive medicine”.……….(rest of para deleted)

85 It cannot be denied that the cost of healthcare and the practice of defensive medicine (which also feeds into the cost of healthcare to some extent) are both real concerns. However, we do not accept that they provide sufficient reason for the court to shut the door to reform entirely. In the first place, it has not been distinctly established that any departure from the Bolam test would in fact have the consequences of more medical litigation, higher insurance premiums and greater healthcare costs….. (portion deleted)….Furthermore, we note that certain factors which have driven up the cost of medical professional insurance in the US – the jurisdiction in which such concerns have been perhaps the most prominent – are not present in Singapore. The US legal system features jury awards which often would, in Singapore, be considered highly inflated; allows contingency fee arrangements (encouraging opportunistic negligence suits); and does not follow a “loser pays” principle of costs (thus reducing the disincentive for litigants or law firms to bring weak or speculative claims). In the absence of such factors in Singapore, we see no reason to believe, without clear evidence, that a carefully calibrated shift in the standard of care is likely to lead to a drastic increase in the frequency and value of medical negligence lawsuits in Singapore.

87 The problem of defensive medicine falls more squarely within the ambit of the court’s inquiry, since it directly implicates the question of whether the proposed standard will fortify or hinder the medical profession’s fulfilment of its duties to its patients. In that regard, we note that unlike a wholesale rejection of the Bolam test and Bolitho addendum, which the court in Gunapathy rightly warned against (at [144]), reform of the more limited nature being considered appears unlikely to contribute significantly to the practice of defensive medicine. The implications of Montgomery are limited to advice, whereas the concerns in defensive medicine pertain mainly to diagnosis and treatment……..We therefore do not think the spectre of defensive medicine is a strong reason to shy away from reform in the area of advice specifically.

Paras 84 to 87 in the 12 May 2017 Judgment on the Hii Chii Kok case was given as consideration on why a departure from Bolam and Bolitho can be seriously countenanced; the promulgation of the MM test then took place later in this Judgment. To summarise:

  • The fear of a rise in malpractice costs and increase in practice in defensive medicine are important considerations as to whether one should depart from the BB test
  • But these fears (as at 2017) were unproven and theoretical at best (i.e. not “distinctly established”)
  • Even if we depart from the BB test, Singapore does not have the pre-existing conditions (like in USA legal system) for a drastic increase in frequency and value of medical legal lawsuits, which in turn will lead to defensive medicine taking root quickly – i.e. contingency fees (i.e. loser pays) and high jury awards.
  • Defensive medicine doesn’t quite extend to the realm of medical advice (of which informed consent is a part of) and is limited to diagnosis and treatment.

Departure from BB test

In a study commissioned by the College of Family Physicians Singapore and Singapore Medical Association to examine the effect of the SMC Judgment in the LLA case on doctors’ behaviour earlier this year, it has been proven that these fears are clear and present and very real.

  • The number of doctors surveyed who provided an H&L injection decreased by 14.6%
  • The median price for the injection increased from the 0 to $100 band to >$100 to $200 band.
  • The number of surveyed doctors who charged more than $1000 went up eight-fold from 8 to 65.

This study therefore documents a quantitative increase in the practice of defensive medicine and healthcare costs when the BB test was departed from . It can be argued that the LLA outcome came about from a botched implementation of the MM test, but it is a departure from the BB test nonetheless.

The ‘free’ SMC process can lead to defensive medicine taking root quickly

The next point that Singapore does not have the pre-existing conditions that the US legal system has is interesting. It is true that Singapore doesn’t have high jury awards and contingency fees. But these advantages apply only to civil suits. For SMC complaints, the environment may be just as favourable for an increase in medical-legal complaints than the US – it is practically free to the complainant (no financial risk) to embark on a SMC complaint! The whole SMC disciplinary process may be no less frightening and painful to the doctor than a civil suit (if not more), hence the flight to defensive medicine in Singapore may be no less quick and intense than the US. So this assumption that Singapore legal system has a more agreeable climate to doctors is correct when applied mainly to civil suits. The doctor does not only flee towards defensive medicine out of fear of being sued in a civil case and paying hefty damages, but also out of fear of getting involved in the SMC complaints and disciplinary process, which is free to the complainant.

Defensive medicine is not static – it goes where the attack is targetted

Lastly, the point on defensive medicine being limited to diagnosis and treatment and not extending to medical advice needs some discussion. Let’s breakdown the words ‘defensive’ and ‘medicine’, for a start.

The practice of medicine is dynamic and ever-evolving. That is why we need to gain 50 CME points every two years, to keep us up to date with the changes in the practice of medicine. The practice of defensive medicine is no different, it is also evolving with the times. It is not static. Just because in the past the practice of defensive medicine is limited just to diagnosis and treatment does not mean that it will always be so.

The word ‘defensive’ has military roots, as in ‘defense’ and ‘attack’. Any SAF serviceman will tell you, defense is not static either. You prepare a robust, in-depth defense where you think the attack will most likely target. High profile cases involving senior doctors accused of not getting informed consent send a strong signal that patients (and lawyers) are focusing their efforts in this area. These well-known cases include Dr Eu Kong Weng, Dr Ang Peng Tiam, Dr Leslie Lam and this LLA case. It doesn’t matter if the complainants were successful or not, just the pain and trauma of going through responding to a complaint is sufficient motivation for doctors to focus their defensive efforts to prevent more complaints in this area.

Defensive medicine is divided into avoidance and assurance defensive medicine. Ordering more and unnecessary tests and investigations is a classic example of assurance defensive medicine because a doctor is afraid he will be complained against or sued for a missed diagnosis. Similarly, an information dump carried out because a doctor is afraid he will be complained against or sued in the area of medical advice, is in the opinion of this hobbit, a new form of assurance defensive medicine. The medical profession should not rigidly limit ourselves to what was previously described – that defensive medicine only exists in diagnosis and treatment. Defensive medicine will occur where the doctors think they will be attacked, be it in the areas of diagnosis, medical advice or treatment.

Information dumping
That brings us to the statement that information dumping is not defensive medicine because “giving too much information will not avoid legal liability” by our learned Judges. The judges are of course absolutely correct since from where they sit – what is inefficacious in avoiding legal liability in the court room or a disciplinary trial should not be considered as defensive medicine.

But as practicing doctors, I suppose, we have to look at things more upstream. As the age-old saying goes, “prevention is better than cure”. What is inefficacious in a disciplinary trial or the court room is an inefficacious or useless cure. But it may still work as a preventive measure. This is because it is human nature to take comfort in numbers or quantity. There are so many examples of this. We usually feel better when we write a longer answer to an exam question when compared to a shorter one (the test scores may have no correlation to the length of answer of course). We take psychological refuge in buying a thicker textbook than a thin one (whether we actually finish reading the textbook or understand what’s written inside is another matter altogether).

It is for the same reason that our consent forms are getting longer and longer. A longer consent form looks formidable and gives us psychological security. Remember the days when we could combine both the surgical and anaesthesia consent-taking into one page? Those days are gone. And if they still do exist, many would wonder – will such a short form suffice?

Due to information asymmetry, the buyer of a service also derives satisfaction and gauge quality by substitute measures of quantity (even though there is little correlation between quality and quantity). An inpatient given a lengthy discharge summary which is no more than a “cut-and-paste” job may think the medical officer has been diligent while a medical officer who has assiduously prepared a concise one-page discharge summary may be less appreciated. For about the same amount of money, a patient given 5 different drugs for common cough and cold often thinks he has been given quality treatment and may consequentially conclude the other doctor who gave him only 2 drugs earlier was tardy.

So, both doctors and patients derive comfort and satisfaction from quantity. This is just simple human nature. If that is so, we will also believe that with more information engendering more comfort and satisfaction, complaints are therefore less likely to occur. It is therefore no surprise that information dumping will be adopted in an attempt to prevent complaints from occurring, even though it is inefficacious in avoiding legal liability.

This psychological comfort derived from quantity is accentuated when there is greater uncertainty, as is the case with the MM test when compared with the BB test. The greater uncertainty arises because It is extremely difficult for a doctor to titrate accurately the exact amount and nature of information that is material and relevant to a particular patient in a particular context under the MM test. This hobbit thinks most doctors believe it is more likely that a patient is dissatisfied with less information than more. As such, most doctors will intuitively also believe that it is probably easier to prove a lack of informed consent arose from insufficient information rather than excessive information.

It should therefore come as no surprise that a doctor will give more information than what is actually needed.

Conclusion

After this long spiel of about 3300 words, what are the take-home messages? It’s still more of the same. We are a law-abiding profession in a society that enshrines the rule of law. Whatever is law, be it legislation or case-law, must be followed. There is no other way. Whatever this hobbit rambles or blabber about, is irrelevant and immaterial.

In the area of medical advice, this hobbit will still give substantially more information than he previously did in the BB test era. This is my form of Survival Medicine.

The answer to the question of when and how a generous amount of information limps across the line and qualifies as information dump, is best left to minds that are far more brilliant and incisive than this hobbit, who admittedly suffers from a little lack of this precious commodity called common sense. This lack may be a result of the imperfect hobbit condition that I am born into.