Doctors’ Day???

July 29, 2011 at 11:15am

It’s the time of the year when we celebrate Nurses’ Day again. And the President will give out the much anticipated President’s Nurse Awards to several nursing leaders each year on Nurses Day. In every hospital in Singapore there will much revelry and gaiety. Hospital administrators and doctors alike will have to demonstrate their affection for the nurses in some way or the other. These include serving food, singing a song or maybe swallowing a live cockroach (especially if Nurses Day falls near a JCI audit). Huge bouquets of flowers will be sent between each and every hospital. I have seen a hospital give out one stalk of rose to each and every nurse. This is no mean feat as some large hospitals have more than a thousand nurses.

Naturally, this begs the all important question, what on earth is the male nurse going to do with all the flowers and bouquets.? Instead of roses for male nurses, can we just give the guy a can of beer? Just kidding.

I don’t know, call me skeptical, my take is all this fanfare and gushing of goodwill on this one day every year is but an annual short-acting anaesthetic to the fact that nurses are still underpaid and overworked in the other 364 days. Of course, seeing Prof Chee Yam Cheng playing the piano may be balm that lasts more than a day but that is only once-off for TTSH.

So we have Nurses Day. We also have others like Teachers Day, SAF Day, Mothers’ Day, Fathers’ Day, Children’s Day, Youth Day, and maybe in the near future Harry Potter Day and Flood Day. This Hobbit thinks we should also have a Doctor’s Day. I hope respectfully the newly Elected President will take up my humble suggestion.

The reason for having a Doctor’s Day is obvious. It is to remind everyone that some doctors think they can make miracles and cure every father-mother-son like Harry, talk like teachers, behave like children, work like nurses, dress like youth and of course earn money like a tropical rainstorm flood.

What can we actually do to celebrate Doctors’ Day?

First, we can conduct an Unlucky Draw whereby the unlucky winner gets to be CMB for one day to see and understand actually how sucky a life of CMB is. The winner will get to sit in the CMB’s office for one day. In the morning, he will hear non-stop different doctors coming into his office to complain about poor pay, promotional prospects, lousy patients and the residency programme. In the afternoon, he can then try to feedback to the higher authorities his problems and of course the unlucky winner will either get no response or be criticized as being “not progressive”. Finally at 5pm, there will be a simulated incident whereby one of his heads of department comes in to hand in his resignation letter. Lunch is not provided, but his personal assistant for one day can buy a kopi and red bean bun from the hospital canteen for this unlucky winner (at the winner’s expense). If we are really going to have serious fun, we can even get this guy to give a talk to 200 doctors in the auditorium on why JCI audits and residency ACGME accreditation are necessary.

And then we can also have Singapore Doctor Idol where folks show off their talent. Possible items on show could include

A GP trying to do a liposuction on a guy with a BMI of 23
A residency program director trying to explain why his department fulfills ACGME’s requirements even when obviously everybody is working 101% everyday trying to clear the patient loads
A foreign trained surgeon who only speaks English trying to take informed consent in accordance with SMC’s standards (warning – long performance hours lasting >2hours)
Two very senior surgeons meeting after 30 years and dancing the tango till midnight

Next, similar to nurses, we can of course also have the President’s Award given to outstanding doctors for their outstanding contribution to medicine and health. Immediately, at least three possible candidates for the award come to mind:

The doctors on the disciplinary committee that set new standards for informed consent, specifically for purportedly running hearings from 2pm to 2am on a few days and on one occasion to 4am and for deciding that obtaining consent in a suboptimal place is a critical factor in deciding what is professional misconduct. Such dedication and prowess cannot be ignored, including the great ability to give and hear sound testimony, think clearly and decide fairly at around 2 to 4am. It is interesting to note that while most resident housemen (PGY-1) cannot work past midnight but DC can run till 4am, bearing in mind folks have been working since the morning (of the previous day). This hobbit stands in awe of the stamina and incisive thinking being displayed…

The doctor that was rumoured to have paid ~$6,000 per square feet for clinic space also deserves an award. After all, he has gone where no man has gone before and has showed that clinic space prices have joined the realm of other gravity-defying manifestations such as COE, Superman and push-up bras.

Finally, we should give the President’s Award to the doctor who decided Singapore should adopt the ACGME Residency system. He symbolizes what a great leader is all about, a man/woman who dares to go it alone, without prior consultation with the professional bodies/stakeholders and goes for a vision that many think is impossible to achieve. This sheer improbability and audacity of thought ranks up there with Singapore in World Cup – Goal 2010 vision, Mao Tse Tung’s Great Leap Forward and Dr Evil’s plan for world conquest in Austin Powers movies parts 1, 2 and 3.

And of course, as part of the pomp and pageantry of the Presidential Awards for outstanding doctors, we must get Chee Yam Cheng to play the piano again at the award-giving ceremony.

The Wonders of the English Language – Reading the Lines Carefully

July 14, 2011 at 12:45am

Reading today’s letter by Ministry of Manpower in the Forum in response to an earlier letter by SMA President Dr Chong Yeh Woei is an exercise in the appreciation of the precision of the English language. Let’s take a look at a few statements found in the reply by MOM.

“However, in order to take sick leave with pay, the Employment Act states that an employee needs to obtain a medical certificate from a company or government doctor” What it means in real life, therefore, is for paid medical leave, the Employment Act states that an employee needs to obtain a medical certificate from a company or government doctor. If you see your own family GP or private specialist, good luck.

Even if “MOM would like to reiterate that employers should recognise medical certificates issued by any registered medical practitioner for the purpose of being absent from work due to illness”, it doesn’t mean the employee would get any pay while away that comes with the employer’s “recognition” of the MC. So MOM’s bottom line is at best recognition of “unpaid leave” when an employee sees a doctor that is not the company or government doctor.

“This is only a minimum requirement to the employer, and does not stop an employer from recognising a medical certificate from any doctor” – that means recognition is at the employer’s discretion” and the recognition by the employer is NOT obligatory

How much protection does an employee really get from the word of legislation found in the Employment Act should he produce an MC from a doctor who is neither the government nor the company doctor remains to be seen. And really what good is an MC that comes without pay is for you to conclude.

This is wonderful civil servant-speak, of the sort that I thought PS2000 was supposed to get rid of. But then again, this is 2011. Oh well….

Flaccid Truths to Keep Your Practice Going – The logical and inevitable demise of trust

July 3, 2011

A patient came to see me recently with a painful ingrown toenail. I see ingrown toenails quite frequently in my practice and have become quite adept at removing them. It’s the nature of my Middle-earth practice – Orcs and Ogres have poor nail hygiene and Elves with their long and thin toes are quite prone to them too.

For patient confidentiality purposes, let’s call my elvish patient Johnny. Johnny is a sprightly 340 year old wood elf. He had seen me for the past 20 years or so for various mild ailments. Otherwise, he was fit as a fiddle. Today, he stepped into my consultation room with an expression that was somewhere in between a frown and a wince. You could always tell he was in pain when the tips of his pointed ears turned red.

He showed me his ingrown toe nail. There was some paronychia around the nail with a small collection of pus and it was obvious it had to be excised. I would usually perform a digital block with lignocaine injections at the base of the toe with the help of a rubber band acting as a tourniquet. The whole procedure usually takes about 5 to 10 minutes.

But today was going to different. I started out enumerating the various benefits of the procedure is and the consequences of not going through the procedure. This of course included the piercing pain Johnny was experiencing round the clock as well as the possibility of getting chronic osteomyelitis from letting the infected ingrown toenail persist.. Frankly, from the look on poor Johnny’s face, I didn’t think Johnny needed any convincing.

Next I told him the risks of the procedure and that of the LA as well. Of course, the risks included cardiac arrhythmias and sudden cardiac death from the lignocaine injection as well as me possibly leaving behind tiny bits of my scalpel blade behind in his flesh for the next 400 years (elves can easily live that long and scalpel blade construction is not what it was with these blasted new foreign talent dwarves we are getting nowadays). Even though the chances were remote of these occurring (at least one reported case of retained scalpel bits) , but because of the severity of these possible risks, I thought I should tell him. I also told him about the other usual stuff like chance of recurrence, ugly nails, keloids, infection, fever, pain, allergies to dressings etc.

I also diligently jotted down all these benefits, risks and complications on his card. I then went on to the alternatives. I told him that he could also do nothing. I can refer him to another doctor or to the nearest A&E in Middle-earth. And since his ingrown toenail was not quite life-threatening at this juncture, I told him he could go home to think about it a day or two before deciding on whether he wanted to go through with the excision of toenail or not.

Johnny was flabbergasted and exasperated. The elves are never good with hiding such feelings. He uttered impatiently (trying as much to contain his frustration and anger as much as his otherwise congenial Elvish nature would allow him) “What’s wrong with you today, Doc? Just go through with the procedure and get the blasted ingrown toenail out. It hurts like hell!”

I then asked him with all the equanimity of Sir William Osler to acknowledge on his patient card with his signature that he agrees to the excision and he fully comprehends the risks, benefits, complications and alternatives which had been listed on his patient card to evince his comprehension.

He signs the card quickly. The process had taken 25 minutes. I then took another 10 minutes for the excision (including applying dressing).

He came back the next day for dressing. I could tell he was rather unsettled by something and I asked him, ”Is something wrong?”

“About yesterday. Why did you have to go through with the litany of risks and complications before the procedure, some of which were utterly remote and unnecessarily troubling? For goodness sakes’, it’s just a blasted ingrown toenail. I’m 340 years old and I have seen more than my fair share of ingrown toenails in elves”. He looked completely nonplussed.

“It’s what my medical council demands of me nowadays so that you can be considered to have given informed consent, if not I may run the risk of being found to be guilty of professional misconduct”

He winced a little as I removed the old dressing.

“Does it hurt?”

“Not as much as your bloody longwinded and scary consent-taking process yesterday”. He took a look at what he signed the day before and muttered “bloody stupid and ridiculous”.

I smiled and replied “I have no choice”.

“Of course you do, Doc. I trust you. I have been seeing you for 20 years!”

“It’s not so simple”. I applied the new dressing, gave him a pat and saw him off

It’s really not so simple. A good practice requires a good doctor-patient relationship. We always say it’s important that our patients trust us. But that’s only half the story. It is equally important that doctors trust their patients. But with recent events in middle-earth, I could not afford to. I still want to trust my patients, but my entire practice, my livelihood, and my family’s livelihood depends on me staying professionally alive. And hence I can no longer afford to trust my patients. All it takes is one of them to turn around and say “I did not give informed consent even though I have signed that I did” and I am dead.

Some folks say consent-taking is not a form but a process. That’s true. But consent is also documentation. And it’s pretty obvious some wise guys have decided for all of us that a patient’s signature and a form is no longer enough.

Some folks also say that specific circumstances lead to specific decisions and conclusions peculiar to those circumstances, so the principle of precedence may not hold here. Unfortunately, that is at best an opinion unless it is tested and tried again in the courts and seriously, I wouldn’t want to be that guy to put this to the test.

It’s not just that patients and doctors need to trust one another, but colleagues as well. How can there be trust if I cannot even depend on a relatively senior trainee and colleague to diagnose an acute abdomen? My colleagues in the hospitals now tell me they trust no one now anymore and the workload and decision-making keeps escalating upwards to the senior staff. Private practice seems the only plausible escape.

By all means, promote transparency and accountability. But we all also know that once trust is lost, it is extremely hard to get back. The fact remains that for trust to happen, the system and regulatory authorities must do what it can to foster this trust and not undermine it. The clear and present threat of professional misconduct is enough to radically change how doctors trust patients and colleagues. Call it kiasu-ism, prudent risk management, whatever.

As far as my medical practice goes, I can no longer afford to trust. It’s logical and inevitable, brought on by external events beyond my control.

For the record, my usual charges in the past for excision of ingrown toenail is about 80 to 100 bucks. I charged Johnny 140. That’s for the 25 minutes I needed to get “informed” consent, which I could have spent otherwise seeing another patient. Thanks to some doctors making decisions and setting standards for the whole profession, Johnny had to pay another 40 bucks which I derived no satisfaction from making. Like most doctors, I have to make rent and pay salaries and there’s only so many hours in a day. So much for healthcare cost-containment and improving productivity.

It’s really not so simple, Johnny.

First Note

July 3, 2011 at 11:37am

Dear Friends and Colleagues

Yes, the SMA Hobbit is back. But on a different forum from the SMA News.

Even an old coot like this hobbit has to keep up with the times and social media simply cannot be ignored.

The social media offers several advantages from an established hardcopy print medium like the SMA News. For one, there is no printing press deadline to meet. The SMA news goes to print every month and this hobbit has strived hard to meet these deadlines and come up with articles with some regularity in the past. There is no such requirement with the social media such as a blog or a post on Facebook. I can post every few days or every few months.

Secondly, hobbit columns in the past in the SMA News have to conform to rough expectations of print space, i.e. about two pages or about 1300 words. With the social media, there is no such expectation. A post can be just several words or a few hundred words or even more than the usual 1300 words.

Thirdly, there is no editing or censorship by the SMA News Editorial Board. What I post on Facebook is entirely my personal business. There are pluses and minuses to this new arrangement. The main plus is that I am not subject to the Editorial Board’s decisions on what to print and what not to print. The minus is that I am entirely on my own here. Don’t get me wrong, I respect the role and responsibility of the SMA News Editorial Board. They are volunteers and they have a job to do. Having said that, that doesn’t mean I necessarily agree with their decisions even though I must respect them when I contribute to SMA News. So when the differences came to a head over a certain article, I exercised my right to retire from the SMA News as a columnist. To be absolutely clear, there were many important reasons that led me to my retirement from the News about half a year back, including the demands of work, family, but the decision of the SMA News Editorial Board not to print a certain article was also a big contributory factor.

Enough of the past, back to the present. Since this is my first long post here, I need to stress that whatever is posted here does NOT represent in any way the official position of the SMA on any issue. The folks in SMA have kindly set up this Facebook account for me to continue my nonsensical and personal ramblings in Cyberspace. I appreciate this opportunity and new forum and I hope you will continue to support me here virtually as you have had in the past in print.

As you are well aware, the Hobbit lives in a mythical parallel universe called Middle Earth. Unless otherwise and specifically stated, events and personalities referred to in this Facebook account are completely fictitious and belong to the realm of utter fantasy. If you do suspect that I am referring to anyone or any event that you think may have occurred on planet Earth (i.e. 3rd Rock from the Sun, and NOT middle-earth), then let me again reassure you your suspicions are totally unfounded and without any basis.

For the avoidance of doubt and to be absolutely clear – all future writings and opinions expressed here on this Facebook account are un-researched, untrue and cannot be substantiated. So read at your own risk, folks.