The Year of the Dragon is off to a very blazing start in terms of juicy news and scandals. For once, Singapore may be outdoing our neighbours to the north on this front. Of course, local healthcare cannot be seen to be left out on the cold either. We have our fair share of dragon flatus, some of harmlessly odorous, while others are plain noxious.

 

Let’s start with the harmlessly odorous – the case of the new Parkway hospital located at Novena, just a few metres away from the Ministry of Home Affairs (which some wise guy has quipped should be renamed simply as Ministry of Affairs) headquarters. Controversy has erupted with it being renamed as Mount Elizabeth Hospital@Novena. Some doctors in the Mount Elizabeth@Mount Elizabeth are unhappy with this and are even considering taking legal action. This Hobbit thinks this is unnecessary. In fact given the exodus of specialists from the public sector (which the Lianhe Zaobao in a recent report has wisely attributed to the residency programme, among other things) as well as this naming precedent set, we can have a slew of new names for existing private hospitals: TTSH GS@Mount Elizabeth, KKH@Thomson, SGH Colorectal@Adam et Paragon etc. The possibilities are endless. We can even have a facility called Nobody@Residency in time to come.

 

More on the residency. It has come to light that some poor ASTs (Advanced Specialty Trainees aka Registrars aka Always Screwed Trainees) and BSTs (Basic Specialty Trainees aka Basically Screwed Trainees) are now forced to pay for and take Residency-related exams. The reason is that by making them pay, they will try their level best to pass the exams. Also, there is claim that they need to take these American exams because the UK exams have changed so much they are no longer good. This logic is astounding. It’s like making a GCE “A” Level student pay for IB exams so that they have a vested interest in passing the IB Exams. Or getting motorists to pay ERP charges even when they have chosen a route from Point A to Point B that hasn’t got any ERP gantries. Or charging hotel guests for room service they didn’t order so that they will order room service anyway. I believe if this was the commercial world where common sense and the law applied, it’s illegal. You cannot charge a person for a good or service he doesn’t need or want. And the geniuses who came up with this really believe that the UK exams aren’t good enough, that’s just too bad. You don’t change things mid-stream and make people pay for it. It’s not the money, it’s the principle. Can you imagine Ministry of Education telling students and parents “Hey, we let you enroll in the GCE system but now it’s not good enough. So now, you have to pay for the IB exams so that you will try to pass it and at the same time, you still have to pass the A levels?” If you messed up by offering a system that is now not good enough, that’s your business. Don’t mess with people in mid-stream. And people only pay for and take exams out of their pockets because they are relevant. Making them pay for the exams matters little to outcome if the exams are irrelevant. In any case, these BSTs and ASTs are already given a raw deal – they have to train junior residents and have heavier workloads to cover up for the residency system. Please don’t make it any worse

 

More disturbing is actually how much hands-on will these residents get. My old Professor of Surgery (arguably the most respected clinical teacher for Surgery in the last 30 years) said quietly to me that he was deeply troubled. He said residents only got to perform simple operations like hemorrhiodectomy as a Year 3 resident and they become qualified specialist surgeons after Year 4 residency! This professor is of the age that he probably won’t ever be operated on by a product of the residency programme. But there is no escape for the rest of us. I think chaps who are promoting the residency programme as a wonderful thing should stand up and be counted and state that they will only be operated on by surgeons who are trained in the residency system. Put your liver/gall bladder/stomach/colon/rectum where your mouth is. That’s intellectual honesty. In case you are wondering, this Hobbit has nothing against residents- these are poor chaps stuck in a situation that offers no way out besides quitting. They are stuck as victims of a cruel monopoly introduced by people with motives best known to themselves.

 

As you are well aware, the SMC has given us a nice New Year present by announcing on 4 Jan 2012 it is raising our annual subscription fees from $300 to $400, because it has been under-recovering and operating at deficit. These are seemingly standard and plausible reasons. For one thing, although SMC is run on our subscriptions, the accounts have never been shown in the SMC Annual Report. There is almost complete opaqueness in terms of SMC’s financial situation to the countless and nameless doctors working on the ground and paying subscriptions to keep SMC afloat.

 

There are two main functions of the SMC – maintaining a registry of doctors (including CME records) and the costs of running investigations and disciplinary actions against allegedly errant doctors.

 

We shall start with the first – maintaining a registry. Anyone who has run something similar to a registry or an association or a club will tell you that it’s all about scale. Except for initial processing costs, unit costs drop dramatically when the size of the membership increases rapidly. And considering that the number of doctors registered in SMC has increased dramatically in the last 6 years, one wonders how come costs have actually gone up for each member. In Dec 2005, when fees were last raised, there were 6748 doctors on full or conditional registrations. Be end of 2010, this number has increased to about 8600, an increase 27%, according the relevant SMC Annual Reports. By now the figure should be about 30%. That’s a lot of doctors in 6 years and a lot of fees paid. Maybe the SMC should why briefly explain why the principle of economy of scale doesn’t apply to the SMC registry.

 

The next big SMC function is that of investigations and disciplinary actions. We don’t have access to SMC records in this area but this Hobbit will hazard a guess that the biggest “customer” of SMC is actually MOH – in other words, MOH is the biggest referral source of cases to SMC. Some of these cases are obviously necessary and the doctor gets disciplined. But one must wonder – how many of these cases could have been unnecessary, in which the doctor is found not guilty? While SMC funds should be used to fund to process complaints from individuals, one must ask should these funds be used to fund complaints from MOH, especially when MOH is so well-funded? Shouldn’t MOH share the costs of such cases, especially for the ones when doctors are not found guilty?

 

Lastly, we really have to look at SMC operating costs. Especially at manpower, which probably forms the largest chunk of costs. One example will illuminate this concern.

 

There are now two executive secretaries in SMC- (link: http://www.sgdi.gov.sg/; accessed on 24 Feb 2012). Executive Secretaries are very senior doctors and they do not come cheap. Let us look at Section 10 of the MRA – “The Medical Council may appoint an executive secretary and such other employees on such terms and conditions as the Medical Council may determine”. That means Section 10 of the MRA states there is only ONE executive secretary at any one time, together with an indeterminate number of other staff. Let’s leave it to Attorney General’s Chambers to advise on the legality of this arrangement of having two executive secretaries since we doctors know nuts about such legal stuff and also the AG Chambers is the government’s legal advisors, but surely this duplication of posts and manpower must lead to increase in costs? Why have two when the law provides for one? No doubt the bureaucrats in MOH will advise the politicians to amend the MRA on this aspect and it will probably be done, but the point is, who is really looking at costs?

 

In case you are wondering if “a” or “an” can mean more than one – Let’s look at the law again – the Medical Registration Act (MRA) that provides for the existence of SMC. Section 18 (1) and (2) of the Act states that “For the purposes of this Act, there shall be a Registrar of the Medical Council. The Director of Medical Services shall be the Registrar of the Medical Council”

 

That means there is ONE DMS and ONE Registrar at any one time and they are one and the same person. Of course, there can be an Acting DMS or Registrar when the DMS is on leave etc. But at any one time, there is only one person holding (and presumably paid for) the two jobs on a long-term basis. In this case, it’s our very esteemed and well-loved Prof K Satku. No one has any problems here with this arrangement or assumes there can be more than one Registrar or one DMS, this Hobbit included. So how can it be that there are two executive secretaries? By the way, if you do go to the online government directory (as given above), in addition to 2 executive secretaries, there are about 36 other staff that of executive level and higher, including one legal counsel. That’s some serious manpower there.

 

This is enough flatus already for 400 bucks. It’s getting kind of hard to breathe in our little shire hut. Gotta go out and get some fresh air. Bye for now.

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.