Private Healthcare Insurance: Trust & Transparency

In life, there are errors of commission, and there are errors of omission. Dr Alan Ong’s opinion piece in The Straits Times on 7 March is of the latter. His column “The coming healthcare crisis: Unsustainable financing” talks about the dangers of having runaway healthcare inflation and offers several solutions.

He is the medical director of AIA Singapore, a major player in healthcare insurance locally. Therefore he must know what he is talking about. And what he commits or omits glaringly is most worthy of our attention.

What does he commit in the abovementioned article?

  • Singapore needs to have a financially sustainable healthcare system
  • Integrated Shield Plans (IPs) will become unaffordable if current healthcare inflation trends persist
  • We need to maximise the value or healthcare outcome out of every healthcare dollar spent

The healthcare insurers feel that to maximise the healthcare outcome of every healthcare value spent, the following needs to be achieved:

  • Appropriate healthcare behaviour
  • (better) Collaborations between healthcare providers and insurers
  • Greater transparency in outcomes

In providing recommendations and possible solutions to the above, Dr Alan Ong quotes extensively from the recommendations of the Health Insurance Task Force (HITF) Report. The HITF was a Taskforce that comprised representatives from Life Insurance Association (LIA) of Singapore, SMA, CASE, MOH and MAS (Monetary Authority of Singapore) and it was chaired by an independent chairperson. The Report of the HITF was published in October 2016.

He states that MOH’s move to stop the sale of full riders (as recommended in the HITF Report) and introduced co-pay riders for new IP plans will promote appropriate healthcare behaviour.

He further opines that the appointment of certain doctors to preferred provider panels will improve collaboration between insurers and healthcare providers. He gives an example of healthcare screening as an example of how having empanelled doctors will prevent consumption of unnecessary tests. He further states by steering higher volumes of work to empanelled providers is good for these select few who will benefit from more work and policy holders will also likewise benefit as insurers negotiate better treatment pricing for them from these empanelled providers.

Dr Ong then goes on to discuss pre-authorisation, which is also a recommendation of the HITF, and says that with the implementation of this through a standard industry-wide form, the insured will have better peace of mind that their claims will be covered.

On the issue of costs, Dr Ong states that “Singapore already has a fair degree of transparency”. What Singapore needs is more transparency on clinical outcomes and quality indicators so that patients can make better informed choices, providers can improve and insurers can know what they are paying for.

All this sounds fairly reasonable. Now let’s look do a deep dive into the facts.

The whole gist of Dr Ong’s article is that as long as there is no unnecessary consumption of healthcare, financing will be sustainable. Actually, that is one big assumption. Sometimes even when there is no unnecessary consumption, financing is still insufficient or unsustainable, because the premiums collected are just plainly not enough or when the middle-man takes too much. Middle-man being people like Managed Care, Third Party Administrators and even folks like actuary practitioners and insurers.

In any case, let’s give him the benefit of the doubt, since he is a public health specialist (i.e. with specialist knowledge of healthcare policy and financing, presumably). Unnecessary consumption can be therefore divided into two categories – overpricing and over-servicing. Often, it is a combination of both.

HITF’s #1 Recommendation

The HITF report made several recommendations. Two were stated in the article, preferred panels of providers (doctors) and pre-authorisation.

Very interestingly, he failed or omitted to mention the FIRST recommendation of the HITF, which is the recommendation to have Medical Fee Benchmarks or Guidelines. Arising from this recommendation, MOH formed the Fee Benchmarks Advisory Committee in January 2018. In Nov 2018, this Committee published fee benchmarks for 222 commonest procedures covering the vast majority of procedures performed in private hospitals in Singapore.

All IP providers in Singapore are members of the LIA, which in turn was represented on the HITF. The HITF had government and consumer representatives as well, in addition to SMA, which represented doctors. Arising from the HITF’s recommendations, the MOH (i.e. government) formed this Benchmarks Advisory Committee which promulgated the fee benchmarks in November 18. It must be stated that these benchmarks serve as guides, and there is no legal obligation of providers to adhere to them. But nonetheless, doctors, being generally obedient people, largely do charge according to these benchmarks nowadays, since they are issued by MOH.

Therefore, in theory and on moral grounds, all IP providers should respect and subscribe to the recommendations of the HITF (because there were members of LIA), as well as the benchmarks published by a Committee appointed by MOH (MOH being a fair, neutral arbiter). Adherence to these benchmarks will effectively stamp out overcharging and go a long way in making healthcare financing sustainable in the private sector.

An Error of Omission

But this is what actually happened. In a brief survey done in late 2019 for common procedures done by doctors, a year after the benchmarks were published, only ONE IP provider fully respected the fee benchmarks: NTUC Enhanced Incomeshield. Incomeshield will pay its empanelled doctors as long as they charge within the benchmarks. AIA and Prudential reimbursed doctors at the lower end of the fee benchmark bands. AIA basically took the lower limit of the band and added another 10%.

For example, the MOH fee benchmark for gastroscopy was $600 to $1000, AIA’s reimbursement rates was $660. For removal of single breast lump, the benchmark was $2500 to $3200, AIA’s reimbursement rate was $2750.

To be fair, that is still OK, because the AIA reimbursement rate falls within the range of the MOH fee benchmarks, albeit at the lower end. But another 3 IP provider’s reimbursement rates fall below even the lower limit of the MOH fee benchmarks!

Frankly, for the MOH fee benchmarks to work (to make healthcare financing sustainable), everyone needs to play their part and NOT UNDERMINE these benchmarks. This would mean doctors must not charge beyond the higher limit of the benchmarks, and payers, such as IP providers, must not reimburse below the lower limit. If IP providers do NOT RESPECT the benchmarks at the lower end, why should doctors charge within the higher limit?

This hobbit is quite sure an experienced industry player like Dr Alan Ong knows all this. But he has not mentioned any of these practices of other members of the healthcare insurance industry. In fact, he makes NO mention of the MOH Fee Benchmarks at all! It is as if though MOH Fee Benchmarks have no role in making healthcare financing sustainable and averting his “coming healthcare crisis”. Hello, these are MOH fee benchmarks, not the hobbit’s grandmother’s benchmarks, ok?

Incredible isn’t it? I call this an error of omission. And a glaring one. As to why this omission happened, you, the alert reader of this inconsequential column, had better ask Dr Ong yourself. Did The Straits Times run out of newsprint because all the paper has been redirected to make toilet paper? But we do have the online version now after all…..

We now go on to empanelling doctors, otherwise as “preferred providers”. He gives the example of how unnecessary screening can be curtailed with this. This hobbit is confused. Since when did IP Plans cover screening? Also, if you want to curtail unnecessary screening, just state clearly what an insurer would pay (and how much) and what it wouldn’t pay for. It’s that simple.

The second point on empanelling is even more disturbing. He wrote “Patients will benefit too, as panels allow insurers to negotiate better treatment pricing, leading to lower co-payments and premiums”. It means it empowers insurers to extract even lower prices from providers (including doctors) when half the IP providers are already reimbursing below the lower limit of the MOH Fee Benchmarks. AIA is now at “lower end+10%”. How much lower do you want doctors to go, Dr Ong?

In itself, pre-authorisation is not a bad thing. But the information sought for in this standardised pre-authorisation from the LIA members initially did not give the assurance that the information will not be used against policy holders when they renew their policies. It was only after repeated attempts by SMA to get this assurance for patients and SMA’s initial refusal to support the pre-authorisation form that LIA finally clarified and assured that information collected from the pre-authorisation form was to be used solely for pre-authorisation.

The Big Picture

Let’s now get back to the big picture.

Private insurance plays a small part in the health financing of Singapore. 40% of the financing comes from government. A lot of the remaining 60% comes from our savings in Medisave, State-run insurance Medishield-Life, employment benefits and out-of-pocket payments.

While private healthcare insurance plays an important part in the bigger scheme of things, fixing it alone won’t make healthcare financing sustainable. This is important to note, in case anyone gets delusions of importance or grandeur with regard to private healthcare insurance. We are actually not as dependent on private healthcare insurance as many other developed countries.

Secondly, there are four big stakeholders in the private healthcare insurance space:

  • Patients
  • Government
  • Providers (including doctors)
  • Private Healthcare Insurance Companies (especially IP providers)

Trust

The patient is at the centre of it all. Who does he trust most? In Singapore’s context, it is probably the government, often seen as a fair (albeit stern) arbiter of various stakeholders’ interests

Who does the patient trust more, after the government? I think if you were to poll many patients and ask them to choose between doctors and private insurance providers, most of them will choose doctors.

This hobbit’s hunch is that generally speaking, the public trust private insurance companies less than the government or the medical profession.

And of course, doctors trust the insurance industry even less.

Life is tough when you have a deficit of trust from both patients and doctors. I don’t know how much the government trusts the insurance companies, so I won’t comment on this aspect.

What can the insurance companies do to improve the situation? The answer is in what Dr Ong went to at length in the second part of his column: transparency

Transparency

He mentioned about the need for cost transparency, transparency on quality and clinical outcomes. This hobbit would like to suggest a few more areas in which we can have much more transparency:

  • Can the insurance companies be transparent about the criteria by which doctors are empanelled? And why some doctors cannot be empanelled? No one now knows how insurance companies select doctors to be empanelled.
  • If we extract price savings from doctors, how much of these savings will be passed onto as savings on premiums of insurance policyholders by the insurance companies? How many cents for the dollar? Some listed companies have a dividend policy, promising X% of their profits will go to paying out dividends to shareholders. Can IP providers make such a commitment? If so, doctors may be encouraged to cut fees  to ease the policyholder’s burden.
  • Can we be transparent on what is reimbursable and what is not and publish these online, so that not just doctors, but policyholders can also see clearly for themselves?
  • Can we also be transparent on doctors’ reimbursement rates to policyholders? As a policyholder holder myself, I would like to select my IP provider based on several factors. One of which must be how the IP provider pays the doctors that take care of me. I might want to choose the IP provider that pays the doctor the most, or the least. That choice should be for me to make as a consumer or patient. But this information is now not available to the public.
  • How many doctors are empanelled in each IP provider? Will every IP provider publish this important metric? I think MOH also has a role in ensuring better transparency in this aspect. If the IP providers do not want to publish this individually, for a start, it can publish how many empanelled doctors there are in each of the IP providers. Split the data into two categories: private specialists and specialists in the restructured hospitals. It would empower the public to make an informed choice when they buy an IP Plan.

Trust and transparency. We all need them to make healthcare financing sustainable in the private sector. The private healthcare insurance sector included.

 

 

 

 

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.

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.

Academic Meritocracy and Medical School Admissions

Recently there has been some disquiet about the NUS Faculty of Medicine (sorry, this YLLSOM thingy never quite jelled with an old coot like me. My degree is from Faculty of Medicine, not some guy who gave a lot of money to NUS) accepting students from ‘less than the best academic’ records and more varied sources (read: not just RI and HCI).

A certain Anthony C.H. Leong wrote in The Straits Times (23 July 2019), “What is wrong with the meritocratic old ways of judging by the quality of the candidate’s academic results, further refined through an interview? We tell our children to work hard academically to get the relevant results for the course they wish to pursue in university, only for them to be denied a place by some populist policy. Their parents will have to cough up a fortune to send them overseas. I don’t think those who are unfairly rejected, especially those who do not have the means to go overseas to study, would think very kindly about their country and its professed meritocracy”.

There are quite a few points raised in this quote that needs addressing. First, we need to understand what is the purpose of a medical school, especially a state-funded medical school. The purpose of the NUS Faculty of Medicine or YLLSOM (OK lah, he did give a lot of money to get his name on this school) is to produce the better doctor, or the best doctors it could to serve Singapore. This hobbit emphasises “to serve Singapore” because YLLSOM is largely state-funded (i.e. by taxpayers). To serve Singapore may be of secondary importance if it was privately funded, but it is not.

The primary purpose of YLLSOM is not to fulfil someone’s aspiration to be a doctor, although the individual’s aspiration and the YLLSOM’s primary purpose are not in conflict with each other, philosophically speaking. This may sound somewhat brutal, but that’s  the hard truth. They only come into conflict because of the scarcity of resources – the number of places YLLSOM can take, with the limited resources it has (funding, manpower, space etc), versus the number of people who want to become doctors.

Second, a primer on meritocracy. The word meritocracy comes from the word ‘merit’ obviously. Meritocracy is about putting people in power and/or privilege due to the ability they have, and not due to other factors, such as wealth or social position/inherited titles. We seldom say it, but the people rewarded in a meritocracy, by a meritocracy, are actually the “meritorious” (deserving of merit).

The Cambridge Dictionary describes meritocracy as a “social system, society, or organisation in which people get success or power because of abilities, not because of their money or social position”.

The next point about a meritocracy is that there are many forms and notions about meritocracy. What Mr Anthony Leong has described is academic meritocracy. This concept of meritocracy is widely held by large swathes of society, no thanks  to cultural or even governmental norms. But it is not the only form of meritocracy. For example, when we reward athletes for their performance in competitive sports or highlight citizens for acts of kindness, service to community, valour, or moral fortitude, these are, in a way, also forms of meritocracy, but the norms are different. A National Day Award from the government, such as the Public Service Star, is based on non-academic norms of meritocracy. A person who swims the fastest 100m butterfly in an Olympic Game gets the gold medal and is given S1M. The world and Singapore society have decided that he is “meritorious” and hence deserving of the medal and cash award. But it is another form of meritocracy that is not academic meritocracy. Academic meritocracy is simply a form or meritocracy based on academic ability and performance.

Dynastic and feudal China since  the Sui Dynasty in 6th century AD practised academic meritocracy through the imperial exams. People who excelled in these exams were put in positions of power as officials of the imperial court. Sometimes, the Emperor himself witnessed the final round of these exams himself and marked some of the scripts! Surely this is sponsorship and belief in academic meritocracy of the highest order! Yet one of the main reasons China faded as a superpower in the Qing Dynasty is that it clung to outdated norms of academic meritocracy. People were rewarded and appointed because they excelled in the Classics and Confucian Texts and not on Science and Maths. The world (especially Europe) moved on while China was stuck in backward feudalism. So even as we support and uphold meritocracy, we need to examine and revisit what are the norms of society so that the form and substance of meritocracy remains relevant to the needs of society. Academic meritocracy is no exception.

Back to YLLSOM. As aforesaid, its main aim is to produce the best doctors that it could to serve Singapore. Academic meritocracy is nothing more than an allocative tool to achieve this main aim. Academic meritocracy is not an end in itself.

There are several ways to look at what YLLSOM is trying to achieve by moving slightly away from pure academic criteria for admission into its ranks. First, it is an admission that academic performance is NOT the only meritocratic norm for admission.

Secondly, the correlation between a good doctor and outstanding A level academic performance is not that strong. It is true that you need to have above average academic performance to survive the rigours of medical education. But is a straight As at H2 with three H3 paper distinctions student more likely to make a good doctor than a student with 4As at H2 with no H3 papers? Or will the student with 2A and 1B at H2 necessarily make a worse doctor than a student with straight As at H2 level? The answer is obviously “no” to these questions. Beyond attaining a minimal level of academic achievement necessary to suggest the student has the ability to complete his MBBS, academic performance at A levels does not predict or correlate with his eventual performance as a doctor.

Thirdly, by admitting people from different backgrounds, YLLSOM is perhaps admitting that it is important to have diversity in the medical profession. We need brilliant people to be the next professors of medicine and make scientific breakthroughs. We also need less brilliant (but still intelligent-enough) people to be  the doctors serving patients in the community. Both are equally important, and everyone else in between.

Diversity also prevents groupthink. The risk and downside of groupthink is very real, whether in the medical profession of any organisation. Just look at the Hong Kong government now and the unrest in its society. It is probably a result of groupthink in its highest ranks that prevented them from seeing the grave repercussions that have arisen from trying to push through the now infamous Extradition Bill.

Actually, the policy of choosing people not just based on the best academic performance for Medicine is not new. It is just expressed in a different form. Those of us who entered NUS Medical School in the eighties will remember that the government then had a policy of deliberately trying to shunt the best students to other fields such as Engineering or the Arts because it felt it needed the best academic talent not to be concentrated just in Medicine. There was apparently a PSC officer at the medicine admission interviews (sitting at the extreme left or right of the panel of interviewers) who would offer you “a deal” of sorts – would you want to consider a teaching scholarship? Or a PSC scholarship to Cambridge to read Maths? We never knew whether these offers were real or not, but we were all advised by our seniors to say “no” to show our resolve to become doctors. I know of quite a few people with A level “perfect scores” who did not get into medicine. And while there was no evidence to prove so, people with less than perfect scores seemed to have a better chance of getting into Medicine in the eighties.

In summary, this hobbit thinks:

  • The job of YLLSOM is not to give out places as awards or rewards for academic excellence under the framework of academic meritocracy. It’s main job as a publicly funded medical school is to produce the best doctors it could for Singapore.
  • Academic meritocracy, which is meritocracy based on academic ability, is not the only form of meritocracy. Academic meritocracy is often used as an allocative tool, but it is not an end in itself.
  • The norms of meritocracy are as important as meritocracy itself. The norms determine who is meritorious, and these norms have to be examined and revisited from time to time so that meritocracy remains relevant to the needs of society.
  • Beyond attaining a required level of academic performance that suggests the person can withstand the future rigours of a medical education, there is little correlation between actual performance as a doctor and his A level results.
  • Diversity in a medical school cohort is important, because each cohort has to fulfil different roles in society. Diversity also prevents groupthink.

 

Emails To The Hobbit 2019

It’s been a long time since we published some of the letters this blog has been receiving. Actually, no one writes letters anymore and they send the blog emails instead, and so, we have re-titled this column as “Emails To The Hobbit”

 

Email 1

Dear Wise and Short One

Up Yours

I am a staff of a Wizard Malpractice Indemnity Scheme known as Am Pee Ass.

This is what happened: An elderly hobbit came seeking help from our indemnity scheme member, hereto known as “Brown Wizard”, to complain of bloatedness and blood in his poop. The Wizard told the hobbit he needs to do a full check up. The hobbit lay down, let Wizard touch his tummy, then followed instructions to lower his trousers and turn over. A digital rectal examination was done. Subsequently, the hobbit went home, and told his family what happened. Outraged, the family got the elderly hobbit to make a statutory declaration and demanded that the Council of Wizards explain why the Wizard did such an invasive check without consent.

Brown Wizard didn’t know what to say. And likewise neither do I. Do you have any advice? BTW, why are hobbits so anal? (pun intended)

Yours sincerely

Rectus Loquitus

Case Manager, Am Pee Ass

 

Dear Rectus Loquitus

Thank you for being so straight talking. The problem is that you did not adhere to the Modified Monty-Monty test which states clearly that you have to take into consideration what are the relevant factors for this elderly hobbit, and take a hobbit-centric approach. I hope this makes sense to you. Because it doesn’t make any sense to my simplistic mind.

 

Yours confusedly

Hobbitsma

 


 

Email 2

Dear Hairy Feet

It’s A Fine World

I understand that my Case Manager has contacted you already about the elderly hobbit who complained against me because I examined him per rectally without informed consent. Actually I have another problem that I wish to confide with you. I was busy tending to my many injured animal friends when suddenly  a magical raven came to deliver a message. “Hi, I came from Rosie, the hobbit Samwise’s wife. You know he’s always having an eating disorder, eat until so fat. Can I get a letter from you to certify that he has this illness, so that I can get the prescription refilled?” In good faith, I wrote the parchment and passed it to Raven to bring back. Unfortunately, it wasn’t Rosie the wife, but Samwise’s mistress the enchantress Lavender who wanted the parchment to pass to the wife, so that Rosie will divorce Samwise.

Samwise is now suing me for emotional distress and marital discord. Council of Elders have ruled that I was at fault, and must pay 50,000 gold pieces. The fact that Samwise’s family situation is complicated, or that Lavender impersonated as Samwise’s wife to get confidential information were discounted or even ignored. The fact that I was busy looking after many sick animals was also not a mitigating factor. They were of the opinion that I could have easily verified the identify with a few simple questions: Does Samwise snore in bed? What’s his underwear size? When was the last time he shaved his feet? And so on. I have been found solely responsible, because I did not ask verify the Raven to confirm that Raven is truly sent from Rosie  and the Raven is indeed who it claimed to be.

I just found out from my case manager Rectus Loquitus that Am Pee Ass doesn’t cover fines and I have to pay the 50,000 gold pieces out of  my pocket! I am now flat-out broke!

Please help!

Yours tragically,

Brown Wizard

 

Dear Brown Wizard

This is truly unfortunate. What I suggest you do is to stop treating all these poor injured animals and go into private practice where you can charge more. Generally, humans and elves pay more. Please consider starting up your practice in the posh Mount Expensive Hospitals. Either the Old or New one will do. Then the next time you get slapped with a big fine, you can still pay.

Yours Cynically

Hobbitsma

 


Email 3

Dear Ring Bearer

Survival Medicine

I need some reassurance. I am an ICU Associate Consultant in a public hospital. And I am your Survival Medicine’s Number One Fan.

A few days ago, an elderly man was found unconscious at the road side after a hit-and-run incident, in extremis. The ambulance crew brought him in, the emergency team intubated him and admitted him into ICU. The next day, 3 anxious people turned up. They claim they are the wife and children. I don’t believe them. I don’t dare to believe them. Maybe it’s the second wife and HER children who wanted his fortune. I demand to see the marriage certs, birth certs and IC of all three. As well as the man’s IC. They produce all. But, the man in the hospital bed now looks NOTHING like the photo in the IC. I don’t think this is the real family, I have no way to verify. The policeman says they found these anxious people at the site of the incident. Oh- maybe they are the driver and passengers of the car that hit the old man! I refuse to update any of them, and escalate every decision of care to the Ethics Committee. I feel good that I have protected patient’s confidentiality, and avoided paying a hefty fine in case I am guilty of not verifying a person’s identity. Do you think I will survive all this?

Yours sincerely

Dr Veritus Verify

Associate Consultant

Department of Vericationology

Wa Gia Si General Hospital

 

Dear Veritus Verify

You will definitely not just survive, but thrive in this new age. I hope your patient survives too.

Yours shortly

Hobbitsma

Emeritus Consultant Verificationalist

 


Email 4

Dear Katek,

Non-Clerical Referrals

I need your advice in a most delicate matter. I am a cleric specialising in the art of clairvoyance. Many fellow clerics refer patients to me for investigations because I can see things that other clerics cannot see and my work helps my colleagues diagnose better. These patients are referred to my department (i.e. Department of Diagnostic Clairvoyance) and my cleric assistants then take clairvoyance images which are later sent to me to read and interpret and report on. These reports are then sent back to the clerics who sent these patients to me for their follow-up. Recently, arising from a case of missed follow-up for a patient referred by a cleric accidentalist, the Lords of Judgement have decided that for referrals from accidentalists, the reports should not be routed back to the accidentalists. Instead, the clairvoyance clerics can decide the appropriate specialists that should follow up these patients referred to us, for example bone-setting clerics, heart clerics etc.

I am most distressed. I chose this specialty because I am rather allergic to physical contact with patients and I do not want to assume primary cleric-patient responsibility. I just like to read clairvoyance images with no direct patient contact. How do I decide who to refer to when I haven’t even met the patient or talked to him or examined him? Does it mean that for all patients referred by accidentalists I now have to take over as the primary cleric? A good and proper referral involves a lot of judgment and is not just looking at images and then performing a simple clerical (pun intended) task like filling a form

This is not what I signed up for. The Lords of Judgment are not trained in the Art of Healing like us clerics, can they change the way we clerics practise?

Yours sincerely

Robert Cork

Most Senior Clairvoyance Cleric

Mount Expensive Hospital (Old Branch)

 

Dear Cleric Cork,

I am so sorry. I really cannot help you there. As you know in the Realms we live in, whatever the Lords of Judgment say, we must comply, humans, elves, dwarves and hobbits included. We just have to suck it up. Only the House of Power can override what the Lords of Judgement say by issuing edicts. And it is not going to happen until the Fifth Age of Man (i.e. a few thousand years from now)

Yours Powerlessly

Hobbitsma