We all know that doctors are talented folks. Even though Hippocrates said that learning the art (of medicine) is long but life is short (Ars Longa, Vita Brevis), many doctors still find time to excel in a whole lot of things other than medicine.

For a start, these obvious overachievers are in politics. Across the Causeway, both the Prime Minister and Deputy Prime Minister are now doctors: Dr Mahathir and Dr Wan Azizah. If you think Dr Mahathir is the biggest or best example of a doctor-politician, overturning 61 years of UMNO rule, many will argue that Dr Sun Yat-Sen (Graduate of Hong Kong University) may have achieved something even greater. In 1912, he overturned more than 2000 years of dynasty rule in China with the founding of the Republic of China. He is recognised as the Father of modern China. But even if maybe not the greatest, Dr M certainly gets the prize of being the oldest medically-trained national leader at 92.

Then there is the Marxist guerilla leader of Cuba – Che Guevara. He’s really Argentinian and a doctor. He is most revered in Cuba and has been called “Castro’s brains”. He lived from 1928 to 1967 before he was gunned down in Bolivia.

President Georges Clemenceau who led France for two spells: 1906 to 09, 1917 to 1920 was also a doctor.

Finally, there is the infamous President Bashar Al-Assad of Syria. Thousands have died in the ongoing civil war with one quarter of the population fleeing as refugees abroad and another quarter being internally displaced refugees. Guess what? Until he was recalled by his father (the original President Assad) to Syria to take over from his elder brother who died in an accident, he was a low-key guy practicing ophthalmology in London.

Many doctors also excelled as a man of letters. Many famous writers were doctors. The creator of Sherlock Holmes, Sir Arthur Conan Doyle, was a doctor. He applied a fair bit of medical knowledge to the mysteries he wrote. The late Michael Crichton, author of Jurassic World and the original Westworld, was a doctor.

Famous short-story writers, Russian Anton Chekhov and Chinese Lu Xun, were also medically trained. Lu Xun dropped out of medical school in Japan. But Anton Chekhov practiced medicine most of his life. In fact he said “medicine is my lawful wife and literature is my mistress”.

Somerset Maugham, the famous short-story writer author and playwright studied medicine in St Thomas Hospital (Now King’s College London). He recalled that medical education was beneficial to him as an author, “”I saw how men died. I saw how they bore pain. I saw what hope looked like, fear and relief”

For the realm of poetry, there is the Romantic Poet John Keats, who lived only for 26 years (1795 to 1821) and studied medicine in Guy’s Hospital (Now also part of King’s College) and wrote famous poems such as “Ode to a Nightingale”, “Sleep and Poetry” and “On First Looking into Chapman’s corner”.

Representing the female gender is Han Suyin. She wrote the famous novel “A Many Splendoured Thing” which was made into a film starring Jennifer Jones and William Holden. It was even made into a soap opera series that lasted 6 years in the United States. She was half Chinese, half Flemish and studied medicine in Brussels and she practiced medicine for quite a few years. In fact, she was a physician in Nanyang University (the original “Nantah”, precursor to NTU) in Singapore when it was founded in the fifties. She was actually invited by the University to teach literature then, but she refused, saying she wanted “to make a new Asian literature, not teach Dickens”.

In the area of mass media entertainment, there are also examples of doctors who made it big. Korean -American actor Ken Jeong  who starred in the over-the-top comedy trilogy  of “Hangover” movies is actually a licensed physician in California.

The famous Taiwanese singer Lo Ta-Yu (罗大佑) is also medically trained. He is generally regarded as one of the godfathers of Taiwanese rock.

New Age spiritual guru Deepak Chopra is also a doctor. And also a very well-trained one. He graduated from a top Indian medical school – All India Institute of Medical Sciences before completing his residency training in the United States in internal medicine and endocrinology. And then he gave that all up to be a guru. He is currently actually a voluntary full professor in the University of California, San Diego, in the Department Family Medicine and Public Health.

In the area of sports, there is the legendary Sir Roger Bannister. In 1954, he became the first man to run the mile under 4 minutes. He later became a much-respected neurologist in Pembroke College, Oxford. Interestingly, he wanted to be remembered more for his work in medicine than in sports. But alas, it is the latter that he is now famous for.

Then there is the captain of the Brazil football team in the 1982 World Cup, Socrates. He is recognised as one of the most accomplished footballers Brazil ever had. He actually earned his medical degree while playing world-class football! This is in contrast to many sportsmen and women who studied medicine after they had given up their sporting careers. A notable example of this is USA swimmer Jenny Thompson, winner of eight Olympic gold medals. She went on to pursue a career in medicine after retiring from swimming.

Lastly, there is an interesting area that many doctors, especially in Australia, like to venture into – the field of winemaking. Many Australian wine estates are named after their founders. These wine estates were generally founded in the 19^th or early 20^th century. Many wine drinkers will recognise these names instantly:

Penfolds, Hardy, Lindeman, Angove, Cullen, Houghton

They were all doctors. Dr Penfolds, Dr Lindeman, Dr Hardy etc….I guess doctors back then already knew that a glass or two of wine was good for you.

These names are some of the largest and most famous wineries Down Under. For example, Penfolds is the largest wine brand in Australia. Hardy and Lindeman are in the top five- or top-ten lists as well. They are now no longer run by doctors.

A living example of a famous winery that is run and owned by a practicing doctor is Catena of Argentina. Catena is often credited for putting Argentinian wine on the world map. The 4^th generation owner and managing director of the winery, Laura Catena Zapata is actually a graduate of Stanford Medical School and still practices medicine.

Perhaps there is more to life than being a doctor, after all.

 

 

Another year. Another year of Salma Khalik. And her style of journalism.

On 26 March 2018, she wrote in The Sunday Times, “Drilling down, the MOH concluded that much of the higher claims was the result of overcharging and overtreatment by doctors in the private sector”. (“Diagnosing the cause of rising costs”).

On 29 March 2018, in another lengthy opinion piece in The Straits Times “Prescriptions to rein in healthcare costs”, she claimed that the “The Competition Act” had outlawed the “price guide set by the Singapore Medical Council”

These two claims of Salma Khalik have resulted in The Straits Times clarifying that they are incorrect (30 March 2018, Page 2). With regard to the claim of 26 March 2018, it stated that “This is incorrect, the Ministry of Health did not draw such a conclusion” (that much of the higher claims was the result of overcharging and overtreatment by doctors in the private sector).

Interestingly, the online version does not have this erroneous sentence anymore. Presumably, it has been removed. Instead, there is this label:

 Correction note: This story has been edited for clarity.

In this hobbit’s humble opinion, the correction note is euphemistic.

Salma Khalik was not being unclear originally and hence there is no need to edit for clarity. She was very clear in what she meant, but, she was just wrong. Factually wrong.

The correction note should really read:

This story has been edited for factual inaccuracy.

C’mon. Call a spade a spade.

And had she succeeded in making that claim that has now been “clarified”, a wedge would have been created between MOH and the medical profession, especially the private sectors doctors. Because the medical profession would have been pretty upset and wondered how on earth did MOH come to such a conclusion when in reality, many factors contributed to the rise in healthcare costs.

The second mistake is obvious to everyone who is even remotely interested in this subject. The price guide (i.e. Guidelines of Fees) was set by the SMA, not SMC.

This hobbit is baffled. If you go to the The Straits Times website, there is this is the description of Salma Khalik (http://www.straitstimes.com/authors/salma-khalik):

“With more than three decades in journalism, Salma Khalik has been in the thick of things, from covering the stock market to general elections. In the 15 years on the health beat, Salma has gone into Sars wards as that deadly bug put fear into Singaporeans, and uncovered “unhealthy” practices such as patients being given overdoses of chemotherapy drugs. With her grasp of the healthcare system, Salma has also helped to explain the impact of policy changes, supporting some and pointing out failings in others. Her over-riding goal is to push for a better healthcare system for all”.

If the memory of this hobbit serves him correctly, Salma Khalik has been writing about healthcare matters since the last century/millennium, not just 15 years. It’s a great write-up for an experienced journalist. If so, how can she mistake the SMA for the SMC?

This hobbit has no idea. Maybe like the old coot that this hobbit is, she is also getting on in age and the effects of ageing are showing. After all, Salma Khalik has been around for ages. Nowadays, many reporters and journalists do not stay for more than 10 years in one job before they move on, or even five years; either they get promoted to management, or leave for other opportunities in the media or press industry, or leave the sector altogether. In journalist-lifespan terms, she can proudly claim to be an example of an object of antiquity, like the Pyramids of Egypt or the Great Wall of China.

She is a walking piece of history herself. Let this hobbit illustrate as this hobbit remembers only too well. Because there is a style to Salma Khalik’s journalism, best  explained by the fact that she has an “over-riding goal” to push for a better healthcare system.

I do not know much about journalism, but if I were a journalist, my “over-riding goal”  would be to be a honest, competent journalist committed to reporting the truth and avoiding factual inaccuracies. But that’s just me.

Let’s take the example of dispensing rights of doctors. In January of 2005, she wrote two opinion pieces in The Straits Times to push for it. In the process, she completely misrepresented what the then DMS (Prof K Satku) meant. The reporting was so pernicious in nature that it warranted the DMS to clarify with the whole medical profession by circulating the minutes of the meeting between DMS and Salma Khalik (which took place on 1 Dec 2004). The minutes reported “On the separation of drug dispensing form the practitioner as in developing countries, DMS said that it would not happen anytime soon”.

From this statement, Salma Khalik made the quantum leap in logic to conclude that separation of prescription and dispensing will certainly come. DMS said in the cover-note to the circulated minutes that “I will strive to mend any damage done to our trust so that we can work together to serve our patients better”.

We can safely conclude from this sentence that trust between MOH and the medical profession was likely to have been damaged by Salma Khalik’s writing in 2005, since DMS is the most senior and preeminent medical officer of MOH, if not the whole of government and hence the office of DMS is well-placed to represent MOH, especially in the area of professional matters.

In the history of Singapore, no MOH official or MOH political office holder has ever saw the need to circulate the minutes of a meeting between MOH and a reporter to the whole medical profession. Salma Khalik holds this singular honour.

To bolster her case that separation of dispensing and prescription was the right thing to do, she then gave the example of Zimbabwe and recommended we should learn from them in this matter. Yes, Zimbabwe. I am not making this up. Maybe that is why Robert Mugabe came not infrequently after that to Singapore, rumoured to be for medical treatment; maybe it is because Singapore was asked by Salma Khalik to learn from Zimbabwe.

That was in 2005, it is now in 2018. Nothing much has changed. The relationship of trust enjoyed between MOH and the medical profession is put under strain due to the inadvertent efforts of Salma Khalik. In 2005, it was about dispensing rights. In 2018, it is about private doctors overcharging and overtreatment leading to higher insurance claims.

In any case, after 13 years, we still do not have separation of dispensing and prescription rights, despite what Salma Khalik claimed in the January of 2005. Maybe she should just humbly apologise for what she wrote in 2005. After 13 years, we can certainly conclude Salma Khalik was wrong in 2005.

An interesting note to the correction by The Straits Times on 30 March 2018 – did the ST themselves realise Salma Khalik made the two factual errors or it had been notified by someone else, such as MOH? If The Straits Times was informed by an external party of these inaccuracies, shouldn’t the correction come in the form of a published letter in the ST Forum rather than some itsy-bitsy column on Page 2?

One more luminary example of Salma Khalik’s style of journalism: She now laments that it was wrong for the Competition Act to outlaw the Guidelines of Fees (GOF) in the aforesaid opinion piece of 29 March 2018. She then asked who is to be blamed for the current situation? Her answer to her own question included a list of blameworthy folks:

• The Government
• Insurers
• Doctors
• Patients
• The Competition Act (for outlawing the GOF)

Let us go back to April 2007. The SMA reluctantly withdrew the GOF in early April of 2007, after its AGM. On 12 April 2007, she wrote an opinion piece titled “Scrapping an obsolete practice” and therein, she opined, “Without a fee guideline, doctors can be more open and competitive. They may post their rates prominently, or even advertise, since that is now allowed”. She also gave “kudos to the Competition Commission” (for outlawing the SMA GOF). She further remarked, “As the world changes, so too must the medical profession. The days when no one questions their diagnoses or their charges are gone”.

Obviously, her 2018 position differs remarkably from what she advocated in 2007.

In retrospect, obviously, three things happened in 2007:

• She explained wrongly the impact of the policy change of outlawing the GOF
• She wrongly pointed out “the failings” in the policy of keeping or having the GOF, and
• She wrongly “supported” the policy of outlawing GOF (versus her 2018 position)

Going by the above three points, in the interests of intellectual honesty, shouldn’t she blame herself too, since she supported and advocated for the outlawing of the GOF in 2007?

But she hasn’t blamed herself. We can only surmise she is either blameless or not  blameworthy.

Let us now revisit her write-up on the ST website

“With her grasp of the healthcare system, Salma has also helped to explain the impact of policy changes, supporting some and pointing out failings in others. Her over-riding goal is to push for a better healthcare system for all”.

Her goal as a senior healthcare correspondent of The Straits Times may be acceptable, but going from the above three examples, obviously her grasp of the healthcare system has been inadequate and inaccurate on more than one occasion.

There are many examples to Salma Khalik’s style of journalism, but let us take a break for now.

---

*Note: For more commentary on the 2005 saga involving Salma Khalik and DMS, readers can check out this link:

https://www.sma.org.sg/sma_news/3701/hobbit.pdf

 

In April, doctor-bashing has reached new heights with the United Airlines episode, even though the aircraft hasn’t even taken off. This hobbit has made a mental note that the next time they ask for any doctor onboard in any American flight, keep very quiet. And definitely no United Airlines. I will rather fly the unfriendly skies with Smaug than UA. Meanwhile, a new word has entered the lexicon – “re-accommodate”. It means bashing the brains out of you so that you will move your butt somewhere else. These guys are so mean, they make ogres look like smurfs. And remember the Korean Air princess that demanded the plane be made to dock again because the peanuts weren’t warmed? That’s literally peanuts and the Korean Air princess looks like Minnie Mouse compared to those “security agents” from the Chicago Airport Mob.

Enough on the subject of doctor-bashing, we now move on to Ms Salma Khalik, who does not ever indulge in doctor-bashing and is the acme of objective, responsible and quality journalism.

Recently, an opinion piece by her in the Straits Times (Two Quick Fixes to Rein in Healthcare Costs; 13 April 2017) on how to rein in private sector healthcare costs came to the conclusion that we need to re-introduce some Guideline of Fees (GOF) for private sector doctors and insurance companies need to do away with riders so that there will be no first-dollar coverage.

This drew out some varied responses in the medical profession (What else is new?). Most are in agreement that some sort of GOF would be helpful and after 10 years of GOFless-ness, it is clear and evident that GOF was helpful in reining in healthcare costs previously, although those geniuses in Competition Commission Singapore are still thinking otherwise apparently. Also, many doctors opined that doctors’ fees are not to be entirely blamed for the rapid rise in bill sizes. Hospital and implant bills have also contributed to the hospital bills that patients or insurance companies have to pay. The growth rate of doctors’ bill is comparable to the growth in implant and hospital bills. While we can rein in doctors’ bills with a GOF, we also need to tackle how hospitals charge, especially in terms of consumables, medicines and implants.

Some folks think that riders are not to be blamed for rising bill charges. And that without riders, patients with catastrophic diseases may not even be able to afford private care even if they had bought private medical insurance. The large amounts of money that go to deductibles and co-payments would be prohibitive. A cancer patient who needs radical surgery or repeated chemotherapy or radiotherapy would be bankrupted by the deductibles and co-payments alone.

Also, there is little risk of abuse arising from first-dollar coverage because no one would want to go for unnecessary and painful treatment options arising from catastrophic diseases such as cancer, stroke etc.

There is some if not much truth in all this. Yet, it would also be intellectually dishonest to suggest that abuse of first-dollar coverage does not occur. For example, do we really believe, hand to heart that doctors do not ever offer the more expensive diagnostic or treatment option to patients just because they bought riders and insurance, when there are cheaper and just as or almost as effective options?

The answer must lie somewhere in between. And it depends on whose perspective. For the unfortunate cancer or stroke or AMI patient who has to undergo long and expensive periods of therapy, he would be glad he had bought private insurance with the rider. There is no point arguing over this. The benefits of having done so in hindsight are evident and incontrovertible.

But from a systems perspective and building a sustainable model, something also needs to be done. Perhaps a rider that offers only first-dollar coverage for catastrophic diseases would be better that the current system where first dollar coverage is offered for everything. Riders should not include first dollar coverage for elective procedures like sleep apnoea surgery, total knee replacement etc and even elective PTCAs (I have heard of elective PTCAs involving 8 stents….but that’s another story for another time).

Personally speaking, I think Ms Salma Khalik has made some good points in her article. But the picture is bigger. Beyond GOF and riders, the government has a big role to play. For starters, it’s how the government looks at private healthcare. A case in point is that of private hospital land. The novena hospital site was auctioned off for ~$1.26B to the highest bidder. The amount went into our reserves but it re-rated the entire private hospital sector and costs have gone up tremendously since then. Contrast this to Hong Kong, they did not give their latest private hospital land in Aberdeen, Hong Kong simply to the highest bidder. The private land sale came with many operational conditions that the hospital owner has to be committed to before the tender was awarded. In other words, Hong Kong government was interested in seeing the private hospital sector develop in a sustainable and healthy way to meet locals’ needs. Singapore was initially just interested in pocketing the money arising from the land sale from the highest bidder. Sure, our reserves grew by $1.26B, but guess who’s paying for it now? Can the government now have the moral authority to ask the private hospitals and doctors to rein in their charges when they had pocketed $1.28B for a piece of land that is best described as “modest”? It’s a tough sell. I think the novena site is still the most expensive hospital site on this planet on a per square foot basis.

Finally, as we seek to control private sector healthcare costs, we should not neglect what is happening in the public sector. It is wishful thinking to believe that the private and public sector are distinct and separated by some great wall, but in actual fact, they are inter-linked, especially in terms of the charges for private patients (Class A or B1) in the restructured hospitals and private sector. Both compete with each other to a very significant extent.

Just last week, I came across an outpatient bill for the simplest and most basic of blood tests –  the urea/electrolyte/creatinine panel from a restructured hospital. The restructured hospital charged $59 + GST = $63.13 for this panel! The lab that my clinic usually uses has the same panel with a list price of $28. As you know, private clinical labs usually offer discounts of 30% to 40% which means the private laboratory only takes about $17 to $20 (+ GST) for performing the test while the clinic keeps the difference to cover administrative costs (syringes, needles, alcohol swabs, procedural effort, disposal of biohazard waste etc, etc) and review of test results etc.

The panel test was ordered by the specialist attending to her at the private SOC clinic and certainly it was warranted. Nonetheless, the patient complained bitterly that investigations were so expensive at this restructured hospital.

I just smiled back. I told myself there were some things she was better off not knowing.

 

 

 

 

All doctors in Singapore stress over their CME requirements and getting enough CME points to enable them to renew their Practising Certificates. Most of the time, we go for CME activities for the free lunch and take a power nap or two. If all else fails, we do CME MCQs to get the required CME points. After that, we forget everything we have heard or read and let’s face it, it’s quite a pointless exercise at the end of the day.

Well, fear not, this Hobbit is here to help you helplessly with another absolutely pointless CME activity. No points will be awarded because this test will never be sanctioned by SMC. As usual, answers will be made known sometime next month, if ever at all. The pass rate you are required to obtain zero CME points is 0%.

1          Which of the following local professional organisations is the oldest in Singapore?

1. Alumni Association
2. Singapore Medical Association
3. Academy of Medicine Singapore
4. Singapore Medical Council

 

2          Which of the following is FALSE about Yong Nen Kiong (“NK Yong”)

1. He is the longest serving President of SMA
2. He writes a weekly cardiac health column for the Business Times
3. He performed the first open heart surgery in Singapore in 1965
4. He performed the first open heart surgery in Malaysia in 1969

 

3          Who was the “Agong” of Alumni Association?

1. Arthur Lim
2. Chee Phui Hung
3. Chao Tzee Cheng
4. WC Cheng

 

4          Which of the following about LMS is TRUE?

1. It was a four-year course and was issued by the KE VII College of Medicine
2. Originally, a LMS graduate was not allowed to take fellowship degrees in UK (i.e. cannot specialise)
3. It stands for Licentiate in Medicine and Surgery and is a recognised basic medical qualification by SMC
4. All of the above

 

5          Which of the following is the odd one out in terms of place of origin?

1. Soo Khee Chee
2. Foo Keong Tat
3. Kandiah Satku
4. Tan Seang Beng

 

6          Which of the following doctors was a paediatric trainee once?

1. Ho Ching Lin (ophthalmology)
2. William Chew (endocrinology)
3. Lee Wei Ling (neurology)
4. All of the above

 

7          Who was the first local Professor of General Surgery?

1. Jimmy Choo Jim Eng
2. Yeoh Ghim Seng
3. Foong Weng Cheong
4. Ong Siew Chey

 

8          Which of the following about KKH is FALSE?

1. It once held the (Guinness Book of World Records) record for the busiest obstetric hospital in the world
2. Was the first hospital in Singapore to perform successfully a IVF procedure using frozen embryos
3. The current hospital stands on a cemetery site and the original address of this site is called 1 Jalan Cemetery
4. It is the first and only public hospital to house a McDonalds fast food restaurant in Singapore

 

9          Which of the following passed the Part 1 exams of all 3: FRCS, MRCP and MRCOG?

1. Ng Han Seong
2. Benjamin Ong
3. Fock Kwong Ming
4. Chee Yam Cheng

 

10        In YLLSOM, there is a Wong Niap Leng Medical Bursary; who is Wong Niap Leng?

1. He is/was a Professor of Medicine
2. He is/was a Dean
3. He was the first person who performed liver transplant in Singapore
4. He was the canteen operator of the canteen in KE VII Hall in Sepoy Lines

 

11        Politically speaking, which of the following is the odd one out?

1. Tan Sze Wee
2. Chia Shi-Lu
3. Benedict Tan
4. Kanwaljit Soin

 

12        Which of the following is FALSE about Tan Chorh Chuan?

1. He was Dean of Medicine and DMS
2. He is an accomplished poet and has published an anthology of poetry 3 years ago
3. He used to be orientation chairman of KEVII Hall (i.e. chief ragger)
4. He played hockey in KEVII Hall as a block fellow after he graduated

 

13        Which of the following is FALSE regarding Poh Soo Kai?

1. He was the first Honorary Secretary of SMA and a founding member of the PAP
2. He was detained under the ISA for a total of 17 years over two spells
3. He was released from detention after he confessed to being a Communist
4. He was a grandson of the philanthropist Tan Kah Kee and a relative of philanthropist Lee Kong Chian

 

14        How much did Arthur Lim take home as the founding director of SNEC?

1. $1,000 a month
2. $10,000 a month
3. $20,000 a month
4. $0 a month

 

15        The first national specialty centre to be set up in Singapore was

1. National Heart Centre Singapore
2. National Skin Centre
3. Singapore National Eye Centre
4. National Cancer Centre Singapore

 

16        Which of the following funded a big part of his undergraduate medical education in Singapore by winning a lottery (i.e. 4D)?

1. Yeoh Khay Guan
2. Goh Lee Gan
3. Teo Eng Kiong
4. Fong Kok Yong

 

17        Which of the following is (probably) the richest doctor in Singapore (by value of shares in publicly-listed healthcare companies)?

1. Lee Hung Ming
2. Loo Choon Yong
3. Ang Peng Tiam
4. Tan See Leng

 

18        Which of the following is FALSE about TTSH?

1. The first location for TTSH was opposite SGH on Pearl’s Hill
2. Tan Tock Seng, the person, was a Straits Chinese born in Singapore
3. It set up the first rheumatology unit in Singapore
4. It was originally called the Chinese Pauper Hospital

 

19        Which of the following is the odd one out in terms of employment history?

1. Ang Yong Guan
2. Paul Ananth Tambyah
3. Lam Pin Min
4. Lim Wee Kiak

 

20        Which of the following statements about Gleneagles Hospital is FALSE?

1. After refurbishment, it was opened by Mr Goh Chok Tong
2. The hospital started out as Gleneagles Nursing Home
3. It is 60 years old this year
4. It is named after a valley in Scotland and the valley is populated by many eagles

 

 

If there is one thing Singaporeans can learn from history – it is history repeats itself. The lesson here is the British will let you down.

Yes, just like how the Brits capitulated to the Japanese in the defense of Singapore in World War 2, how they also withdrew their Armed Forces prematurely in 1971 from Singapore, the MPS (A British organisation) has also now abruptly refused to continue incidence occurrence medical indemnity plans for our Obstetrician and Gynaecologists (OGs) in Singapore.

For those of us not familiar with the facts, here is a brief summary of the situation:

Until now, MPS has always offered incident occurrence (IO) plans. IO plans cover the doctor for events/claims that occurred in the past as long as the doctor had bought the IO plans from them then. For example, if you had bought a IO plan in 2005 and a claim was made against you in 2015 for a 2005 incident, you will be covered by the medical indemnity provider even thought in 2015 you are now buying a plan from another provider.

This is in contrast to claims-made (CM) plans – which is more akin to a car insurance scheme. To claim medical indemnity from a CM plan provider, you must remain in continuous membership with the CM Provider – from the date the incident occurred till the time you are aware a claim has been against you. There are also some extended reporting benefits(known as “tail cover”) that you can buy but here’s the rub – the tail cover offered here by MPS is only 5 years with no assurance of renewal or extension. And most of the time, it iscontinuous membership – which implies you cannot change provider. You are stuck with this organization for better or for worse.

This really sucks because for OGs (or for that matter anyone dealing indirectly with obstetrics or newborn, such as neonatologists and anaesthetists) because under Singapore law, the patient can sue you for up to 3 years upon turning 21. That means they can sue you until they’re 24. So a 5-year tail cover is plainly put – grossly inadequate. If you are covered under an IO plan, that’s OK, because the cover is forever as long as the incident occurred when you had bought the plan under MPS. So at least for now, the neonatologists and anaesthetists are OK since they can still buy IO plans. But for the OGs (both public and private sector), the writing is on the wall.

Since the OGs will not be able to buy IO plans once the current one expires, what’s the advice for OGs going forward?

If you are a resident training to be OGs –

Time to change specialty before its too late. Or make sure you get into an OG subspecialty that doesn’t do deliveries. Or train to be a medical indemnity lawyer. The sector is booming.

If you are a peri-retirement OG, in your mid to late fifties or older –

Time to quit altogether, retire or at the very least, drop obstetrics from your practice. MPS still offers IO plans for gynaecology ONLY. Many are already doing this as we speak. Many mothers have already been told by senior OGs that this is the last baby the OG is delivering and subsequent pregnancies will have to be managed by other OGs. There is a mass movement to retirement by many such experienced OGs, which is very unfortunate, both for the OGs and the patient.

If you are somewhere in between…

As the saying goes, the glass is either half empty or half full, depending on how you look at it. In places like Taiwan, there is no such thing as a medical indemnity provider and the doctor self-insures. In other words, the doctor sets aside a part of their earnings in preparation for the possibility that someone will sue them. You now have to set aside money enough for 24 years post-retirement. That’s probably when you are about 90 years old. All that has to be factored in when you charge your patient today. You have to probably raise prices because your costs have gone up. When you “self-insure” you do not enjoy the benefits of risk-pooling which indemnity organisations and insurance companies enjoy. Therefore costs go up. Delivering SG50 babies just got a lot more expensive.

The glass is half full because with the sudden retirement of many senior OGs, there is much less competition. You will probably get more deliveries per OG. Business will boom. If you are in your mid forties or younger, you probably have a long enough career runway before retirement to make enough money to fund your post-retirement tail-cover.

But do remember, when in doubt, please do an LSCS. No more mucking around with doulas, water deliveries, or even forceps or vacuums. Just get the baby out safe and sound as quickly as possible. To hell with giving your patient “a good birthing experience” when you want to avoid fully funding yourself a litigation experience later on. And do remember to order the full gamut of pre-natal testing to cover  yourself. Defensive medicine works when medical indemnity fails.

Other dark side ruminations….(The really useful/useless advice for OGs)

Plan A

Well, since there is only a 5-year tail cover available for you from MPS, you have to time your retirement and death carefully. You have to die within 5 years after your retirement. This can be achieved by working until you drop dead. Which is the usual case anyway for many doctors. Frankly, we should also consider legalising euthanasia for OGs. Then you can tell your favourite anaesthetist to give you a lethal injection because “my tail cover expires tomorrow”

Plan B

An easier or more palatable option is to transfer most of your assets to your spouse/mistress/boyfriend/children when you retire. Leave nothing much in your name so that the plaintiff cannot get a lot of money out of you even if he wins the suit. You may be made a bankrupt but it’s no big deal when you are a retiree and your beneficiary still takes good care of you. There are obviously certain risks to this plan. The person/beneficiary whom you leave the money to must be trustworthy. When in doubt, do not give your money to a Mainland Chinese travel agent. If the beneficiary runs away, please see Plan A’s option of lethal injection….

If you are the patient….

Your child gets to keep his/her right to sue the doctor that delivered him/her up to 24 years from birth. But otherwise,you are quite royally screwed.

Firstly, you have less choice because as aforesaid, OGs are running for the exits. They are retiring as fast as they can. It may even come to the point where midwives will be the ones delivering your baby. Provided we can even find them because as far as this Hobbit knows, we haven’t trained a midwife for at least 15 years and many of these (old) midwives haven’t performed deliveries on their own for many years. But perhaps midwives are the way forward because patients don’t usually sue nurses or midwives for the simple reason that you can’t get a lot of money out of them. It doesn’t do you much good financially to bankrupt a midwife and also get stuck with a large lawyer’s bill. Doctors can pay – that is why they get sued.

Secondly, because there is no adequate tail cover available, OGs has to raise prices to self-insure their own tail. You, the patient, are paying. Hopefully, the baby bonus will cover this increase in costs.

What does this all mean?

 

The first lesson we should glean from this is that we need to be independent and masters of our own fate. We have been independent for 50 years, yet for all intents and purposes we are still a British colony when it comes to the area of medical indemnity as this incident has demonstrated. A local provider needs to step up to the plate. This will not happen on its own because medical indemnity as a business is simply not very profitable compared to other areas of insurance and indemnity. In other words, the market will not sort itself out. Government needs to lean on someone….

The second lesson is that the law is meant to protect the people and their rights but there are limits to this protection before it backfires on the people. This is a clear example. The confluence of the law and the withdrawal of IO plans for OGs has worked together to undermine the patient’s and public interest. Everyone is a loser here – the OG and the patient. And probably the patient is the bigger loser than the OG. The law needs to be changed to balance the rights of the patient and the doctor for a win-win situation rather that the current lose-lose one. Again, the law will not change by itself. Changing laws is the prerogative of parliament and the government. For a start, look at the 24 years of tail. Do we really need to give the patients or their parents such a long period to sue the doctor? Can we also limit the amount of damages payable?

The third lesson is that this is only the tip of the iceberg. Any specialists or specialty that deals with the newborn and young will suffer from a long tail of potential litigation. After OG, which specialty is next? Will it come to the point where all specialties can only purchase CM plans with no adequate tail cover or worse, self-insure? Costs will escalate sharply when this happens. This has already happened in other countries. But this is not inevitable if all stakeholders make the correct decisions now.