Let’s go straight to the hottest topic of the day – SMC. SMC in its letter to The Straits Times on 9 January 2013 clearly thinks there is no potential conflict of interests in the system and SMA thinks otherwise in its reply on 11 January 2013. We will have to see how this plays out.

However, there are some important points to note. Chief of which is nothing much has changed for decades in the system. The DMS has always been the Registrar and a member of the SMC. The MOH has always been a user of SMC services and the regulatory arm of MOH reported to the DMS. The secretariat has always had several staff seconded from MOH. The terminology may have changed somewhat, from Preliminary Proceedings Committee to Complaints Committee, from Disciplinary Committee to Disciplinary Committee to Disciplinary Tribunal etc, but the system really hasn’t changed a lot. Defendant doctors have always had good legal representation at SMC hearings, so the excuse that doctors today employ more legal resources to defend themselves is a limited consideration at best.

In other words, whether potential conflicts of interests existed or not, we have lived satisfactorily with this set of conditions for a long time. So why the discomfort and discontent now? The answer lies in context.

The practice of medicine is contextual. We learn in the wards here how a jaundiced neonate looks red rather than what is described in textbooks written in the West – yellow. GPs here do not practice much obstetrics even though those elsewhere often do. These are contextual considerations.

Therefore, since medicine is contextual, the regulation of medicine is also contextual. But policymakers and regulators sometimes do not see this point. Take this case in point- which can occur in any GP practice – a middle-aged male patient has been seeing the same GP for 20 years. He consults the GP regularly, and so does his family. Occasionally, before he goes for his year-end holiday, he would ask for a few tablets of low-dose short-acting benzodiazepine. The GP would give him five days of medication each time. The GP has never given him more than five days a year and he has never asked for them except when he goes for a trip to Europe or America to cope with jet lag. In fact there are several years when the GP never gave him any because the patient never asked for them. On two or three occasions in the last twenty years, the GP has also given him a few tablets of “librax” (which contains chlordiazepoxide) for dyspepsia.

You would think the above seems innocuous enough and probably practiced all over the island in many GP clinics. The patient, a well-mannered family man with a good job, is probably not a benzodiazepine addict. However, if you look at the relevant guidelines, this GP is already in big trouble.

Let’s refer to “Administrative Guidelines on the Prescribing of Benzodiazepines and other Hypnotics” issued by MOH on 14 Oct 2008. It states that “Patients who require or have been prescribed benzodiazepines or other hypnotics beyond a cumulative period of 8 weeks…. should not be further prescribed with benzodiazepines or other hypnotics and must be referred to the appropriate specialist for further management”. If you think you have any professional liberty to vary from this “guideline”, rest assured that you DO NOT. In the covering note to these Guidelines signed off by the Director of Medical Services (DMS) himself, it is further stated that “all medical practitioners are requested to comply with the administrative guidelines with immediate effect…. Your strict cooperation is appreciated”.

A reasonable student of the English language may think that a guideline is only a guideline and one can sometimes vary from it. But for all intents and purposes, once you read the strongly worded covering note, you will know you have no leeway and any variance from the guideline will render you exposed to the distinct possibility of punitive action by the authorities. A GP giving a patient only 3 days of benzodiazepine medication a year over 20 years would mean he has not complied with these Administrative Guidelines.

We have no doubt that the said Guidelines are well-meaning and are targeted at the scourge of benzodiazepine abuse. The problem is that these Guidelines ignore contextual factors. The condition of “beyond a cumulative period of 8 weeks” over a short time appears reasonable, but once you extend this condition to long term patients who have been seeing the same GP for 10 years or even 20 years or longer, then the condition of cumulative period of 8 weeks is most difficult to comply with.

Another example of context is our American-based Residency. By adopting the American-based residency system almost lock, stock and barrel, we again ignore the context of how the American Residency system operates. The Residency System in America operates against the backdrop of healthcare spending of 17.9% of GDP, of which more than half comes from public spending (~9.5% GDP). How much is ~18% of the economy? Let this Hobbit put things in perspective – According the Ministry of Finance website – The entire Singapore government lived on a revenue budget of 15% GDP and expenditure budget of 14.2% GDP in 2012, the difference between the two being our surplus.

The entire Singapore government means literally everything, from defense, home affairs, housing, health to the prime minister’s office. In other words, Americans (public and private) spent more on health than Singapore’s government spent on everything. Residency training, whether in America or Singapore, is largely public-funded. America’s public spending amounted to 9.5% GDP. 9.5% as a fraction of the American economy is more than what Singapore government spent on its top four (budget-wise) ministries combined in 2012: Defense (3.5%), Education (3%), Transport (1.5%) and Health (1.3%)

So once you take these numbers into context, it’s easy to realise Singapore can never, ever adopt the American Residency system without experiencing either great pain or great increase in training costs. The other more insidious corollary is that doctors are really one of the biggest drivers of healthcare costs. How they practice has a big effect on healthcare costs. The American doctor is trained to operate in an environment that is dependent on a national healthcare expenditure of 18% GDP. We were trained to live within 3 to 4% GDP, of which only 1.3% GDP is government spending. Our residents will take the almost the same exams as their American counterparts (Some sources say it is 80% similar in content). Guess where are our healthcare costs are heading if our residents are trained to think and dispense care in almost the same way as their American peers?

Don’t get this Hobbit wrong, we should spend more on healthcare, and public spending of only 1.3% GDP is clearly unsustainable given an ageing population. However, when we adopted the American Residency, we ignored the vast differences in funding context that the two countries’ healthcare sectors operated in, all in the name of providing more “structured training” that our old system seemingly did not have. Let’s hope the money is there from Ministry of Finance when the full implications of this policy takes effect years down the road.

Now, let’s move back to the issue of SMC. Singapore is a small Asian country with a limited talent pool. People holding multiple appointments is not an uncommon phenomenon. Hence, it is not unexpected that potential conflicts of interest may exist. But these can be managed, as it was in the past. Some ambiguity in the Asian context is also sometimes not undesirable. From a Machiavellian point of view, power, backed by the law and buffed by ambiguity can be a potent deterrent.

But here’s the catch, for this sort of milieu to work, you need leaders who are deeply discerning about context as well as being discrete and precise in the exercise of power. You need people who are reflective and above all, masters of finesse. Finesse is what separates those who can thrive and extract the most, and the rest who bungle and mess up in an environment where some ambiguity and potential conflicts of interest exist. Finesse requires insight, precision and a deep appreciation of context. Finesse is even beautiful.

If you look at the Permanent Secretaries/DMSes of old, you cannot but appreciate that they were men of finesse – how they managed to “outsource” the problem of overcharging to SMA by getting SMA to come up with the Guideline of Fees (GOF). Since the SMA GOF had no direct legal bite, it was really quite an ambiguous thing in terms of addressing the issue of overcharging. But it was effective for the 20 years it existed and MOH didn’t even have to do the heavy lifting. Now that’s finesse!

Now witness the letter written to The Straits Times on 9 January and you decide independently for yourself if it is a work of finesse. Fixing potential conflicts of interest (If any exist at all) may not actually solve the more difficult underlying problems.

These are exciting times in the local healthcare fraternity. We are not talking about groundbreaking research being performed by A*STAR whales or the renovations that are underway in the Most Expensive Old Hospital so that doctors can admit their patients to the Most Expensive New Hospital.

We are talking about the reproductive process. At the Singapore Gonad, sorry, I mean, General Hospital no less. We have ex-senior civil servants purported having sex in a carpark somewhere on the hospital campus. Now this is a true mystery to me. The Hospital is a 24-7 place where there are busy people working on shifts and family members and friends visiting patients round the clock. And the car-parks are reasonably well-lit, even for the multi-storey carpark located in the equivalent of Siberia within the campus. How do you have coitus discretus in a hospital carpark? Unless it’s the one in the mortuary…..or the one across the street behind the big white building. Some of those guys working in that building are so brain dead that they wouldn’t notice two humpback whales humping in the carpark if they walked past them. Your only worry is if a helicopter suddenly lands next to you.

And there is also this mention about a carpark near a women and children hospital. You may want to deliver your baby there, but seriously, you don’t need to “do the do” near it. Personally thinking, I think the carpark at IMH has the best ambience. But that’s the psychotic side of me speaking.

You would have noticed that the carparks at private hospital have been ignored by the SP and chip folks. That’s because at the rates the private hospitals are charging, you might as well check into a room in a six-star hotel.

So much for the mucus stuff. Now for the serious.The SMC elections are underway again. Please remember to vote.

Anyway, I know a chap who is so disillusioned with the whole thing he voted “00” three times. I am more optimistic. I voted for the person I didn’t know so that should I ever need to appear before SMC,  at least there is one SMC doctor who can chair the disciplinary tribunal instead of getting a senior lawyer or retired judge. Then they can’t all claim they know this Hobbit and stuff me with a lawyer chairperson.

Speaking of SMC, it’s has been in the news recently. And if I may say, for the wrong reasons. Some of its work has been described as “legally embarrassing”. As a doctor, this hobbit has absolutely no clue what is “legally embarrassing”. But I can give examples of what I think are “medically embarrassing” situations:

• You prescribe Propecia to a bald monk
• When a female patient complains of urinary urgency, you attempt a per rectal prostate examination on her
• You certify someone as dead and he/she comes back to life

In most medically embarrassing cases, I think the doctor will waive their fees or at least offer a big discount. I am not sure what applies in “legally embarrassing” situations. Maybe the lawyers can advise us.

Anyway, the SMC just issued a press release stating that the two cases that had been cited as controversial were processed under the old Medical Regsistration Act (MRA) and new cases will come under the new and better MRA that was amended recently. I have read through the press release and this Hobbit is still unsure how these new changes in the amended MRA will prevent similarly legally embarrassing situations from happening again. They said having a retired judge or senior lawyer on the Disciplinary Tribunal (DT) will improve things. Maybe they will. But how are these learned ladies and gentlemen going to prevent legally embarrassing charges from being drafted? Are they supposed to help in the drafting of charges and also to judge the case as well? I hope not.

I am no great fan of aesthetic medicine. Having said that, the SMC action to apply to the High Court to set aside the Disciplinary Committees’ previous decisions on two doctors practicing aesthetic medicine is to be welcomed. The next question that should be asked is who should pay for the legal costs of all parties of what are now legally embarrassing efforts? It would seem grossly unfair if the two doctors have to pay. If SMC pays, it means all registered medical practitioners end up paying and perhaps increase in subscriptions if SMC cannot balance its books. Guess who gains from these legally embarrassing cases?

Finally, the SMC press release stated a Review Committee will be formed. It will be chaired by a senior doctor and assisted by a senior legal practitioner and will comprise senior doctors and other legal practitioners. That’s good news. This hobbit has a few serious suggestions to make:

• The doctors, especially the Chairman on this Committee should be doctors in active practice, in touch with what is happening, especially in the private sector, since many SMC cases involve the private sector.
• The doctors in this Committee should not be current or recent SMC Presidents, Registrars, Secretaries, members or even SMC lawyers. You can’t review yourself objectively. They should be at best resource persons
• This Committee should present its findings and recommendations publicly
• The ultimate decision to accept or reject the Committee’s recommendations should rest with the Minister for Health and not anyone now in SMC.
• All new SMC members must undergo substantial training in ethical principles of medicine and legal processes. All our trainees and residents take a two day ethics course organised by the SMA before they can exit. How many days of training do these new SMC members get?
• Maybe we should get the Legal Service to permanently second a legal officer with DPP experience to help SMC draft charges and SMC can stop relying on law firms to do so. The legal officer is probably more experienced in drafting charges and cheaper.

As readers of this column will know, this Hobbit rarely if ever says anything serious. But things in SMC are really at the cross-roads now and even this super –idle hobbit feels compelled to make these serious suggestions.

Finally, a word on residency. All of you know how this Hobbit feels about the residency that we have adopted from the American system. To underscore how hugely complex the American residency is, the latest Nobel Laureate in Economics actually wrote a landmark 49-page paper on how residency applicants are matched with training positions in the USA: “The Redesign of the Matching Market for American Physicians: Some Engineering Aspects of Economic Design” by Alvin E. Roth (one of two of this year’s Nobel Laureate for Economics) and Elliott Peranson (American Economic Review, Vol 89 (1999) pp 748-780). It is a fascinating read on how complex things can be in America. I think I will just settle for the good old days when Chee Yam Cheng and his PA settled all HO and MO postings in a small corner of MOH. Maybe we should nominate him for Nobel Prize for Economics and Medicine next year. Simplicity and elegance:- We don’t see that often nowadays.

After the last two posts on Facebook which were kind of heavy going, it’s time to revert to something light and cheery again. This hobbit doesn’t have much of a choice. Peter Jackson has been reported to have chopped up the movie “The Hobbit” into only three parts. But the evil wizard has been rumoured to have asked the orcs working in the ivory building up the road to chop up this hobbit into 19 transverse sections. Gulp. The Hobbit is very scared.

The recent report about the several Korean plastic surgeons coming to town to “see” or “interview” prospective patients is kind of disturbing. It is disturbing for a variety of reasons:

• Very soon, all our girls will look exactly like each other or like one of four famous Korean starlets now acting simultaneously in 2,614 serials with essentially the same plot.
• The patients have probably done their sums – paying for a return airticket to Seoul and getting a nose job is still cheaper than going under the knife in Singapore.
• People actually don’t mind getting plastic surgery from a country that gave the world PSY and the “Gangnam Style”. Good luck

In deference to all those guys on Nexium, Dormicum and Prozac up the road, I promise this column will have no adverse mention about the residency. This hobbit does not wish any old chap to kick the bucket with the cause of death stated as “Reading SMA Hobbit posting on FB”. So all you guys up the road, please relax – You can again go back to your usual state of denial and brainstem existence as you try to hatch your next evil plan to make lives more miserable for doctors.

Talent is everything and aside from the quality of residents, the quality of the people we choose into medical schools is also equally important.  Once we again, we have reason to believe that the medical school has always gotten the cream of the crop, even better than law schools. This can be seen by the case of the law student purportedly having sex and lavishing expensive gifts on her lecturer in exchange for good grades. It’s a lot simpler in medical school in our time. On the night before the exam, as per the advice of our wise seniors, we sent two female students to a male lecturer residing in the hostel. Don’t get me wrong, it’s not that the lecturer was into threesomes or other kinky stuff. These two girls were just sent there to cry (they are professional grade criers) and inevitably, the soft hearted lecturer would give the two a cryptic tip or two. And these two girls, in the true public spirited and selfless nature that differentiates medicine from the rest, then shared the tip with the other 132 classmates who were mugging away outside the medical library at 11pm in the night.

That’s it, no gifts, no sex and no corruption. Of course, sometimes the tip isn’t accurate or the girls were hard of hearing. “Angle of Louis” became the “Circle of Willis” and a quarter of the class had to take the viva or the re-paper for the 1st Pro. Sigh. In case the CPIB is reading this, let me state clearly that this happened in the very mythical Middle-earth Medical School which has got nothing to do with what’s happening or had happened in Singapore.

I think the main issue with men is that men can’t really think when women are involved. If the world’s greatest detective, aka Batman can’t figure out that Marion Cotillard is the villain until the last 15 minutes of a two and a half hour movie (and only after he was stabbed by her), how can we fault the law lecturer for not doing the right thing under such affection from the female student?

The biggest healthcare news that broke recently is that Singapore is the richest and healthiest country in the world. This is great news for everybody and sort of explains why we just bought those Brompton bikes when our founding father ministers refused to pay hotel laundry charges and washed their own briefs. But this Hobbit thinks we still need to renew this spirit of frugality by telling all senior civil servants and politicians that they cannot claim laundry charges when travelling. They should be issued with disposable briefs – one for each day of travel and an additional one in case of emergencies. This practice should continue until we have firm evidence that:

• Patients in the private sector actually pay less for more without the Guideline of Fees when compared to the time the Guidelines existed (inflation-adjusted)
• Our GDP per capita rises to that of the richest country in the Milky Way, surpassing the planets of Krypton, Alderaan and Vulcan.
• All the management, training and exam design consultants the public sector have hired in the last 10 years actually contributed to better health outcomes for the population in a way that we could not have achieved by ourselves had those guys in the big offices only trusted us and actually gave us the money to do it.
• Our total fertility rate (TFR) for Singaporean humans or wild boars reaches 2.1 (whichever comes first),

That brings us to the issue of assumptions. Everyone works on assumptions because our knowledge is incomplete and imperfect. But we need to revisit them when new information becomes available.

So beware the false prophets that make policy pronouncements about this and that when there is obviously no evidence to substantiate the claims. The profession has experienced a gut-wrenching, blood-draining and spirit-bashing ride in the last few years in terms of professional regulation, licensing and training. And for what? Where is the evidence that all this was necessary and the best option available? For example, are patients better off without the Guideline of Fees? Now according to SMC, there is an “ethical limit” to what doctors can charge and that you can’t charge rich people more because they are rich. But wasn’t the SMA GOF pretty ethical for the 20 years it existed but it was killed out of a legality (otherwise known as the Competition Act)? Law trumps ethics. As far as this hobbit is concerned, the lemon law IS the Competition Act.

Speaking of charging the rich, logic dictates that if you can’t charge the rich more, you can’t charge the poor less either. So like the Sheriff of Nottingham, we may have accidentally outlawed Robin Hood here. This is not a good thing because I know many doctors in private sector practice who have behaved a bit like Robin Hood pretty often. So after killing GOF, Dr Robin Hood may have to die as well.

So here, we see the tragic irony of law versus conscience. The GOF was originally put in place by the SMA after much persuasion by MOH in the eighties. Those old doctors running MOH then knew what they were doing. They left the issue of charging to the conscience of the profession. The SMA’s GOF served the public well for 20 years because the unspoken message of GOF was to behoove doctors to be better beings in the matter of charging and that charging should be guided by a collective conscience as embodied in the SMA. When SMA’s GOF was outlawed, the issue of charging was forcibly removed from the collective conscience of the profession and now we see what we are seeing. It’s difficult to put Humpty Dumpty back together again.

Today I was listening to radio station 93.8’s program “Talkback” which featured doctor’s fees and the subject of overcharging. It is interesting that most lay folks who called up favoured guidelines of some sort. So while we are trying so hard and maybe going around in circles trying to curb overcharging now, can someone just eat humble pie and admit they screwed up and let SMA bring back the GOF? Is pride so important?

Anyway, let’s close off on a lighter note. The London Olympics just ended. One sport that struck me as particularly pertinent for those guys up the road is synchronised swimming. Synchronised swimming has much in common with bureaucracy –

• They don’t listen very much because they spend a lot of time submerged
• They can literally turn their whole beings upside down when submerged
• When they are visible, they all have this plastic smile, glazed look and do the same thing, just like how all bureaucrats give the same answer when they are questioned
• Once in a while, for effect they do a spectacular stunt like throwing someone up to do a somersault
• But seriously, seconds after they all leave the pool, the pool returns to its usual self and whatever the synchronized swimmers did had no lasting impact on the waters, other than dirtying it.

I think all the guys up the road will be very good at synchronized swimming. Other than table tennis, we may yet get another medal from synchronised swimming in the next Olympics.

4 Sep 2012

You know life is getting interesting around here when the new Permanent Secretary for Law doesn’t have a law degree but a MBBS (S’pore). Given the mindset on health regulation in recent times, maybe the next DMS should have a law degree and not a MBBS.

We have been grappling with the business of aesthetics for a long time. Much angst, vexation and even anger has come forth. But after years of mucking around, we are still no nearer a well thought-out solution to this problem than finding a cure for the common cold

But first, let’s remind ourselves of how we doctors got into the realm of aesthetics. Other old coot doctors like this hobbit will remember the days of yore when doctors do not practise aesthetics. This was when locums charged $45 per hour, the polyclinic only had beta-blockers and diuretics and medical officers were paid forty bucks a call. In other words, this was circa 3rd century BC when Hannibal and his barbarians wacked the daylights out of the Romans and middle-aged people had sex (if they had any at all) in a bedroom and not in a Big Splash car-park lot. Hannibal actually looks rather civilized in today’s context – I am told he had fun on a bed. Those were also the days when we had a drive-in cinema where people made out. We have of course progressed a lot since then, we now know the cinema bit is redundant and we only need a car park lot. Which brings us to the point as to why we don’t have enough babies on this island – we don’t have enough car-park lots.

Seriously, other than the odd skin peel that GPs performed on patients, aesthetic practice was rare beyond plastic surgeons and a few dermatologists back then – in the nineties. Generally speaking, the people who did this beauty stuff on homo sapiens were either morticians or beauticians, depending on the GCS score of the person concerned. What happened then? Some beauticians were performing procedures that were way over their heads. I remember there was a case reported in The Straits Times where a beautician injected silicone directly into a lady’s eyelids and nose and caused gross and permanent disfiguration. The beautician was charged under the Medical Registration Act (MRA) for illegal practice of medicine. The fines were rather low then and the MRA was amended sometime after that. This happened about 15 years ago and it was only in the last 10 to 12 years or so did aesthetic practice take off in a big way among doctors.

One can rationalize this trend to a few simple reasons

• Demand for aesthetic practice has always been there and is increasing. The question is who is performing the service? Most people feel that it’s a lot safer to get their fix from a medically trained person than a beautician.
• Other than safety, doctors can avail themselves to drugs that the beautician has no access to
• The high cost of practice, i.e. rent, salaries etc means GPs have to generate more revenue faster than before and it’s a lot easier to do with aesthetics than seeing common ailments

But then problems arise when we then try to fit aesthetic practice into our “normal” framework of medicine. Its like a bad donor-host rejection from a botched transplant job.

Let’s consider what the normal framework of medicine is: –

• There is a patient complaint and a consequent pathology or symptom to address and manage and in most cases, a therapeutic end-point.
• There is evidenced-based body of knowledge that the doctor should rely on whenever practically possible
• There is a social contract between the patient and doctors, such as that described by Parson’s sick role.
• There is the ethical framework for informed consent which is based on risk, benefits and alternatives to a certain treatment modality to manage a symptom or a disease.

Now in aesthetics, there is no real pathology or disease. Maybe at best, a “symptom” (if it can be called one at all) of a feeling of a lack of beauty. And since there is no real disease to treat, there is also no therapeutic end-point that can be objectively agreed upon. As such, how can there be good evidence to say that a modality works (maybe some evidence, but certainly not the good evidence you can get from say, a randomized control trial)? There is also no real sick role – nothing for the patient to be excused from and he doesn’t need to want to get better and hence,  the social contract that exists in clinical medicine doesn’t quite fit here either, and neither does consent as we know in the usual sense of  the word.

Let’s face it, other than in some instances involving reconstruction work, the majority of aesthetic work doesn’t quite fit into the realm of clinical medicine. In fact, one would argue that aesthetic practice is not clinical medicine. It is a service provided by a medically trained person for safety reasons. And maybe we will be better off by acknowledging as such. There will be much less angst for folks like us that do not offer any aesthetic services and for those that do so almost all the time, the full-time aesthetic practitioners.

So really, there should be another register of aesthetic practitioners who are medically trained. These guys can then be governed by a different set of professional registration laws and ethical codes while they retain the right to use drugs and perform invasive procedures so that consumer (not patient) safety is ensured. The PHMC Act can also have a different class of clinics called “aesthetic clinics” with its own set of requirements.

How about those doctors that want to retain their clinical work while still offering aesthetic services part-time? Well, we can learn from the example of a registered medical practitioner who is also a registered TCM practitioner. Here, the same person must practice in different premises. The TCM premise must have its own signboard and entrance which must be apparent to the patient or the aesthetic customer. Or if this not feasible, as a minimum, the clinic should state clearly and separate the operating hours for clinical medicine and that for aesthetic practice, so that the patient or consumer walking into this one clinic will know up-front if he or she is walking in as a patient or as a consumer of an aesthetic practice.

This hobbit is not trying to put down doctors who office aesthetic services, on the contrary, they try to fulfill a desire in many people to look better. But to continue to foist stuff like evidence based and clinical medicine and even clinical practice ethics on this group of people is not going to solve the problem. They will feel frustrated and over-regulated. The only aspect we should not compromise is consumer safety. But what is safe need not be evidence-based to be therapeutic. This is the principle of TCM regulation today as well. We don’t really have hard evidence that many TCM modalities work, but we still allow the practice of these modalities as long as they are reasonably safe.

What is the alternative? We crush the development of aesthetic services here through the weight of current laws and SMC ethical framework and people will still try to get their fix overseas or to the local beauticians who will try to fill up the gap. The current approach makes it easy to find doctors guilty but it will not address the consumer’s desire for beauty.

Many people will obviously not agree with the views expressed in this note. They are fully entitled to their opinions. But we could perhaps at least agree that the current approach is not working out well and a new mindset and a new approach is needed to deal with regulating doctors who offer aesthetic services.

In the meantime, we should also ensure that we have an environment that does not push more and more doctors into offering aesthetic practices so as to make ends meet. The joke going around these days is that with HDB heartland clinic rents exceeding $30,000 a month, the only way for these clinics to survive is to turn them into 24 hour aesthetic clinics.

But there may be a little light at the end of the tunnel – with all this obtaining sexual gratification stuff going around, it is rumoured that certain IT companies’ recruitment advertisements now come with the tagline “Beautiful people need not apply”.

 2011 was a tough year for the medical profession. Legal and ethical precedents were set which made the environment more difficult for doctors. Eventually this will impact on patients negatively as well. There were no winners in the long run. As we go into 2012, let’s look back and take stock of the lessons 2011 offered. It’s not a pretty sight, but we have to face reality. These are the lessons and values others are foisting on us. The younger doctors especially will probably easily come to accept these values as accepted and established norms of medical practice even as we old coots adapt to these – the “new normal” of healthcare

Lesson #1

It’s better to decide on the specialty before you graduate (if not why offer the option at all?).– What those big-shots say –  it’s only an opportunity for you to apply, you don’t have to apply for a residency before graduating if you are not sure of what you want and you can take your time – once you know what’s happening on the ground, you would know this argument is all rubbish and devoid of intellectual integrity. Take-home message – Kiasu-ism pays. If you choose later, all the places in the popular specialties may have been taken up. You also don’t want to be the non-resident doing all the unwanted postings (or even if you are working in the same posting as residents – to end up working harder than residents).

Lesson #2

It’s OK for residents to work less than non-residents. Take-home message – Those that are given more will be given even more. Again, the lesson is – be a resident! And be one fast! But should you end up in a specialty you don’t like, tough luck.

Lesson #3

If you have exceeded your workload limit as a resident, do not log-in the additional cases or hours worked. It’s OK to lie to the training auditors. After all, telling the truth may get your whole department into trouble. Take-home message – don’t rock the boat, and to hell with honesty

Lesson #4

Signed consent is not good enough, even when the patient actually gave consent after two consultations and had a cooling off period before the operation. Take-home message – maybe it’s advisable to make an audio recording of your consent taking with the patient. Basically, you can’t trust your patient not to screw you royally later on.

Lesson #5

It’s OK to reveal residents’ names even when guilt is not proven. Take-home message – the days of your boss covering for you and taking the bullet for you, the junior guy, are OVER.

Lesson #6

Consultants have to review patients in person and you cannot trust your residents to make a clinical judgment. Take-home message – there is no team-based responsibility in reality even if the big-shots pay lip-service to promoting team-based practice. Better go into private practice when workloads are lower and you can do everything yourself and don’t have to trust junior doctors. Also, when in any doubt, cover your gluteus – order a CT scan/MRI etc.

Lesson #7

CMBs and Division Chairmen going into private practice. Take home lesson – do your own career planning, if even the CMB or Div Chair hasn’t got a life in the public sector after being CMB, you certainly don’t have one in the public sector either

Lesson #8

As long as you tell the patients beforehand and they agree, there is no such thing as overcharging. Take home message – Free market fundamentalism triumphs over professional ethics.

Lesson #9

When a patient/family member is unhappy with a SMC verdict, he can always appeal to the Minister to re-open the case with SMC. There is a significant chance the Minister will ask SMC to re-open the case and the doctor then be found guilty by a second panel. Take-home message – patients have multiple bites of the cherry including SMC, appeal to Minister, appeal to courts, civil suits etc.

Lesson #10

SMC wants to know sensitive stuff about you – Be careful about your past – e.g. whether if you have ever seen a psychiatrist. And then there can be an abrupt change of mind with SMC. Take home message – flip flops are possible with SMC. Hold on tight for the roller coaster ride. And even if we welcome the change in mind from SMC, one must wonder, what was the thinking behind the initial act of even asking all those strange questions in the first place?

In Summary

They may say they want to promote stuff like doctor-patient relationship, team-based care etc but actual incidents seem to suggest otherwise. All these stuff require trust – trust between doctors and trust between patients and doctors. But people in power don’t seem to understand that. Or maybe they do, but they rather not stick their necks out to foster such an environment of trust. It’s easier to hang a chap than to stick out for someone, that’s for sure.

So we have to distinguish politically-correct hype from harsh reality. As a doctor, trust no one. You can’t trust your boss or the hospital administration, and you certainly can’t trust your junior doctors. You cannot depend on SMC for consistency and you certainly can’t trust your patient. Better look out for yourself more, even if it means being defensive in your practice. To quote former Intel boss Andrew Grove – “Only the paranoid survive”

2011 may well be remembered as the year trust quietly died in Singapore healthcare. Welcome 2012…

Being a writer is tough. Let’s face it, inspiration doesn’t quite come simply all the time on tap like water or draft beer. Every writer goes through bouts of writer’s block. I was having one for the last couple of weeks. But just when I was vexing over what to write and wondering if I have lost my writing mojo or if the world has finally sorted itself out, the ever reliable SMC has come to the rescue of this hobbit again.

The latest letter from SMC on “Application for Renewal of Practising Certificate” to all doctors contained quite a few really tough questions that were never seen before and it’s no surprise that many doctors are confused/upset/constipated by these new questions.

I recently spoke to a SMC member and even he was seeing these new questions for the first time. Obviously the “new normal” of politics, policy and consultation hasn’t quite reached the folks running SMC yet.

Anyway, alert reader of this column, Dr Tjio Pee Wee has written in for advice. We reproduce his letter here, sans expletives and grammatical mistakes.

Letter from Dr Tjio Pee Wee

Dear Hobbit

I have just filed my application to renew my practicing certificate. I am now in deep, deeper and deepest trouble. (Original letter contained the phrase “cheam, cheamer and cheamest trouble”)

I am in deep trouble because I had carelessly ticked the “No” box in all six questions, not realizing the last question (i.e. Question 4) should be ticked “yes” when you do not owe the SMC any money. Yes, it’s my fault, I had fallen prey to the oldest trick in the MCQ business, that of not reading every question carefully and looking out for that old trick of putting in a question that should be answered “yes” after a slew of questions that should have been answered “No”.

I am in deeper trouble because of Question 3a, because while I have never been convicted of any investigation, I have been the subject of an inquiry. I think it was 25 years ago and I was a MO in psychiatry posting and some mad guy with a frontal lobe problem complained that I had assaulted his mother, stole his hospital baju and slept with his Hello Kitty toy. The psychiatric hospital conducted an inquiry into me and of course found his allegations to be baseless, especially when the hospital found that the patient’s mother had been dead for many years and that I slept usually with my Ultraman toy and it was the patient in the next bed (not me) that was sleeping with his Hello Kitty toy. He even tried feeding the toy hospital food in a vain attempt to pry open its non-existent lips…..he eventually borrowed lipstick from a female nurse and drew lips on it…..Lastly, and most importantly, of course everyone knows a doctor only steals doctor’s baju, never the patient ones…..

I had forgotten all this until now. I realise I had made a false declaration because at the time of my posting in this particular psychiatric hospital, the hospital was not restructured yet and it was a government hospital and a department under the ministry of health. In other words, it can be construed to be “an authority” as the hospital was run by government officers. Do I now have to report this episode in my latest SMC declaration?

In addition, I have been accused of overcharging in 2001 because I charged my patient $50 for a housecall requested by this patient. I understand this difficult patient wrote to the SMA Complaints Committee which decided my charging was entirely appropriate. Is SMA considered a “professional body” and hence, do I have to declare this as well?

Finally, I am in the deepest trouble because I have a deep dark secret which even my wife doesn’t know about. You see, when I was a kid, I used to wet my bed. This continued till I was in primary school. My parents were rather distressed and brought me to see the family doctor. The family doctor reassured my parents that I would grow out of it. But my mother would not be persuaded and brought me to the specialists. The specialist included a urologist and (sigh) a paediatric psychiatrist. So now, do I tick “Yes” to question 3c – Have you ever consulted a psychiatrist or are you currently undergoing psychiatric treatment?

This is driving me nuts. I have not wet my bed since I was eight years-old and even my wife doesn’t know about this. Do I have to tell SMC? This is deeply personal, embarrassing and irrelevant to my medical practice now. I may start bedwetting myself again with all this stress.

Please advise me, dear Hobbit!!!

Hobbit’s Advice

Dear Dr Tjio Pee Wee

Please do not worry about ticking the wrong box in para. 4 on money owed to SMC. First of all, no matter what you tick, civil servants always behave like you owe them money. Besides, at the rate SMC processes cases, it may be quite a few years before they get to you. By that time, you may well have retired

As to your second problem – You should report to SMC on the inquiry by the authorities and civil servants- mainly because you did steal the doctor’s baju, you bloody idiot. As to the complaint on overcharging made to SMA, don’t worry, I was told that some powerful but misguided soul has always thought that SMA is nothing more than a “trade association” and not a professional body. So you should be OK if you keep quiet on this.

As to your enuresis problem when you were a kid and your wife not knowing- I don’t think your wife will respect or love you any less if she knew you wetted your bed when you were 7 – Unless you are still sleeping with your Ultraman toy now.

I hope this helps.

Yours Shortly,

The SMA Hobbit

p.s. – can I have the Ultraman toy? Thanks!

Anyway, since SMC has added so many new questions to go with the renewal of practicing certificate application, let us be constructive. The Hobbit would like to suggest a few more questions for the administrators running SMC to consider –

Possible Additional Questions for Doctors

• Have you ever harboured evil or impure thoughts against any SMC member, or the Registrar or Secretary of SMC?
• Did you do your National Service in a military camp or in a laboratory?
• Have you ever visited (accidentally or otherwise) any Internet pornographic websites?
• Do you think we should introduce similar questions for lawyers, nurses, accountants and pharmacists when they renew their practicing certificates as well as to potential Elected Presidency candidates when these candidates apply for Certificates of Eligibility?

Possible Additional Questions to SMC

On the other hand, even as SMC introduces a plethora of questions, I think we, registered medical practitioners should also be entitled to ask the chaps running SMC a few questions, such as

• Do you know what is the “new normal” in politics, government and policy implementation?
• Have you heard of the subject of “questionnaire design” and “user-testing” before you threw up all these new questions for every doctor to answer?
• Even though we know you know that you are empowered by the Medical Registration Act to do many things, do you have a clue what is “Stakeholder Engagement and Consultation” before shoving new stuff down our throats, such as these new questions?
• Can you spell H-I-G-H – H-A-N-D-E-D?
• Why do you need all these new questions when doctors treating doctors are already statutorily bound to report to the Health Committee of SMC if they think their patients (i.e. doctors) are possibly incapable of medical practice?
• SMC is a statutory body “self-funded” by doctors’ license fees and MOH has a budget of billions. How is it that the biggest user of/complainant to SMC is MOH and MOH doesn’t pay practically anything to SMC to use SMC services? Do you or do you not consider this to be an utter irony?

For the avoidance of doubt, the SMA Hobbit advises all doctors registered with SMC to answer all those questions truthfully and to send in your application for renewal of practising certificates before the closing date.

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

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

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

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

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

What can we actually do to celebrate Doctors’ Day?

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

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

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

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

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

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

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

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