A Happy New Year to the readers of this ridiculously irrelevant column. 2021 has been a year of shattered hope (that we would have gotten the pandemic under control) and realised fears. Delta and Omicron bookended 2021 and the world spent another year in a surreally sad state of ( albeit milder) lockdowns, social distancing and masks.
We now look back at the year that has passed and we dish out various awards to folks who gave colour to 2021, through the eyes of a halfling who is stuffed with beer and suffused with melancholy….
First World to Third Award
Recently, it was reported that close contacts of patients who had contracted the Omicron virus were quarantined in hotel rooms. Many of them were made to share room with complete strangers. Seriously, after spending billions on disease control for the pandemic, we have to save on such stuff? We have to bear in mind this is more than a one-night stand and complete strangers are made to share rooms for several nights. Maybe folks such as Singaporean boys who have done NS and slept in army bunks can accept this, but how about other folks?
Sharing a room with family members and friends is probably OK. But complete strangers?Whoever thought of this needs to get his mind checked (to see if any brain is present in the first place). The foreign press took us to town for this and perhaps justifiably so.
Best Cultural Advancement Award
For centuries, humankind has frowned on nose-digging, especially in public, as a uncouth, distasteful act. Now we have to do it twice weekly in the form of regular ART tests. Now, it is not only public but if you return from VTL flights, it is supervised nose-digging. Trust this hobbit, most people can dig their nose pretty well, with their fingers or with a swab. They don’t need supervision. I actually think these chaps have a strange job – all they do is watch people dig their nose, day-in, day-out…..
No Reality Check Award
This goes to the unknown genius that believed that KTV lounges/clubs etc will willingly pivot to become food establishments without any hanky-panky business. This of course we know became the KTV cluster later on. This is made all the more incredulous when it was discovered that many of these “pivoted” food establishments do not have kitchens to do any serious cooking.
Fat Cats Award
In 2020, Integrated Shield Plan (IP) providers collectively made S103.75M. This hobbit thinks 2021 will likewise be a bumper year for them. Will they pass any of these earnings to the policy holders? Will premiums not rise as such? Will they stop threatening to raise premiums at every call for increasing doctor panel size or improving reimbursement rates for doctors? This hobbit is not holding his breath for this. They are the big winners of this year’s Fat Cats Award.
This goes to the Life Insurance Association (LIA) of Singapore. For years they have been singing the familiar tune that private healthcare costs are increasing unsustainably because patients are overconsuming and healthcare providers are overservicing and overcharging. This will lead to premiums likewise increasing at an unsustainable rate.
Well, it turns out that for the Integrated Shield Plan (IP) sector, from 2016 TO 2019, Gross Premiums (i.e. total premiums collected) went up by a compounded annual growth rate (CAGR) of 10%; while Gross Claims (money paid out to policyholders who made claims) increased by 11%, while Management Costs went up by 16% and Commissions by 15%!
In other words, the main causes of unsustainability is that the amount of money these IP providers are paying themselves is increasing at a far faster rate than that of premium growth! And all this while, nobody really noticed until recently.
LIA wins the Stealth Award (quietly and invisibly)
Circular King Award
Current DMS wins this award for the second time running. 244 circulars were issued in 2020. 192 circulars were issued in 2021, slightly fewer. But this hobbit thinks that 192 may be an underestimate because a new practice may have emerged. Quite a few circulars were re-issued with updates and amendments and given an alphabet suffix; e.g. Circular 188A/2021 and so on. So the actual number may be around 200 or so.
Not all circulars apply to all doctors. But let’s say we halve that number – to 100 circulars. That would mean that an average of 2 circulars a week require my complete understanding and compliance. That’s pretty scary isn’t it?
Common Sense is Uncommon Award
We allow passengers to take public transport (such as buses MRT trains) with practically no social distancing. But till now, we continue to have alternate urinals and wash basins taped up so that no one can use them.
In some toilets, we even see every other toilet cubicle with full-height partitions likewise adorned with signs that state they cannot be used in order to maintain adequate social distancing.
Do the folks who implement this realise Covid-19 cannot spread through full height partitions, and also one spends considerably less time at a wash basin or a urinal (unless you have serious prostate problems) than in a bus or train ride?
The persistence of such practices reflects what my professor taught me long ago, “common sense is uncommon”.
Up till early Oct 21, before the introduction of the simplified 3 Protocols, the country’s policies and regulations on Covid-19 quarantine, treatment and recovery were so complex it was really impossible to understand, let alone remember. This was best encapsulated in a flow diagram published in Lianhe Zaobao on 4 Oct 21. You don’t have to understand any Chinese, just look at the diagram. Adjectives such as “bewildering” and “befuddling” are but euphemisms in this instance:
Kudos to the folks who contributed to the vast array of policies and regulations that controlled our lives for a few weeks. Even bigger kudos to the Zaobao team for understanding them and compressing all that into one single expansive flow diagram. They are the deserved winners of this year’s Complexity Award.
Road to Endemicity Award
This goes to the Delta variant for breaching our defences at the Jurong Fish Port shortly after the KTV cluster. After these two clusters there was no turning back for us. We were truly well on the road to endemicity…..
Online commentator Calvin Cheng on 22 May 21 posted, “What are GPs? They are general practitioners who got a degree in medicine, who then either chose not to specialise in a certain field, or were not good enough to be chosen to be specialists. So they became GENERALISTS. They look after small every day illnesses, and once an illness or disease is too complex for them, they refer them to the real experts, a specialist”
Enough said about this guy. He likes to be heard I guess. Even for the worst reasons. He gets this year’s Clueless Award hands down.
Contrast this to what the Prime Minister said at the recent celebrations of CFPS’ 50th Anniversary on 3 Dec 21:-
“As family physicians, you are specialists in your own right. Hospital specialists see patients for a specific condition, but you see patients holistically as a person, across their range of conditions”.
The Facepalm Award
This is a new award category. It is given to the folks who make the most ridiculously embarrassing actions in the previous year. The inaugural award goes to a small bunch of anti-vaxxers who do the silliest things. There was one chap who claimed on social media that he can be contacted via DMS. That was another one who threatened to sue people, including the DMS, the prime minister’s wife and a prominent infectious disease specialist.
By all means, be an anti-vaxxer if you so choose. But don’t do or claim things that make you look stupid or even looney. This is no way to heal any divide….
The Grinch Award
This hobbit thinks Omicron is like the character Grinch in Dr Seuss’s book – How the Grinch stole Christmas. It appeared in November and literally took out the festive spirit in December, just when many people all over the world believed we had the Delta strain under control, and were prepared to travel for holidays and take part in end of year festivities. Maybe we should rename Omicron as the Grinch variant.
While it is not enshrined in the Constitution, I consider it my fundamental right as a citizen to be able to sit down in a coffeeshop or hawker centre every morning and have my kopi-O. So when this is taken away from me, I take it that we are in lockdown mode.
Of course this lockdown is not as tough as last year’s CB and Tightened CB. It’s a lot looser this time around. I can still go to my barber, see my dentist and see a show at the cinema. It’s a very ‘loose’ (as opposed to tight or tigher) CB, if it is a CB at all. Unlike what some people say, you can still have a little fun with a very loose CB.
But somehow the wordsmiths have failed us this round by not coming up with something catchy to describe what we are in (like CB and tightened CB). Instead, they have come up with a term like “ Phase 2 – heightened alert”. (Face-palm++).
I take umbrage at the use of the word “heightened”. The use of this word is very insensitive to us short people. As a halfling, I feel I am targeted if not discriminated against whenever I see the word “height” or “heightened” being used. Why can’t people use other terms like “broadened alert” or “widened alert” or just “light lockdown”? Which is why this hobbit really hopes this country will have a short(er) prime minister soon, who can stand tall, I mean stand-up, for us short fellows.
To avoid the use of this very vexing word “heightened”, I will call the current phase as “loose- lockdown phase” or “LL phase”. “LL” sort of describes rather well how I feel now.
Many friends have asked this hobbit how should we respond to this new LL phase. Well, it’s obvious – just follow law. Stay at home if you can. Cook at home, eat home, work from home etc. Don’t go anywhere unless necessary and if you do, wear your mask and bring your TraceTogether along.
But beyond legal compliance, others have asked – how should we respond intellectually and emotionally?
Some chaps ask rather difficult questions like –
- Could this LL have been avoided?
- Could we have closed our borders earlier to countries that were having an exploding number Covid-19 cases?
- Could we not have this LL phase now?
- Could we have diversified our foreign labour sources and not take just from one region in the world, just like how we now have four taps to meet our water requirements? Isn’t there just too much risk concentration?
- Should we have segregated high risk and low risk travellers in Changi Airport like what a Straits Times Forum writer said a month ago prophetically (https://www.straitstimes.com/opinion/forum/letter-of-the-week-stricter-covid-19-measures-needed-for-inbound-passengers-at-airport. (hobbit’s postscript: obviously the writers of the official reply dated 21 April didn’t think so –https://www.straitstimes.com/opinion/forum/airport-takes-multi-layered-risk-based-approach-to-curbing-infection)
- Should we have better anticipated double mutation strains like B.1.617 are far more infectious than the old Covid-19 strains, considering what was happening in their place of origin?
- Do we really need to do Routine-Rostered Testing (RRT) for all healthcare workers (HCWs)? Do we not trust our PPE, infection control measures and vaccination to protect our HCWs?
In short, these nasty questions centre around two themes – what lessons can we learn from this setback and are we managing this current wave correctly?
One angsty dwarven banker even asked – between keeping foreign labour coming in to support the construction, process and marine sectors (and helping with economic growth), and now the LL phase – which has a larger effect on the economy and emotional, mental and social well-being of the citizens? What is the trade-off we are talking about? The dwarf remarked – these policy wonks love talking about trade-offs all the time, but somehow nobody is talking about trade-off between keeping the process, marine and construction sectors going and what we are suffering now for four weeks.
I will be honest, having grown up in a fun-loving, carefree, beer guzzling shire in Middle-earth, all these questions are terribly complicated and distressful to me.
But a wise elven wizard helped this hobbit see the light when he commented on this statement:
“These cases all originated from imports because all borders are porous. All it takes is one case to cause an outbreak, and no country can seal itself off totally. At the minimum, citizens and residents must be allowed to return home”. (MOH Facebook Page, 15 May 2021)
He said, “this means it was all inevitable. Just like the Mother of All Clusters (MOAC) in the dorms last year. That was nothing we could have done. MOAC would have happened anyway. Similarly here. It was pre-ordained that we need to have those foreign workers coming in to support the process, construction and marine sectors. Thus we need to take the risk of these imported cases coming in, even though we know that it takes only one case to cause an outbreak”.
He added, “It was also predestined that the super-infectious B.1.617 strains would have led to the Changi Airport and TTSH clusters and probably now the tuition centre/schools clusters as well”.
He concluded, “Everything was preordained and predestined and hence inevitable. We made the right calls, no error of judgment was made. This is the way”. (In an elven accent – not Mandalorian)
Yes, it was all inevitable. And once we accept this explanation, a lot of other questions are also answered or become moot as well. It’s like you are playing an online role-playing quest game, and your avatar discovers this powerful magic item (more like you paid bucket-loads of money for it) that gives your avatar enormous benefits. Example – you discover the Amulet of KNN – which renders your character immune to psychic attacks, -8 to mace attacks, +5 to dexterity score and +50 hit-points.
The elven wizard then introduced me to this magic item called the Ring of Inevitability. He fished it out of the pocket of his Cloak of Non-culpbability; the Ring burnished under the midday light and I was immediately desirous to obtain it.
He whispered to me that once the wearer has the great magic item called the Ring Of Inevitability, he will be immune to questions such as “if only we had….?”, “Could we have…?”, “Could we not have….?” etc., etc. from all those around him, including himself. Such tiresome questions become inconsequential once we wear the Ring of Inevitability.
And he was right. Once I bought the Ring of Inevitability from him and wore it, I was happier and more peaceable immediately. I no longer asked myself all these vexatious questions and could accept the current LL phase with the kind of equanimity that Sir William Osler described. I also dismissed such questions from those around me as irrelevant and even irreverent to me, the mighty Ring-wearer. I felt l have become invisible to obnoxious questions as they passed right through me. I no longer took umbrage to these questions anymore as I became as invisible to these questions as the Nazgul Ringwraiths of the Second Age in Middle-earth.
I didn’t even feel LL at all about this LL phase anymore. Gosh, I hadn’t felt so good since I was given fentanyl by my anaesthetist for a procedure years ago…..
Before he left, the elven wizard grinned and said, “You should consider taking the Cloak of Non-culpability as well. The Cloak makes all accusations against the wearer hollow and ineffectual. It goes extremely well with the Ring of Inevitability”.
Note: for the avoidance of doubt – this post is a satire.
Yesterday’s meme was rather well-received. So here’s another one….from the classic movie Downfall that has been memed a zillion times…
Meme No. 2
2020 was a year with no comparison for healthcare. Of course, Covid-19 was the every visible elephant in the room but there were other memorable incidents and people that managed to share some of the limelight as well. This hobbit recaps this momentous year with the 2021 Hobbit Awards. And the winners are……
Circular King Award
A total of 244 Circulars were issued by MOH in 2020. They were issued by either our new DMS, Prof Kenneth Mak or his lieutenants. If you think about it, there are 366 days in 2020 (leap year), 104 weekend-days and 11 public holidays. That leaves us with about 251 working days (give or take a few). In other words, we had to keep abreast with about one new MOH circular per working day! That’s incredible. I think the current DMS has issued more circulars in one year than any of his predecessors. He is this hobbit’s choice for Circular King Award.
Superman Baby Award
In the beginning of every version of a Superman movie, the opening scenes invariably involve the parents of Superman putting the Superman baby into a spacecraft. The spacecraft then blasts off planet Krypton for Earth and within seconds Krypton explodes.
That about sums up the previous DMS, Prof Benjamin Ong. The first case of Covid-19 hit Singapore on 23 Jan 20. His last day in MOH as DMS was 31 Jan before the current DMS took over and MOH promptly exploded with the Covid-19 outbreak in Singapore. Prof Ong is a deserving winner of the Superman Baby Award.
Best Communication Award
This goes to our wordsmiths in the civil service and political leadership for coming up with the term “Circuit Breaker” in lieu of the commonly used “lockdown”. The acronym “CB” is now widely used. More interestingly, on 21 Apr 20, it was officially announced that CB measures would be tightened. Only in Singapore do we tighten already a very tight CB.
Most Useless Relic Award
Remember long, long ago, in a galaxy far, far away, there was this one colour code to rule them all – DORSCON? Well nobody talks about it anymore. Although it has a few colour grades to the Code, no one takes it seriously when we realised ‘Red’ is a hypothetical, mythological colour that will NEVER be used even when we faced the closest thing to Armageddon (aka a tightened CB – please see above) and more than a thousand new Covid-19 cases were popping up a day.
DORSCON should be thrown into the fires of Mount Doom to be destroyed forever like all useless relics.
Best Witchcraft Award
This prestigious award goes to the Ministry of Trade and Industry’s GoBusiness Portal for deciding in an incomprehensible and opaque way who is an essential worker and how many staff is a clinic entitled to. How is a GP clinic assistant deemed to be an unessential worker is just beyond this hobbit.
Animal Advocate of the Year Award
This goes to the genius that decided that “basic” pet grooming services could resume on 1 June 2020, even before the resumption of “human” aesthetic medicine.
Best Cartoon Comedy Award
This award undoubtedly goes to the folks who approved the Virus Vanguard, who existed for about a day before it was disbanded. Even so, the timeless superhero legends of Circuit Breaker, MAWA Man, Care-Leh Dee, Dr Disinfector and Fake News Buster will remain etched in the collective psyches of Singaporeans forever. It shows that some decision makers in the government have a (strange?) sense of humour/reality.
This hobbit confesses that he may still be suffering from Virus Vanguard’s Dissolution-related PTSD.
The Special Destiny Award
This goes to the Minister for Manpower and her team for pitching to us the seminal point that the outbreaks in our foreign worker dormitories were inevitable. This hobbit now believes that we were just fulfilling our destiny when 47% of workers (152,794) living in foreign worker dormitories were infected.
Best Educator Award
This definitely goes to Minister Chan Chun Sing for educating a younger generation of Singaporeans on the use of the term “sia suay”. Even an old coot like me hasn’t used that in a long time.
He also educated us on the unnecessary use of masks and hoarding of toilet paper, eggs and instant noodles, amongst other things.
Evidence-Based Infection Control Award
This very relevant and timely Award goes to the Elections Department of Singapore for demonstrating with strong evidence during General Elections 2020 what most healthcare workers already knew – you can’t put on gloves when your hands are wet with disinfectant/alcohol/water etc.
Best Voodoo Healthcare Award
This goes to the Health Insurance industry, in particular the Integrated Plan (IP) providers for
- Not respecting fee benchmarks that were issued by MOH
- Selling IPs to 70% of Singaporeans when the combined hospital beds market share of private hospitals and A and B1 bed classes restructured hospitals is only about half of that
- Empanelling only about 20% of specialists in the private sector and not telling potential IP customers that they can only choose from a very limited pool of specialists.
On the other hand, they are still telling the public to buy more IPs when there is really no capacity to fulfil demand down the road.
If this isn’t voodoo healthcare, this hobbit doesn’t know what is.
Company of the Year Award
DoctorsXdentists (DXD) won this hands down. In this one year, they managed to achieve the following:
- Misrepresented MOH compliance officials
- Irritated the hell out of several professional bodies such as Academy of Medicine, SMA and CFPS
- Used information from the SMC doctors’ directory without SMC permission
This is the most breath-taking healthcare company we have seen in a long time.
Declaration: this article is completely 100% satire and opinion, and hence does not come under the purview of the Protection from Online Falsehoods and Manipulation Act (POFMA). Nowadays, one cannot be too careful about such things…..
OK, here we go…..
If private hospitals were handbags…..
- Mount Elizabeth Orchard would be a Birkin (The older tai tais’ favourite)
- Mount Elizabeth Novena would be a Kelly (More stylish for the younger but equally rich tai tais)
- Gleneagles would be a Chanel 2.55 (always reliably upmarket)
- Raffles would be a Kwanpen (local and upmarket)
- Mount Alvernia would be a LV
- Thomson would be a Coach
- Farrer Park would be a Kate Spade
- Parkway East would be a Bonia
If recent healthcare events were like Marvel Comics Universe heroes….
- Informed Consent would be Spiderman (Swinging from doctor centric to patient centric and very sticky)
- Third Party Administrators would be Thor (getting fat by doing little or no work)
- HIV data leak would be Loki
- NEHR would be like the Avengers Headquarters (Always getting attacked & repeatedly destroyed)
- MOHH would be Captain Marvel (missing all the action when half the universe died)
If SMC affairs were likened to Marvel Comics’ Universe Infinity Stones
- Lawyers would be the Power Stone (makes all other stones more lethal)
- MOH would be the Mind Stone (can make SMC ownself appeal against ownself)
- SMC Disciplinary Process would be the Time Stone (Can make time stop and really delay you to no end)
- The latest SMC ECEG would be the Soul Stone (controls all life)
- The Modified Montgomery Tests would be the Space Stone (warps spatial realities and laws of physics and increases uncertainty)
- Court of Three Judges would be the Reality Stone (Can override SMC-judgment realities)
- SMC Leadership possesses the Pym Particles like Antman (nowhere to be seen when a crisis like The Snap strikes)
If Public Hospitals were Star Wars Planets
- Toa Payoh would be Alderaan (completely destroyed)
- SGH would be Coruscant (very crowded, crazy traffic and damn stressful)
- NUH would be Naboo (since it has produced three Sith Lords in succession)
- TTSH would be the forest moon of Endor (where the fuzzy cute teddy bears live)
- CGH would be Mon Calamari (Where all the blur sotongs came from, like Admiral Akbar)
- SKGH would be Hoth (Frozen and Forgotten in the North)
- NTFGH would be Cloud City of Bespin (All the verandahs look like they are in the clouds)
If doctors were Lord of the Ring places
- CFPS would be like Gondor
- Academy of Medicine Singapore would be like Rivendell where the very cultured and elegant immortal elves rule (or so they would like to think)
- The Alumni would be the Dwarven Moria in the Misty Mountains
- SMA would be Hobbiton
- COMB would be Barad-dur, and
- Chee Yam Cheng would be Gandalf
If public healthcare were like the Game of Thrones
- The public healthcare clusters would be like the kingdoms and households of Westeros
- IMH doctors are like the Night’s Watch order (they guard The Wall and the rest of us don’t really know or want to know what’s beyond it)
- MOH HQ is like the Targaryens in Pentos, Essos (Not really in charge anymore but still want to go back to the glory days, but be careful, they still own the dragons)
- MOHH is like the House of Stark (it has taken over effective control over the running of King’s Landing)
- Medisave, Medishield Life, Medifund, Fee Benchmarking, CHAS, Pioneer Generation Package, Merdeka Generation Package make up the Faith of the Seven
If Healthcare were like the world of Harry Potter,
- Lawyers would be folks skilled in Parseltongue (A language that is associated with the Dark Arts)
- Managed Care and TPAs would be dementors (They can suck the life out of you slowly)
- Doctors who are senior hospital administrators would be Animagi (Can transform into animals once they are promoted to these positions)
- Doctors who work in MOH HQ would be Metamorphmagi (who can change their appearance into something completely different once they work in MOH HQ)
- Medical Concierges who ask for 15% or more of your bills can be considered as Death Eaters (like Voldemort)
If medical schools were like car brands
- YLLSOM would be like Toyota (Cheap and Reliable, but boring)
- Duke-NUS would be like Maserati (great engine sound, but performance-wise still cannot compete with the best)
- TTSH would be like Nissan and Renault alliance (a bit confusing, considering its linkup with Imperial in the LKCSOM
- Most Irish Medical Schools would be like Saab (no longer seen here)
If tertiary public hospitals were supermarket chains….
- NUH would be Cold Storage (more atas)
- TTSH would be Sheng Siong (Cheap and friendly)
- SGH would be NTUC Fairprice (trying to be atas, like Fairprice Finest)
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”
Dear Wise and Short One
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)
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.
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!
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.
Dear Ring Bearer
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?
Dr Veritus Verify
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.
Emeritus Consultant Verificationalist
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?
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)
It has been quite a few years since this Hobbit published the Movie Awards. It is once again the awards season and therefore the time to give out these distinguished awards again to worthy individuals, initiatives and figments of our imagination for stuff that captured our attention this the last year.
Best Honest Performance Award for a New Comer
This award goes to Senior Minister of State Chee Hong Tat for his great speech on 30 Sep 17 at the SMC Physician’s Pledge Ceremony. He basically said that JCI and Residency need serious relooks. In particular the Residency was implemented in a suboptimal way. His honest and sincere performance giving this speech moved this hobbit to tears and made his feet hair stand.
There were no other nominees for this award. Honesty, unlike residents and associate consultants, is a rare commodity.
Best Solo Performance
This goes to Solo the Movie featuring the Solo GP. He gets this award for working alone to get things done in the upcoming Solo the movie. His job is getting tougher too, given the additional demands that have either come or are coming his way. This include supplying information to the NEHR and meeting the demands of the new medico-legal climate. Of course he still doesn’t realise that once the law is passed, the Solo GP as the licensee of the clinic can be fined up to $50,000 and jailed for up to 12 months if he doesn’t contribute the required information to the NEHR. And you thought being suspended or struck off by the SMC was a big deal. That’s chicken shit compared to this.
Lifetime Achievement Award
Minister Gan Kim Yong gets this award. He has gotten most things right in his 7-year term as Health Minister – rolling back excesses of the previous era such as residency and putting back good stuff such as benchmarks/guidelines of fees. Setting in place new initiatives that benefit patients and doctors such as CHAS, PGP etc. His last big test is the NEHR. It’s like Luke Skywalker meeting the Dark Side in the swamps of Dagobah….will he survive the Big Test?
Best Sequel Remake Award
We have seen this before, like the tired Transformer franchise. Getting bigger but hopefully not worse. First there were 2 clusters then 6. Now 3. 3 makes sense, but it’s still bewildering for the folks in KTPH who were once in NHG, then out, then back in NHG again. Likewise for CGH and Singhealth. Hopefully this clustering and reclustering process has come to an end finally. More confusing than the ending of Inception.
Best Make-up and Costume Design Award
Outlawing the SMA Guidelines of Fees (GOF) has proven to be a bad idea after ten long and painful years. So GOF has to be brought back in some back without losing face for the bigwigs and powers that be. And so, the MOH Fees Benchmarks Advisory Committee was born. The aim is to essentially produce the same outcomes that the SMA GOF did for 20 years from 1987 to 2007, but to save face, it has been repackaged. This is great make-up and costume design for essentially the same face and body. This award without a doubt goes to MOH Fees Benchmarks Advisory Committee
Best Science Fiction/Suspense Thriller Movie Award
The Modified Montgomery Test (MM Test) wins in two categories. First, the MM test tries to impose a certain pattern of thinking which 99% of doctors will find alien. (By alien, this hobbit means the aliens in the Alien movie franchise – it will eat up our brains). It’s also a great thriller movie as many bewildered patients will find that their doctors no longer make any decisions or even recommendations and they themselves now have to make decisions based on the mass of ‘relevant information’ given. What great suspense as everyone awaits the patient to digest the information and make the best decision for himself.
After a wait of 10 years, some say the MM Test is a worthy sequel to the 2007 Jack Neo box office hit, Just Follow Law.
Best Movie Soundtrack and Score
National Electronic Health Record (NEHR) wins this hands-down. So far, the NEHR soundtrack only offers all the positive-feeling homilies like “connecting healthcare professionals for patient-centred care” and “achieves better health outcomes” and “raises patient safety”. The soundtrack and score is completely silent on “privacy rights of patients”, “increased medico-legal liabilities for healthcare professionals” and “what are the liabilities and responsibilities of the NEHR”. The silence of the official NEHR soundtrack and score is masterly deafening. A maestro is obviously at work here.
Best Supporting Actress Award
This award goes to the senior paediatrician who was suspended for misdiagnosing Kawasaki Disease. She was originally slated to get the Best Actress Award until some 1000 doctors signed a petition to MOH stating the punishment was too harsh.
Box Office Bomb Award
The biggest bomb of the season goes deservedly to the ACGME-I Residency Programme which is due for a major overhaul/reconstruction/remaking/dismantling (depending on how you look at it). The number of newly minted specialists with no long-term employment contracts continues to rise and some are already flooding the private sector market. These poor fellas look like the extras who are milling around the film studios looking for bit roles and part-time work. The big difference is that extras cost nothing to train but these specialists each cost the taxpayers hundreds of thousands of dollars to train.
Best Box Office Hit
This one is walking straight to the finishing line with big bucks. Third Party Administrators (TPAs) are making the big bucks with their arrangements with insurance companies and big corporates while being entirely funded by collections from participating doctors. Latest heard – TPAs want to claw back on money already paid to doctors because some of their clients claim to be losing money. Can doctors claw back from TPAs if they are found to be losing money from TPA contracts?
Best Studio Award
This goes to MOH for their acquisition of the functions, departments of another ministry (MSF – Ministry of Social and Family Development). MOH is now a mega-studio set to become even larger as it absorbs the social aged care functions of MSF. It’s like Disney buying up the Marvel and Star Wars franchise. Questions abound: – will MOH end up with severe indigestion after this exercise? Will Han Solo and Luke Skywalker be killed off in the exercise?
Best Actor Award
There were a few characters vying for the very prestigious Best Actor Award this year. But there was really no contest. The thespian performance by the private hospital orthopedic surgeon who apparently accidentally severed the popliteal artery and vein and the peroneal nerve during a Total Knee Reconstruction (TKR) and then flew off on a holiday leaving the resident medical officer to manage the patient was a once-in-a-lifetime experience. It was a once-in-a-lifetime experience because the patient died a few days later due to complications of the TKR and subsequent limb salvage surgeries.
Best Director Award
As usual, this was a contentious item on the Movie Awards List. This year the award goes to the haematologist who was appointed to be the director of a tertiary-level cancer centre. That’s like appointing an ENT to run the eye or dental centre or a psychiatrist to head the neuroscience centre. Not say cannot do, the disciplines are indeed a bit related, but still it looks a bit strange, lor…..no matter how you look at it…….
Best Film Award
This year goes to a surprise winner, the Finance Minister, for announcing the GST hike of 2% that will be implemented soonest 2021. This will undoubtedly spur “optional” healthcare consumption in 2019 and 2020 like aesthetic procedures to avoid the impending GST hike. This hobbit predicts that folks will rush to have their liposuctions, boob and butt jobs etc over the next two years. Huat ah!
“I remember my former boss Mr Lim Siong Guan used to remind us that “implementation is policy”. The effectiveness of a policy is not measured by how elegant it looks on paper, but how it is translated into reality during implementation. On this yardstick, we have to be honest and acknowledge that while the residency programme has its advantages and good points, some of the outcomes have not been as positive in practice as what we had originally hoped for. As with all major changes, what could have been better was a more gradual, step-wise implementation, with appropriate channels to acknowledge concerns of the medical fraternity, and to consider the impact of the changes from a holistic systems perspective.
After having some years of experience with the residency programme, the time is right for MOH to now review the programme. We want to retain the positive elements of the residency programme while taking concrete steps to address the problems we have encountered and improving the outcomes for our doctors. For this effort to succeed, we need to work closely with our professional bodies and doctors to listen to your feedback and see what we can do together to enhance the system. We need your help to work with us to achieve better training outcomes for our doctors and deliver quality care to our patients. I hope we can count on your support to embark on this review together”.
Senior Minister of State for Health, Mr Chee Hong Tat
Speech at SMC Physician’s Pledge Ceremony, 30 Sep 2017*
There you have it. Someone very senior has finally come out to declare that the Residency under the ACGME-I framework was and is a bad idea. Or at the very least, the implementation of the American system almost wholesale really sucked. This took honesty, courage and clarity of thought. Well, it was not for want of trying by many senior doctors and this hobbit as well to try to get the message across, but of course no one senior in MOH was really listening then.
Many fellow doctors have opined that the decision to introduce the American-based ACGME-I residency system was the brilliant work of some scholar or admin officer. This cannot be further from the truth. This was the idea of doctors, implemented by doctors, for doctors. Completely self-afflicted.
In my humble opinion, the urge to build personal legacies has a power to blind and deafen even brilliant and confident people, let alone insecure and lesser mortals. Many innocent and sincere people who tried to give real and useful feedback around 2008 to 2010 were steamrolled over like mush on the road after heavy monsoon rains. Some of them have left for the private sector as a result. They are now vindicated. May their professional souls rest in peace. Many of the others that remain continue to struggle daily to do their best to keep this residency system going, some against their best instincts. Hats off to them as well.
As for the residents themselves, they are also struggling. Junior MOs struggle to get a residency place now, since the number of places on offer are now greatly diminished. Those that are already residents know they need to see more patients and work harder to be properly trained, yet are curbed by work limits imposed on them by the ACGME-I system and they struggle to pass the British exams which are still part of their lives. And many of those that have exited as registered specialists with SMC and SAB now find themselves without jobs as Associate Consultants and have to settle for jobs with lower status and salaries in restructured hospitals. It is a lose-lose-lose situation that could have been entirely avoidable.
Anyway, just for old times’ sake, this hobbit reproduces two old articles about residency. The first is something he wrote which was published in the Nov 2009 issue of the SMA News (When he was still a regular contributor to the publication), “The Hobbit Residency Rap”. The second was a posting on this blog in Nov 2011, about a year after it had been rejected by the SMA News Editorial Board: “Residency Turkey”.
Dammit, I was funnier then.
“The Hobbit Residency Rap” (2009)
We should and must support residency
Just like we support urgency, hesitancy and intermittency
Yo! Doctor, please don’t criticise
Trust me, your words may get you ostracised
Don’t question and don’t be negative
Some folks take things personally and are very sensitive
If some things don’t make sense to you now
Please tell yourself, “That is because I am just dull”
Hey, we need many more specialists fast!
So too bad, apprenticeship is a thing of the past.
Trust the Americans to get healthcare right!
The traineeship system can go into the night.
Let the residents see fewer patients
While the rest see more with pure zest and elation
Hey baby, I know it sounds paradoxical
And some may even whisper, “It ain’t practical…”
But remember brother, you must not oppose this change
Lest they call you inappropriate or strange
You can decide which facets of truth you want to see
Unlike with BPH, then surely you cannot pee
Residency Thanksgiving Turkey (written in 2010)
As you read this, it’s near the end of the year and the holiday season is again upon us. Time flies. As with all things healthcare in Singapore recently (like Duke, JCI, Residency and Board Exams, the Hobbit goes American and celebrates Thanksgiving. For a start, here’s a recipe for a good Residency Thanksgiving Turkey:
One 7kg turkey, preferably caught from around College Road and slain by brute force with the bare hands of a simple-minded orthopaedic surgeon. If not, then get a frozen one imported from America that is suitably defrosted with naivety and bewilderment. Whatever the case, remember – remove the brain, heart and guts COMPLETELY! If not, this recipe will NOT work.
Juice of 2 BIG Singapore lemons
5 tablespoons of stupidity
5 tablespoons of single-mindedness and myopia
One cup of deafness
One cup of blindness
Mix the following:
One cup of hubris
One cup of white flour (Made from pure American Wheat)
Common Sense, boiled for 2 hrs, cooled, peeled and then finely chopped
National Pride – pounded violently and minced to paste
A finger of Local Tradition, grated to a fine dust
A sprig of parsley
One carrot finely chopped
One onion diced
Salt and Pepper to taste
A sprig of acceptance
A stem of blissful ignorance
3 tablespoons of cornstarch
2 cups of water
Salt and Pepper to Taste
Clean turkey. Remember to remove guts completely. Squeeze juice of two big Singapore lemons into cavity. Season skin and cavity with stupidity, single-mindedness and myopia. Stand for 30 minutes to soften muscle. Rub deafness and blindness onto skin and cavity liberally. Stand in roasting dish for 3 hours in the DARK. This is to ensure that when the bird is cooked, it is soft, compliant, tasty and quite divorced from reality.
Stuff Turkey with Stuffing. Close neck cavity and tail openings with string (not Prolene sutures, you idiot!).
Line roasting pan with lots of grease, preferably from Chicago or North Carolina. Roast Turkey in pan (breast-side down, to restrain/contain national pride).
For a 7kg turkey, 200C (or 400F, for the residents who are familiar with the American way of measuring things) for the first 30 minutes, then reduce to 175C (or 350F) for 2 hours, then reduce to 110C (225F) for next hour to hour and a half. Then raise temperature to 260C (500F) for 5 minutes to brown skin.
Remove bird to cool. Collect Oil and drippings into saucepan, add cornstarch and other gravy ingredients, flavor (Not “flavour”) with ignorance and acceptance. Bring to a boil and over low heat, reduce to a suitable opaque consistency.
Note – Residency Turkey usually tastes better when carved by senior medical administrators on footstools (never both feet on the ground). So do invite them for your next Thanksgiving Dinner!
Things to give thanks for over the Residency Turkey Dinner
We give thanks for
The fact that, like their American counterparts, our house officers (or R1) can only work continuously for 16 hours (i.e. no more over-night calls) and other residents will be entitled to 5 hours of uninterrupted sleep. They can only clerk several cases a day on call. In other words, they will probably stop work at 3pm when their quota is filled up.
And for all this, they will not get a pay-cut
We also give thanks that somehow with the residency programme, productivity and efficiency will seemingly be unaffected and healthcare costs will not go up, even though USA spends 16% of their GDP on healthcare and we spend 4%. Presumably, consultants can pick up the slack for free.
Finally, we also give thanks to the British training system that had more or less served us well but can now rest in peace.