Source: The Hobbit Awakens

Regular readers of this column will realise that this Hobbit has been silent for more than 2 months. Yes, this Hobbit has been busy with some personal business, which includes trying to tattoo BB-8 on his hairy chest, getting to get Mark Hammil to lose weight and renewing the SMC Practicing Certificate.

Regular readers will also notice that this column is on a new platform as a blog. The old Facebook account has been deactivated. This is because Facebook now requires that this Hobbit provides documentation that this Hobbit is this Hobbit. Hobbits do not have birth certificates or NRIC! Do you think I would have had to climb and crawl my way to Mount Doom if I owned a Driver’s License? I suspect Facebook is now advised or run by evil management consultants from McKinky or Boston Chowder Group, who are in turn spiritually enslaved by Sauron.

Old articles written in the Facebook-period have also been reproduced in this blog.

Anyway, this Hobbit has awakened after two months because another shorty also awakened in the last couple of days. I am of course talking about R2D2. And I have got the map to locate that something rarer than the last Jedi – the last general medicine physician in Singapore – Chee Yam Cheng. Prof Chee is apparently hiding in the Irrawaddy System because he feels responsible for not taking up the offer to be DMS 12 years ago which led to the beginning of the Dark Ages, otherwise known as the Residency System, which is more toxic than The Dagobah and Jakku Systems combined.

Speaking of Practising Certificate renewal, SMC has done it again. Somehow the guys who plan and operate this organisation has a wonderful gift of irritating doctors. Their natural propensity to irritate doctors is akin to Rey’s attunement to the Force. Only now, do I realise the power of the SMC side. I now understand that the expiry date on my practicing certificate is a source of distraction. The really important factoid is that you must apply to renew your practicing certificate three months before the current practicing certificate expires. In the past, this is an automatic process once you have met the CME requirements, but somehow this time round, having met the CME requirements, you still have to apply for its renewal online. If you apply late, (i.e. less than 3 months before the current practicing certificate expires), there is a late renewal fee of $80 payable.

What this means is that:

• You don’t have 24 months to obtain your 50 CME points, you have at most 21 months, if you want to avoid paying another $80
• Even if you have the 50 CME months in record quick time, you still have to apply for the renewal, even when say, you have put your SMC practicing certificate fee on GIRO (automatic deduction from bank to SMC) at least 3 months before the current certificate expires.

These guys are truly evil. They make Kylo Ren look as lame as an Ewok (OK, I gotta admit, Kylo Ren, aka Adam Driver unmasked is lame. Period. He looks like a younger version of Friends’ David Schwimmer, aka Ross Geller, another super lame guy).

Next on the list is the recently announced Committee on Future Economy. This is the biggest thing to hit Singapore since Singapore Conversation, Remaking Singapore and the launch of McDonald’s Hello Kitty toys. 30 of the most important persons will advise the government on how and where our economy should be heading over in the next 5 to 10 years. It was reported in The Straits Times that this Committee would tackle six key areas

• Future growth industries and markets
• Corporate capabilities and innovation
• Jobs and skills
• Urban development and infrastructure
• Connectivity
• How did the Millennium Falcon do the Kessel Run in 12 parsecs?

There are businessmen, management consultants, lawyers, unionists, bankers and fund management professionals etc in this Committee but NO representation from healthcare, much less doctors. The finance sector gets representation in the form of 2 bankers and 4 fund managers; manufacturing gets five representatives. Healthcare and healthcare professionals? One Big Zero.

That shows you more or less what the folks in power think of healthcare as a key plank in the future economy. This is more baffling if you consider that healthcare is one of the key hubs of Singapore now. Healthcare is where Singapore still enjoys a competitive advantage over other regional players. On the other hand, what are the competitive advantages that Singapore has in manufacturing which would justify five representatives? Instead of trying to leverage and improve on existing strengths in healthcare, we are trying to flog the ailing and ageing horse of manufacturing….Seriously folks, in Japan and certain parts of Northern China, they just eat the horse and move on.

It would appear that current thinking on healthcare has regressed back to the pre-90s thinking that healthcare is solely a social/domestic issue and a cost to society, rather than an economic driver that creates jobs and brings in foreign exchange. It’s Back to the Future all over again.

Another sad development is that of the recent news that Peacehaven’s plans for a different model for a nursing home that caters to demented patients have been shelved because MOH does not support it. (The Straits Times, 21 Dec 2015).

This is a sad development because it appears that the folks who decide on government subsidy policies cannot or are unwilling to accept the medical fact that patients with dementia who need to be put in a home are very different from the average nursing home patient.

Dementia patients have more complex emotional issues and needs than say the stroked-out patient- bed- or wheelchair- bound and on tube feeding and can barely talk, let alone socialise. Rooms with one or two residents will do wonders for dementia patients’ self-esteem. This is borne out time and again by many studies. But of course, bean counters will not understand this, or accept this. In this area, we are definitely NOT first-world. Instead, we choose to build and fund general hospitals that look like a holiday resort hotel in Bali (First-world plus). If it is truly a matter of operating cost (It cannot be capital cost, because the affected NGOs had agreed to fund $10M out of $15M that was needed to build the new home), then why not remove the en-suite bathrooms and toilets, but at least give every one or two patients four walls for more privacy (and self-esteem) instead of the large cubicles containing up to eight or even ten patients?

Our approach to healthcare funding has been concretized into dogma. And the dogma involve the following:

• Funding must be tied to bed-class. The level of funding is inversely proportional to the physical comforts of the class so as to prevent people taking advantage (i.e. moral hazard or ‘buffet syndrome’) of the subsidies. Even though we already have means-testing in place which already addresses the ‘buffet syndrome’ issue.
• General hospitals and acute care enjoy generous funding and funding policies because they are expensive to run. On the other hand, stringent policies govern funding of intermediate and long-term care (ILTC) services. This is strange because ILTC services are cheap to run in comparison with general hospitals and the potential savings that can be achieved are very little even if you try to squeeze blood out of the ILTC stone. On the other hand, the generous buffet in acute care and general hospitals continues. If we are really trying to contain healthcare costs, one should try to contain costs at the expensive end, not the cheap end.

Then there is this half-baked letter in The Straits Times Forum on Christmas Day by a certain Francis Cheng that completely misses the point. It is not a premium service. It is a service for dementia patients that is very different from normal nursing home patients.

Even if one concedes the point that it is a ‘premium’ service, one must ask, are we building nursing homes based on the past or based on what we expect in the future? What is the definition of ‘premium’? What is yesterday’s premium will become tomorrow’s ‘basic’. 25 years ago, air-conditioning in polyclinic was premium, now it is basic.

Will Singaporeans (even poor ones) accept staying in a large room with 7 other residents in 10 to 20 years’ time? It is true that most poor Singaporeans today in their 70s and 80s accept this arrangement. But people who are in their 50s and 60s may not accept this when they require nursing home services in 20 years’ time. Are we going to reconfigure and rebuild all these nursing homes that we are building now to cater to anticipated needs and demand?

It is also superficial to call a one or two-bedder ‘premium’ across the board from a general hospital to a nursing home. The two are very different animals. The average acute hospital inpatient stays in the hospital for about a week. Hence, the majority of Singaporeans may accept B2 and C class arrangements with six to eight patients per cubicle with little privacy given the short period of stay. But nursing home patients often spend one to two if not three years in a home. And the period is probably longer for demented patients. Will the majority of Singaporeans accept living in a large room for one to three years with seven other residents in 10 to 20 years’ time? These are hard questions policy makers and bean counters have to ask now and not kick the can down the road. Times change and we must change with them.

Finally, we come to the biggest issue of the last three months, the ‘Starkiller’ issue. Yup. The Hepatitis C outbreak in SGH in which several patients died. It is a tragedy, plain and simple. Heads will roll and blood will be let (That’s what certain committees are eventually meant to do, implied or otherwise). Many heads and a lot of blood. But it would be a mistake to believe that after forming high power committees and blood letting, such an event would not happen again. It will happen, and most likely it will still be a large hospital like SGH. Especially SGH. Because for some strange reason, after clustering and reclustering and building of hospital after hospital, the majority of immune-compromised inpatients in Singapore are still served in SGH: the cancer, renal and haematology patients. This is not to absolve SGH staff’s responsibility in this tragedy, especially in the delay in informing higher authority and the infection control lapses, and those that if necessary, have to be reprimanded, punished or even removed, should be.

But it remains a fact that SGH is the most dangerous hospital in Singapore by virtue of its workload and casemix of patients. It is said that the Outram campus has a one-third market share of all public hospitals’ workload and handles more than 50% of the aforesaid immune compromised inpatients in Singapore. Having a SWAT team may help to quicken the response and escalation, but the SWAT team will not prevent outbreaks.

It is time that we spread some of this risk to other public hospitals. It is never wise to put all or in this case, most of your eggs in the same basket. Which is what the bad guys in Star Wars never learn, from Episodes 4 to 7. You shouldn’t be building huge battle-station after battle-station than can be blown up by small one-man starfighters; spread the risk, dude…..

Enough said for now. Time for this Hobbit to go on his next quest, which is to locate the one thing now most heavily sought after by the evil First Order – a plate of grass carp raw fish….(I confess: I am actually going to play with my remote-controlled BB8 now)

Here’s to a better 2016 for the medical profession.

Greetings from Middle Earth.

Yet another new year beckons. Another year of laughter, tears and long letters from SMC, going by the trend set in December of 2014.  We received two long letters in the space of 2 weeks from SMC. The first, dated 16 December 2014, was titled “Clarifications on the SMC Disciplinary Process” and the second, “SMC – Consultation Exercise on the Draft SMC Ethical Code and SMC Professional Standards in Practice” was sent out on 29 December 2014.

The two letters seem as long as The Hobbit Trilogy but not half as much fun unfortunately.

Let’s deal with the earlier letter first. Para. 2 states “We cannot discuss the specifics of the case involving Dr Lawrence Ang as the matter is still pending before the Courts”. When a stupid lay-halfling (read: this hobbit) like me reads this sentence – the first reaction was “you mean after the Court of Three Judges decided he is innocent, Dr Lawrence Ang is still NOT off the hook???”

But fear not.  Some snooping around by this hobbit and his friends in the dark pits of Don Guldor reveal that Dr Lawrence Ang is truly, really, completely, verily, off the hook. The only issue pending before the courts is that the parties are debating as to who pays how much of the costs.

Obviously, there is either a cunning linguist running around drafting letters for SMC or this hobbit is very bad at English comprehension, for which I unreservedly apologise.

That brings us to the issue of costs. And the Lawrence Ang appeal will go down in the annals of SMC and legal history as the first time the Courts have ordered costs incurred by the doctor to be paid by SMC. This is no small deal. It’s a big deal. Hitherto, SMC has NEVER paid a doctor’s costs incurred in a disciplinary hearing. At most, it pays it own costs when the doctor is innocent, and when the doctor is found guilty, the doctor has to pay both his and SMC’s costs as well.

The next issue that was brought up in the letter dated 16 December 2014 is that “The SMC process, while not perfect, has worked well in an overwhelming majority of cases. The numbers bear this out. Over the past six years, i.e. since 2008, SMC has processed over 1000 cases lodged against doctors and, as to date, about 110 formal inquiries have been conducted before Disciplinary Committees or Disciplinary Tribunals. Out of these, four outcomes were reversed by the Courts”.

This is one perspective of things. Let this hobbit give you another perspective with this hypothetical scenario – “The Middle Earth Justice System, while not perfect, has worked well in an overwhelming of cases. The numbers bear this out. Over the past six years, Middle Earth Police has processed over 1000 cases of alleged assault and/or battery. To date, 110 cases were tried before the Courts and of these, four poor fellas were found to have been wrongly convicted by the Appeals Courts”. These four fellas would have gone to jail for about 6 months had not the Appeals Courts decided otherwise”.

Yup. It’s all a matter of perspective. To some, it’s 4 out of 110. To others, it’s 4 out of more than 1000. To the guy at the centre of the case, it’s the end of the world, or at least the end of his career. It is not a percentage or probability to the doctor being tried. It is either 0 or 100%.  One is one case too many.

In any case, no matter how we wing it or swing it, euphemise it or defend it, when a statutory body like SMC has to pay costs, to borrow a Chinese phrase, it can be described as SMC 死得好难看。(Bad Singlish Translation: SMC die until look very ugly”)

SMC is funded by doctors’ subscriptions and government funding (i.e. taxpayers money). Acting in such a way as to be ordered by the Courts to pay the doctor’s costs in addition to its own is not exactly the best (or even decent) way to spend the medical profession and taxpayer’s monies, even as the same letter claims that SMC is (and indeed, should be) acting in the interest of the public.

We now go on to the second letter dated 29 December. The first thing to note is that the layout is very different from the first letter. It is in very small font, single spaced. It is meant for elves or anyone that graduated in this century and not the last. And the sentences are kind of long. Obviously the aforesaid cunning linguist was not around when this second letter was drafted.

For a start, can SMC standardize its letters’ layout? Otherwise, the content of the letter is pretty encouraging, especially when it is stated that the original intention was not to make “the guidelines seem like a long check-list that is to be followed religiously”. Well, calling this “guidelines” and not “professional standards” is a good start. Whenever I see the words “professional standards”, I feel like I am being strangled by a boa constrictor. “Guidelines” is far less suffocating. Also please shorten this document. My humble GP clinic table-top deskjet printer CANNOT print out the document at one go. Seriously. Or should I make use of the Productivity Fund to upgrade my printer to one of those massive ones that can print, fax, scan, photostat, speak English and make skinny lattes?

The last bit we want to look at this month comes from the lawyers. I consider our judges and lawyers to be very smart people. A lot smarter that some folks in MOH or the Competition Commission of Singapore. At the opening of the 2015 Legal Year the Honorable Chief Justice mentioned that a major concern in the area of Civil Justice is the management of litigation costs. And one of the three key steps undertaken to address this is “the imminent publication of costs guidelines in the Supreme Court Practice Directions and on the Supreme Court website. Although the issue of costs remains fully at the discretion of the court, these guidelines will serve as a signpost to the parties of the level of costs that they can expect at various stages of litigation”.

I guess the Chief Justice is a believer in cost guidelines, like this Hobbit, like SMA, and like most doctors; although we called ours guidelines of fees (GOF).  But the idea is quite similar, because for professional services like legal or medical professional services, cost guidelines are not too much different from fee guidelines.  Unlike what the CCS proposes, the Courts are not going to publish actual bill sizes etc and hope the consumer/client does his research before engaging a lawyer.

The only difference is that the Courts is an organ of state and the SMA is an association. Fine, if some wise guys think an association cannot publish fees or costs guidelines, then get someone who can.

Like the SMC.

Oops. Did I really just say that?

Before we know it, it’s the end of the year again and the year-end holidays are upon us. But there is no letting up in the pace of things and major events and crises continue to befall us. We are not talking about calamities like HDB flat prices falling or international disasters like the Ebola virus epidemic in West Africa. Such tragedies pale in comparison to the biggest crisis of 2014:

Many NTUC Fairprice supermarkets have run out of toilet paper in late October

No shit. Literally.

How can Fairprice, the largest supermarket chain in Singapore, run out of “pang sai chuah”?

We can run out of rice, MRT trains can stop, SGX can stop trading. But no toilet paper? This has serious public health implications in our Singapore’s fight against SARS, Ebola and whatever viruses that Norton Antivirus cannot kill.  All that shit needs to be dealt with. Do you know how many diseases are spread by the faecal-oral route?

So this Hobbit is totally horrified that toilet paper stocks can actually depleted in Singapore, where we have enough N95 masks but apparently not enough loo paper. (N95 masks can also filter out 95% of faecal matter, I suppose). It’s enough to make a hobbit constipated.

But to lighten things up, at the end of the year in mid-December, the biggest movie of the year, the final installment of The Hobbit trilogy: The Battle of the Five Armies, will hit the big screen. This Hobbit will be there.

Peter Jackson will really let it rip here with all kinds of monsters and humanoid and humans slugging it out for 45 minutes in the finale. And you know what? These guys do NOT run out of toilet paper.

While we are on the subject of paper, it is also timely to point out there is another kind of shortage of paper. Many hospitals and clinics have also run out of A4 size printer paper and printer toner.

This has been caused by doctors trying to print out the draft SMC Ethical Code and Professional Standards (ECPS) which runs to about 110 pages long. Many trees have been felled in the process and this has contributed to global warming and even the haze in early November (Whoever heard of haze in November till now?). Numerous toner cartridges have been expended in the process and small desk jet printers that are commonly being used in clinics have overheated.

This is an ecological disaster in the making. The Ewoks are crying, folks. All because some wise guy decided to write an Ethical Code and Professional Guidelines that is longer than a Taiwanese afternoon Hokkien TV serial.

Folks that have finished reading the document have discovered that one or more may have happened in the meantime:

• Murphy Cooper is now a great-great-grandmother in Interstellar 3

• Jurong General Hospital is finally operational

• Yoda has reincarnated itself as Mickey Mouse in Star Wars Episode IX and most importantly of all,

• The grass has actually grown to a respectable height in our new National Stadium

Actually this Hobbit wonders if ALL the SMC members have read through the entire draft ECPS? Seriously folks….

For those that have actually printed out the document, here are some suggested uses for this document after you have read it:

• Use it as a doorstop

• Wrapping fish with it till 2020AD or till the City Harvest trial is over, whichever comes first

• Seventh Month burnt offering for your least favourite relative

• Lethal weapon for pummeling a cockroach to pulp

The next big thing that happened recently is the ban on Shisha tobacco smoking in Singapore. I must declare my vicarious conflict of interest here. Many hobbits are not averse to the occasional puff. But despite this, it is indeed good public health policy to ban the stuff before it takes root in a big way like cigarette smoking. In addition to banning Shisha, this hobbit also suggests that the MOH consider banning the following idiotic stuff:

a) ACGME-I Residency

b) Licensing Exams

c) Hello Kitty Runs

d) Any managed care plans that reimburses the doctor ten bucks or less for consultation

e) 110-page documents that cannot be printed by a small deskjet printer

Shisha is the lesser of all these ills….

We move onwards to the international arena. The newly-elected Prime Minister of India has appointed a minister to oversee Ayurvedic Medicine and Yoga. The minister of state, Mr Shripad Naik has been tasked to oversee the new ministry called the Department of AAYUSH. AAYUSH stands for Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy.

Actually, we can learn from the Indians. We can also appoint a minister of state to run the Department of AIYAH, not AAYUSH. This department will be overseeing the implementation of the Pioneer Generation Package (PGP) and Medishield Life (MSL).  The PGP has generated many AIYAHs in the land as it is being implemented now. The PGP was launched to much fanfare a few months ago. But our pioneers have come to realise that the PGP has some obvious limitations:

• It only covers subsidized care. If you want to continue with senior consultant Prof Chin Boh Eng, you have to continue seeing Prof Chin at the private clinic. PGP doesn’t cover the consultation, investigations and medicines at the private clinics. I.e. you still pay what you have been paying before PGP was implemented.

• It obviously doesn’t help the pioneer much who wants to be admitted into a private ward class for now. Let’s see what happens when the MSL is implemented next year.

• Even if you are being treated at the subsidised specialoist outpatient clinic, PGP doesn’t cover the cost of medications until 2015. For now, it only covers consultations and investigations. Why the PGP is being implemented in such a phased manner is really quite a mystery. Please ‘tahan’ for now.

• The PGP also doesn’t give you additional discounts at the Polyclinics if you choose to be seen at the Family Physician Clinics.  You have to be seen at the general clinics manned by MO at the polyclinics.

So, despite all the initial goodwill that was generated by the PGP, there are now many choruses of “AIYAHs” being sighed aloud all over the island. “AIYAH, talk so much, but in the end, still this cannot, that cannot” is being refrained by many pioneers as they discover the fine print intricacies of PGP.

That’s not to say PGP is not good. The PGP is doing a lot of good. But the public messaging could have been clearer from the onset so as to better manage expectations.

Well, that’s about it for November. 2014 had its fair share of humour and frustration. Let’s hope 2015 will be better. Hope springs eternal. In the meantime, remember, the Force will always be with you.  Actually what I meant was, the SMC will always be with you.

2015 will be a momentous year mainly because Episode VII of the Star Wars, The Force Awakens will be released. The first part of the final trilogy may include the following:

• Donald Duck and Goofy as Jedi Masters doing a  Disney Crossover and teaching the youngling recruits to use the Force to levitate the draft ECPS (only slightly heavier than an X-wing starfighter).

• Mark Hammil reprising his role as Luke Skywalker and teaching the three children of Han Solo and Princess Leia the finer skills of Shisha smoking in Yoda’s old hut amid the swamps of Dagobah.

• Chewbacca running out of toilet paper on the Millennium Falcon in a zero-gravity environment in hyperspace.

• A geriatric Harrison Ford making out with a postmenopausal (but still bikini-clad) Carrie Fisher after they get their PGP card.

Well, the plot thickens since the last posting. Like a good beer, this yarn is chillingly good, has a thick head of froth and a satisfying rich taste to it. And I mean really, really, extremely rich taste.

We are of course talking about the Susan Lim legal saga. Since Oktoberfarce Part 1, much more has been revealed. For the avoidance of doubt, this posting in no way suggests that this hobbit supports what Dr. Susan Lim has done in terms of charging her late patient. On the contrary, this hobbit believes that Dr. Lim did overcharge and therefore had to face the professional consequences of doing so, especially with regard to the mark-ups she put on other doctors’ charges.

Anyway, back to the issue of the costs Dr. Lim was made to bear by SMC. It now transpires that there are TWO bills in question. There was a first bill sent to Dr. Lim for the costs incurred for work done in a High Court Case. The bill of ~$1 million submitted by Wong Partnership (SMC’s lawyers) was taxed down to $370,000 after appeal by SMC. A second set of bills for work performed in the SMC hearings of two disciplinary committees (the first committee recused itself, and a second one had to convened) amounted to some $1.3M. They included bills submitted by legal assessors and expert witnesses and costs of stuff such as binders. This $1.3M was slashed after a taxation hearing to $317,000. The main bulk of this being the $900,000 legal bills submitted by Wong Partnership, which was cut to $180,000.

Then, The Law Society of Singapore weighed in on the matter by way of a letter to the press (not specific to the Susan Lim case) that (The Straits Times, 16 October, “Don’t equate reduction of costs with overcharging”) “a winning party’s bill of costs was reduced on taxation should not automatically be construed as overcharging. Indeed, if a client is dissatisfied with his lawyer’s bills, he can also tax that bill in court”.  This Hobbit must state that The Law Society’s letter also said these comments are general in nature and do not refer to specific cases. They are nonetheless illuminating to this shire-bound hobbit.

Firstly, it is true that not all reduction of costs after taxation can be construed as overcharging – actual work may have been done and payable, but it is just that this work should not be paid by the losing party and has to be paid by the winning party. But there can also be instances that both parties should not pay and the lawyers just sent in a very high bill that the court had to tax down drastically.

Secondly, while overcharging is not automatically imputed after taxation cuts, what is the “ethical limit” whereby the magnitude or proportion of reduction becomes so egregious that overcharging becomes a distinct possibility that has to be considered? Indeed, in the aforementioned letter by The Law Society, it was stated that, “The Law Society does not condone overcharging by lawyers, and complaints about overcharging are subject to a statutory regime. Complaints made to the Law Society are referred to independent committees for investigation”. 

For the information of doctors, The Law Society is a statutory body with regulatory powers, unlike say, the SMA, which is just a registered society with no statutory powers.

Since the Courts have decided that charging by doctors is subject to an “ethical limit”, this hobbit supposes that lawyers too have some ethical limit in charging. For discussion’s sake, would a lawyer who charged five times of what he should have (as decided by a taxation hearing) be suspected of overcharging? This hobbit doesn’t know what should apply to lawyers, but certainly if a doctor charged five times more than what he should have, then this hobbit thinks this doctor should be investigated for overcharging. Especially when the bill claimed cannot be apportioned to the winning party as well – in other words, the total amount of work, regardless of who or how many parties pay, is only one-fifth of what was billed.

The next piece of nugget came on 26 October 2014. The Straits Times reported that, “the SMC is appealing the latest decision”; i.e. the second set of bills when $1.3M was reduced to $317,000. As mentioned, the bulk of this came from the $900,000 of legal bills that was reduced to $180,000.

If this is true, then it must be asked – why is SMC appealing? Why does it NOT agree with the Courts? The logic is stupendously baffling.

This hobbit believes strongly that the ONLY credible, responsible and right thing to do is for SMC to bargain down the bills with SMC’s lawyers. Failing which, SMC should tax its own lawyer’s bills in Court. It should not appeal against a Court decision.

Let this hobbit explain:

• In any SMC hearing, there are only TWO possible final outcomes – either the doctor is guilty or the doctor is innocent.

• Almost all doctors in Singapore buy professional indemnity (e.g. MPS) to pool risk.

• If the doctor is guilty, the professional indemnity organisation or insurance provider will foot most of the bill. This translates to higher indemnity premiums for practically all doctors in Singapore and yes, it would probably lead to higher healthcare costs, because doctors will factor this in when they charge patients.

• If the doctor is innocent, SMC has to foot its own bills. Since SMC is funded largely by doctors’ subscriptions and some government funding, this will lead to higher SMC registration fees and government taxes

• In other words, it doesn’t matter whether SMC wins or lose the case, bigger legal bills are borne by the medical profession and the government, which would ultimately lead to higher healthcare costs and taxes.

• The only one that benefits financially from bigger legal bills is the lawyer. Even the patient or complainant doesn’t benefit financially since SMC hearings cannot award damages to patients.

In other words, this is a classic case of the “heads you win, tails I lose” scenario.

The only exception to the above algorithm is when the doctor who doesn’t buy any medical indemnity protection also loses the case and has to fund the SMC lawyer’s bill from his own pocket. But how rare is that?

Therefore, the only sustainable and prudent stewardship that SMC should practise in the long run is to lower the rates that its lawyers charge. SMC should not, and indeed must not, appeal against the Courts’ taxation decisions, for goodness’ sakes! And if does, it should fully explain why it is doing so clearly and publicly.

Let’s get back to the bills again. Again, there are only TWO possibilities: either SMC has already paid the bills or it hasn’t.

• If SMC hasn’t paid the bills, then SMC should just go back and bargain down the bills with its lawyers or send the bills for taxation.

• If SMC has already paid the bills, and now finds out that it is seriously out of pocket since they can’t recover the costs from the losing party, then more questions need to be asked. Why was it so hasty in paying the bills? Who approved payment? Was there any appraisal and approval process put in place to check whether the bills are reasonable or not? Are the charges competitive? After, all SMC is buying a service using public monies and should check around for competitive pricing

This hobbit seriously thinks that the Auditor-General should be sent in to take a deep, hard look at the financial arrangements and operations of SMC. Because the purported decision of SMC to appeal is, at least on the surface, quite out of whack with what it should be doing – which, in addition to upholding medical ethics and professionalism, also help to keep healthcare costs and public expenditure down in the long run.

This is not your normal brew, folks. Something is brewing, and it is beginning to smell strange. Really strange.

Hi folks. Many apologies for my absence in September. I was on the quest of my life last month. I macerated orcs, turned a whole mob of undead and even slayed a dragon. On the way, I endured untold physical hardship, fought with my darkest inner demons and I had stared into the eyes of death itself. And I have survived. Perceptive readers will know that I am talking about seeing through my son’s PSLE. Compared to today’s PSLE, Mount Doom was a walk in the park and Sauron was a piece of cake, dude.

I am back. Because “I am front” sounds rather uninspiring. (As you can see, there were some permanent side effects to surviving my son’s PSLE; one of which is I am even cornier now than ever before.)

And so it was on 1 October when I was celebrating the National Day of The People’s Republic Of China by chewing on my last vintage 2001 tin of Ma Ling luncheon meat, drinking my can of Chinese apple juice and eating White Rabbit candy that I noticed an article in The Straits Times which I originally thought was one of those April Fool’s joke article one gets every year in some newspapers. The only problem was that it was 1 October and not 1 April 2014. I also noticed that the tin of Ma Ling luncheon meat had expired about 13 years ago.

The article (on Page A2, 1 Oct 2014, The Straits Times) was titled “Susan Lim case: Court slashes SMC’s costs claims” – “it awards $317,000 of the $1.33M it claimed from surgeon”. The first paragraph goes like this, “Two years back, the Singapore Medical Council (SMC) had found surgeon Susan Lim guilty of overcharging. In an ironic twist, the High Court ruled that the legal bills sought by SMC from Dr Lim were themselves inflated, and slashed them from $1.33M to $317,000”.

The bulk of the $1.33M came from the $900,000 bill for work done by SMC’s lawyers. The Assistant Registrar who did the High Court taxation hearing reduced the $900,000 to $180,000. For the appeal hearing (because Susan Lim appealed to the Court of Three Judges), the bill was reduced to $70,000 from $150,000. One of the legal assessor’s bills was also slashed from $235,000 to $22,000. (In addition to having lawyers to represent SMC, SMC can also hire a legal assessor to advise SMC’s committees on points of law)

I am told by lawyer friends that a taxation hearing in the Courts is the Court’s way of guarding against overcharging. It is similar to what SMA used to do in its complaints committee when the Guideline of Fees existed. The main differences are that SMA only gives an opinion based on the GOF and it is non-binding. A taxation hearing decision is of course legally binding and the legal profession doesn’t really have any guidelines on fees.

From this Hobbit’s point of view, all this is actually good news for the medical profession and the public because if lawyers cannot charge so much against doctors who are defendants in SMC hearings, the likely consequences are

• Our medical indemnity costs and subscription rates can go down
• SMC’s lawyers also cannot charge SMC so much for cases when the doctor is found to be innocent and SMC bears the costs in these cases (in contrast to cases when doctors are found guilty and may have to bear SMC’s legal costs too)
• SMC’s operating costs also go down with lower legal costs
• And since SMC is funded by every doctor’s annual registration fees and some taxpayer’s money, the burden on the taxpayer is lessened, and our annual SMC registration fees don’t have to increase so quickly

Does this make sense? Sounds simple right?

Here comes the sucker punch. In the last paragraph of this news article: “SMC, which is understood to be appealing against the decision, declined comment when contacted yesterday”.

This not April Fool’s but an October Fool’s joke? This normally gentle Hobbit is so flabbergasted he wants to shave his hairy feet.

If The Straits Times is correct in it’s understanding (that the SMC is appealing), the SMC should declare what and why is it appealing against the taxation hearing decision?

Does the SMC think the Courts should cut the sums even lower? I.e. less than $317,000? If that is the case, then this Hobbit and I think 99.9% of SMC-registered doctors have no problems with the appeal.

If the SMC is appealing that the taxation hearing was unduly harsh and it’s lawyers should be paid more, then all doctors in Singapore (and even the public) should ask some serious questions about what is the role of the SMC and how the SMC is run and how decisions are arrived at in SMC.

• Firstly, the SMC is about safeguarding public interest by ensuring the medical profession practices medicine ethically. SMC is not about safeguarding SMC’s lawyers’ bill size.

• Secondly, has anyone in SMC looked at the bills its lawyers have been charging SMC in recent years? It doesn’t matter if SMC is paying the bills or the guilty doctors are. The fact is, the work done is for SMC, so SMC has to look at all the bills.  Could there have been many more bills that could have benefited from taxation hearings, if only the guilty doctors had the means and knowledge to use the taxation process of the Courts?

• Thirdly, since SMC certainly has the knowledge and the means to use the taxation process, would SMC consider sending the bills it had paid its lawyers to the Courts for taxation hearings if SMC comes into knowledge that a number of the bills it had paid can be possibly and probably reduced? Does the taxation process allow for retrospective analysis? Do we need a SECOND SMC Review Committee to look at the old and current “in-flight” bills?

• Lastly, since the SMC is a statutory body, would the Auditor General consider conducting an audit to see if any of the bills had been unnecessarily large in the last couple of years?

SMC, please do not decline comment. The monies SMC has in its accounts belongs to the profession and the taxpayer. The members and staff of SMC are mere stewards of these monies. We trust you as stewards. It is time you demonstrate that our trust is justified. This is no time to keep silent.

On a second note, the SMC has come up with draft Ethical Code and Professional Standards (ECPS). It has written to all doctors asking for feedback. You can access this document from the SMC website with your SMC password.

This hobbit strongly urges all of you to read the document even if you do NOT sleep, eat or poop for three days.

Because, in all likelihood, it will take you that long to get through it.

The old or current Ethical Code and Ethical Guidelines (ECEG) have a total of 8,076 words. The draft Ethical Code and Professional Standards (the Professional Standards is supposed to replace the Ethical Guidelines) have a total of 46,670 words.

These word-counts were arrived at by doing a “cut and paste” job from the PDF format to Microsoft Word format, so the numbers may not be entirely accurate but the numbers will make a reasonably good estimate for comparison purposes. In other words, the ECPS is at least 5.7 times the length of the current ECEG. In my bootleg Microsoft Word version of the ECPS, where the text size is size 10, it runs to 170 pages long.

In addition to the issue of length, you must take note of the following:

• The ECPS  “are to be regarded as the minimum stands upon which your performance and behavior may be assessed. As the disregarding of, or failure to abide by, these standards can potentially lead to deleterious consequences to patients and bring disrepute to the profession, such actions may subject you to disciplinary proceedings” (Introduction & Preamble, Section 1 (iv))

• “In this edition of the SMC’s ECPS, the use of the words “must”, “shall” or “will” indicates that the standard is generally to be met, save for extenuating circumstances” (Introduction and Preamble, Section 6)

• “Breaches of these guidelines (i.e. professional standards) could lead to your being asked to defend your actions. Disciplinary procedures for professional misconduct will refer to the ECPS as setting out the standards by which you will be judged”. (SMC Professional Standards of Practice, extract from introductory paragraph)

Now here is a sampling of these professional standards:

• When you work in teams, to ensure quality of care, you must “when delegating care within the team, be aware of the team members’ capabilities and limitations and compensate for any such limitations.” (Part A, Good Clinical Care,  Section 5(c)

• If you offer screening, “offer only testing modalities that have good quality evidence benefit” and “Advise patients on any important medical, social, psychological, financial or insurance implications of undergoing the tests and of the results that will be received” (Part B, Good Medical Practice, Sections 2.1.1 (d) and (h)

• Behaviours which you must avoid include

1. “Rude of inappropriate comments, excessive and unwarranted criticism or sarcasm” (Part D; Relationship with Colleagues Section 7ii(d))
2. “Persistent lateness and tardiness in carrying out duties” (Section (ii)(f))
3. “Lack of cooperation with team members” (Section (ii)(i)

• “Not put undue pressure on patients, for the purposes of earning a higher fee, to receive treatment from you in the paying class of your institution, or your private practice outside of your institution, when they can be reasonably managed by you in the subsidized classes” (Part H: Finances in Medical Practice, Section 1(iii)(c)) – (The point here is that even if you do not put any pressure, all your private patients may use this against you if they are not happy with you)

This Hobbit can go on and on. But the point that needs to be made is that if the ECPS is implemented in its current form, probably 95% or more of the profession cannot meet the requirements. And because most of these requirements are “strict liability” clauses (i.e. “must”, ”shall” or “will”) where the legal test is that they have to be met except for extenuating circumstances (which you, the defending doctor has to prove why it’s extenuating), there is a high chance that a lawyer can easily find you to have run afoul of one of the many, many clauses in this 46,670 word-long document. You really have little chance of professional survival should a patient or a colleague should to complain against you to SMC.

Some wise guy who has read this document joked to me that the draft ECPS is a “WMD” or Weapon of Mass Destruction. Another colleague thinks more of it like a Doomsday Device that we see in many sci-fi movies. He thinks a professional holocaust may be in the works.

So please, give your feedback now to the authorities. Maybe they will change their mind. And if not but at the very least, be acquainted with what the new ECPS will be about.

As for this Hobbit, I am an eternal optimist. Time to relax and have a beer. It’s Oktoberfest. I am sending my application to law school as soon as possible. I want to be SMC’s lawyer when I grow up.

The recent National Day Rally by the Prime Minister was in this Hobbit’s opinion, rather light on content in some aspects. Maybe he is saving the heavy artillery for next year when we celebrate our 50th National Day. You know it’s National Day Rally-lite when a delay in the construction of a regional health system general hospital becomes a key item in a National Day Rally. There are many other delays that are more worthy of mention – these include delays to MRT services, delays to HDB flat construction, delays to clearing Causeway checkpoint, delays to the Kong Hee trial and of course the very traumatic delays to anybody’s teenage daughter’s period. Why pick on a hospital? To this and all other delays, we should learn from the Hong Kong T-shirt inscription: Delay No More!

Yes, we are facing a bed crunch in our public hospitals but there are many ways to tackle this. Many of these hospitals have seen their Average Length of Stay (ALOS) statistic go up rapidly in the last few years. The usual reason offered is that patients are now older and hence have more complicated problems that demand a longer stay. But if you think about it, demographic and epidemiological factors do not change so quickly (over just three to five years) as to bring about longer ALOS figures in some restructured hospitals.

Is care now more fragmented and so nobody makes the big decisions? Do senior staff see the patients frequently enough to make important discharge decisions? More importantly, does the system back the doctors to make such discharge decisions, because such decisions are unpopular and involve risk. Are there disincentives so that patients and their families do not want to stay longer than necessary in our restructured hospitals. Are there enough community hospitals and nursing homes beds to help with the discharges’ needs?

If all general hospitals bring down their ALOS by one day, we have “created” the equivalent of about 1500 beds into the public healthcare system. That’s like one more TTSH or SGH. If we cut by half a day, we have another KTPH or CGH.

In fact, with the Pioneer Generation Package and Medishield Life coming on-line soon, the problem with discharging patients and keeping ALOS down will get worse, as the attractiveness of staying in a restructured hospital’s subsidised bed will only increase.

Let me give you an example. Yesterday my part-time clinic cleaner told me of her problems. She earns about $1,000 a month serving three clinics in the vicinity and stays in a 3-room HDB flat with her husband. The flat thankfully is fully paid-up. They have no children. Her 64 year-old husband suffered a stroke recently. He is now bed-bound and needs to stay in a nursing home. The medical social worker (MSW) in the restructured hospital helped her get a placement in a nursing home. She was told she was getting the highest subsidy rate possible for her husband to stay in a nursing home – 75%. That sounds like a decent deal. But the total amount came to about $1450 a month. She still has to pay another $500 to $600 to the nursing home. On top of this, she still has to pay for other expenses such pampers, medicines and transportation costs to hospital for further treatment and follow-up etc. The comes up to another $500. The husband also gets an Eldershield payout of $300 a month for about 5 years.

In other words, even with a 75% subsidy rate and being subsidized at about $1500 a month, she has nothing left to feed herself from her $1,000 a month income.

As suggested, she can rent out one of the bedrooms in her flat and collect say $700 a month but (rightly so,) she has come to the conclusion that keeping her husband in a C-class bed is really the best option for her. The best care, the best facilities at the cheapest price (after Medisave and Medishield Life payouts). And yes, she thinks she may still rent out the HDB flat room and take the $700.

Many people in similar situations will likewise come to the same conclusion and resist moving to a long-term care facility.

Houston, we have a problem.

On a lighter note, the government recently posted another minister of state and permanent secretary to MOH. This is the most beefed-up MOH we have ever had in the 49-year history of the nation.

We now have at the political appointee level one cabinet minister, one senior minister of state, one minister of state and one parliamentary secretary. That’s four politicians. At the senior management level, we have two permanent secretaries, one DMS, two deputy secretaries and one more deputy secretary –level person running MOH Holdings. That’s six persons at the senior management level.

Altogether that makes ten persons at the highest levels of MOH. Let’s call them the “tua-liap” ten. This number of tua-liaps (big-shots) raises very important questions:

a) How do you find enough rooms for all ten of them plus their personal assistants at the top floor of the College of Medicine Building (COMB)?

b) Who gets the coveted four car-park lots at the back entrance to COMB?

c) Are there enough seats in the MOH Boardroom, and if so, who gets to sit in the front row around the table and who gets kicked to the back row of seats and most importantly of all…

d) Can the foundations of an old building like COMB take the top-heavy MOH line-up?

The appointment of the Second Permanent Secretary to MOH, MG Ng Chee Khern is perhaps the most interesting one in a long time. Firstly, he was formerly the Chief of Air Force and hence Top Gun. Secondly, he was Director of Security and Intelligence Division of MINDEF – that makes him chief spook. A fighter pilot ace and master spy is not to be trifled with. He probably already has a dossier on this Hobbit which is thicker than Gimli’s beard.

But that’s not all, he has written this 29-page masterpiece on staff work in the MINDEF publication POINTER. This is accessible to the public at the URL link below. I urge all MOH staff and restructured hospitals staff to read it. They are also advised to read it while sitting on the toilet bowl because in all likelihood they will be defaecating bricks while they read this seminal work. 2PS (Health) is not only Top Gun and Chief Spook but he is also English Wordsmith, as evidenced by Section 2.2: Using clear, concise and correct language.

But seriously folks, many civil servants have spent a lifetime honing their language skills so that they communicate, confirm and conclude NOTHING in their writings. How can they be asked to use clear, concise and correct language? 2PS(Health) has a better chance with a Wookie or Groot.

Now onto the really serious matter of the day- allegations of overcharging and over-servicing.  Dr Tang Kok Foo’s two letters to the press have raised quite a maelstrom as things go. (After reading 2PS(Health)’s 2009 Pointer article, this Hobbit is inspired to use one big word hopefully correctly – maelstrom).

There are those who protest against Dr Tang’s allegations. They claim that the medical profession is still largely ethical and that respect for patients is the most important guard against unethical behavior. They are right. But they are missing the point – overcharging and over-servicing is indeed on the rise recently. Of course, one can claim that overcharging is very rare except in the most egregious of cases. But this Hobbit would like to introduce a new concept – that of ‘uncomfortable’ charging. There are more and more cases of specialists in the private sector who are charging in a way that makes many in the profession uncomfortable. It may be wrong to label these folks ‘overcharging’ since the guidelines for fees no longer exist. But the quantum charged makes many of us uncomfortable.

But doctors charging uncomfortably are not just the ones to blame. Indeed, private hospital charges are also part of the problem. So this hobbit found the MOH’s letter to the press on 26 Aug 2014 about private hospital charges not coming under the purview of MOH to be lame and disappointing. It is another fishball stick incident in the making. So whose purview does this come under? Do we need a Ministry for Private Health or Private Hospitals to be in charge of this? The Ministry of Health (Public and Private) has a responsibility to keep private healthcare affordable as well. And this begins with costs. If you leave everything to the ‘free’ market without understanding the real forces at work here that drives behaviour, then you will get people bidding $1.28 billion for hospital land, prices of $8000 to 9000 per square foot for clinic suites with only ~65 years left in the lease, charging $10,000 for colonoscopy and fixing of clavicles.

We now even have private hospitals offering rental rebates for doctors renting clinic space from these hospitals. These rebates are directly and mathematically linked to the patient billings they generate for the hospital. Such an arrangement offered by private hospitals obviously encourages over-servicing by participating doctors. Whose purview does this come under?

We cannot afford to wait any longer to fix these problems. We claim to be a medical hub. But already, hundreds of patients from Indonesia are going to Malaysia everyday to get medical treatment. This number is greater than the number coming to Singapore, although Singapore still gets the more complex cases. Many more from Myanmar, Pakistan and Bangladesh are going to India. And if and when Thailand sorts out its political problems, Bangkok will draw many more regional medical patients to its hospitals. Singapore is fast losing its allure as a regional medical hub. If we do nothing, we will certainly lose our hub status in 10 to 20 years’ time.

Every right behaviour starts with the right policies. Not having a purview of certain things means a policy of having no policy about these same things. There are exceptions, but a policy of having no policy seldom engenders the right behavior.

http://www.mindef.gov.sg/content/imindef/publications/pointer/supplements/onstaffwork/_jcr_content/imindefPars/0013/file.res/ON STAFF WORK(L)_280809.pdf