July has been a very rough month for Singapore. No. We are not talking about DBS, Stanchart or UBS being inadvertently involved in suspected money-laundering activities. We are not even talking about the multiple murders that took place. We are talking about the fury over the first Singapore Edition of the Michelin Guide. Imagine a bak chor mee stall getting one star. Seriously folks, we should get Eric Khoo to do a sequel to his 1995 hit with “Mee Pok Man 2” – with a Michelin/healthcare twist. It can feature a legendary obsessive-compulsive mee pok man who goes into depression and ends up in IMH after he overcooks his mee pok for the Michelin inspectors (How hard is it to spot a few angmohs eating meepok at a hawker centre??).

Speaking of stars, this hobbit understands that Managed Care (MC) and Third Party Administrators (TPA) have also started to rate or rank doctors. Nothing wrong with that in-principle. Not all doctors are equal. But ranking should be based on facts and objective measures.

For example, recently, certain doctors were preferred by a certain MC company because these doctors were purported to be experienced with good clinical outcomes and their clinics were equipped with good clinical facilities. Maybe this is true. Maybe this is not. On what basis are these doctors deemed to be experienced or well-equipped? Isn’t this kind of laudatory? And while it is not self-laudatory ostensibly, by allowing such practices to continue in the MC and TPA industry, aren’t we allowing the SMC Ethical Code to be circumvented and hence making the Code nugatory?

Is anyone in power doing anything about this? Probably not. Because the market has frequently triumphed over ethics for healthcare in this country, this Hobbit is not hopeful.

Speaking of rankings and lists, here’s another one. A website which describes itself as “an Ego-Stroking Men’s Lifestyle Portal focusing on empowering Men with the latest updates and news relating to Fashion, Business, Health & Grooming, Lifestyle, Technology and Current Affairs” has just published a list of “Ten GoodLooking Doctors in Singapore”. The list includes both male and female doctors. It’s really quite hilarious and if I were on the list, I would have volunteered to be quartered slowly by a bunch of trolls riding on giant worms. Just in case you are wondering, “good looking” is also laudatory but this Hobbit will let this pass. We live in an increasingly miserable world and everyone needs some comic relief.

We move on to something that is more that affects everyone in the medical profession. This is really important, unlike most of the stuff that goes on in this column. In last month’s column, the Hobbit speculated that the Court of Three Judges overturned the SMC Disciplinary Tribunal’s (DT) judgment on the case of the orthopaedic surgeon giving only two days MC to a foreign worker after fixing his fractured wrist was maybe because the DT had erroneously concluded that it had to find intent on the surgeon’s part before it could find him guilty.

Guess what? This hobbit’s speculation was largely correct. (gloating like Smaug this hobbit is….) No, this hobbit is definitely not legally trained. SMC cases and ethics is still about a lot of common sense and listening to how your conscience speaks and not so much “legalese”, unlike what some what the previous bigshots said in the Ivory Building (note: not Tower) on College Road.

But there is a very important development in this case that EVERY doctor must know. And this is the point regarding how the Three Judges gave a suspension of six months while the SMC lawyers only asked for four. This is quite unprecedented.

The ground for decision for the abovementioned case have just been released and on page 48, under the section “Recalibration in Sentencing Benchmarks”, the learned judges felt the need to deviate from sentencing precedents and give harsher punishments because current conditions are different and warrant more severe punishments. It said that there were several SMC cases where sentencing was inadequate in the past.

This is so important that the relevant paragraph (para. 117) is reproduced here:

“As can be seen from Lee Kim Kwong and Kwan Kah Yee, we have on at least one previous occasion referred to and, on another, exercised our discretion to depart from precedents that do not reflect the prevailing circumstances and state of medical practice. In our judgment, public interest considerations weigh heavily in imposing deterrent sentences on errant doctors who are found guilty of professional misconduct. In this regard, we expressed at the hearing that we found the sentences imposed in the Dr K case, Dr L case and Dr Amaldoss case (“the Relevant Precedents”) to be lenient. We observed without reservation that these sentences should have in fact been longer. We highlighted to the parties that this court has given fair notice of its intention to recalibrate sentences across professional misconduct cases, and would do so in the present case.”

Doctors have to know that the final powers of interpreting legislation passed by Parliament lie in the Courts, and not SMC or even MOH. In this case, the relevant legislation is the Medical Registration Act (MRA) which provides for the existence of SMC and empowers the SMC to punish doctors. While the courts cannot give out punishment that is more severe than what the legislation specifically allows for, it certainly can decide on how severe the punishment should be as long as the punishment is within the limits provided for by the relevant legislation.

So here, the “this court” has, in the name of public interest, interpreted the relevant part of the MRA and within its powers, decided that the surgeon deserves six months of suspension instead of the four asked for by SMC. More importantly, this is not a once-off decision as “this court has given fair notice of its intention to recalibrate sentences across professional misconduct cases….”. “This court” which consists of the Chief Justice and two Judges of Appeal, is for all intents and purposes, the highest court in the land with regard to SMC appeal cases. There is no higher court. Repeat: this is a new development that is not once-off.

All doctors are hereby warned.

You know, just when you thought things are getting so depressing here, it can’t get any worse? Well, it sure can.

Recently, this Hobbit heard of a resident who on realising there is no specialist job available for him upon completion of residency, quit residency with less than a year left to go. He has since joined a bank, I am told. The lack of jobs upon completing residency is now commonplace.

The sort of long-term Confucian relationship between a department and their residents and between the boss and his juniors is now truly gone. Gone by shortsightedness and a utilitarian approach to manpower planning. And it’s about to get worse down the line with the large number of undergraduates we are producing locally and those returning from abroad after getting their MBBS. For those of us not in the know, the three medical schools are now taking in more than 500 students a year. Where are they going to find training and long term jobs beyond their bond period nobody knows.

The public healthcare system thinks it needs a lot of junior medical staff to run the public healthcare system. (undoubtedly exacerbated by the low-efficiency residency system), but it doesn’t know what to do with all these junior doctors beyond the first few years. We need to change direction soon but everyone is mired in policy inertia, much like how our population policy was still stuck in the “Stop At Two” phase when our birth rates had long declined to justify such an anachronistic position.

The legal profession is more responsive and cleverer than us. They clamped down on the list of overseas law schools recognised locally recently as soon as they realised that a glut looked imminent. As for the medical profession, we now have residents with no jobs after finishing residency but nobody is clamping down on nothing.

Maybe in the years to come, we will have another one-star Mee Pok Man; one with MBBS, MRCS. His surgical training is probably more relevant to cooking than to being a banker.

SMC is back in the news again. Like some wild boar that keeps charging back in Kranji and Punggol….the difference is that some will say the boar has comparatively more grace and finesse.

It gives this Hobbit no pleasure to write about this. Some of them are what you call legacy issues. Others are current and the ball is in the court of those sitting there now.

The first case is that involving an orthopaedic surgeon in private practice who was suspended by the Court of Three Judges for six months because he gave the poor foreign worker he operated on for a wrist fracture only TWO days of MC.

Obviously, this is wrong. I was an orthopaedic MO once and I wrote many MCs for patients discharged after such a fracture was fixed. If I gave any such patient only two days of MC post-op, my consultant would have burnt me at the stake during the weekly department trauma round.

But interestingly, the SMC Disciplinary Tribunal (DT) acquitted this orthopaedic surgeon. The SMC lawyers appealed against the Tribunal and asked for the doctor to be suspended four months, citing aggravating factors.

The Court of Three Judges that heard the appeal not only overturned the ruling of the DT, but gave the SMC lawyers more than what they asked for – a suspension of six months!

I am not a fan of the SMC lawyers usually. But I guess they were right to appeal in this case and press for punishment.

The detailed grounds for decision of the Court of Three Judges for this case is not out yet publicly. But SMC said in its press release that “The Court noted that Dr Wong had considered “irrelevant factors” in issuing the medical certificate and “disregarded the patient’s wellbeing”.

What is significant is that this case is heard under the latest revised Medical Registration Act (MRA) in which every DT must have one member who is a senior legally trained person or legal service officer. I am told there was a very senior or retired district judge on this DT. So what happened? What went wrong even with the mandatory legally trained person on the DT?

Remember when many doctors were unhappy and protested when this provision was made? The then Director of Medical Services defended this provision robustly as if this was the panacea to several SMC’s problematic rulings.

Obviously, with this latest case, it can be seen that having a senior legal officer is no panacea. There is a lot of egg on some folks’ faces.

This Hobbit is no lawyer, but here is some speculation. ALL SMC cases are considered quasi-criminal in nature. This sounds terrible but actually it’s a blessing for doctors. Because it is quasi-criminal, the standard or burden of proof is “beyond reasonable doubt”, as opposed to civil suits where it is just the “balance of probabilities” (>50%).

If the judge finds that you are wrong based on the probability of just more than 50%, you lose a civil suit; i.e. balance of probabilities. But it is much, much harder to prove you are guilty “beyond reasonable doubt”. One of the key factors is intent. That’s why it’s not a bad thing for SMC cases to be considered quasi-criminal.

But the key word here is “quasi-”. SMC cases share a lot of similarity with criminal cases, but the two are not entirely the same. Hence “quasi”. One key dissimilarity is that you do not have to prove intent if the damage done to the patient is so gross and the suffering so great and obvious.

For example, a patient is known to be allergic to penicillin and the junior ward doctor gives it intravenously to the patient due to oversight, fatigue, or whatever. The patient dies. You do not have to prove intent here. The junior doctor is still guilty of professional conduct and would probably have been suspended.

To give another example. If another orthopaedic surgeon accidentally amputated the wrong leg, you do not have to prove intent. The harm is so gross and the suffering by the patient so great that the surgeon should be suspended.

The first part of Paragraph 16 of SMC’s press release on 16 May 2016 is reproduced here:

“Nevertheless, the DT acquitted Dr Wong on the basis that SMC had not proven beyond a reasonable doubt that Dr Wong’s departure from the applicable standard of conduct was intentional and deliberate.”

This Hobbit speculates that the deviation from standards and the suffering of the patient is so great that there is no need to prove intent here beyond reasonable doubt. And that is probably why it is speculated that the Court of Three Judges overturned the DT’s decision of acquittal and even gave a sentence stiffer than what the prosecution had asked for. This is just pure speculation on my part. Let’s see what the Court of Three Judges say when their Grounds for Decision are released in due course.

Enough legal talk. Let’s move back to ethics. It is now out in the open. No, I am not talking about Taylor Swift smooching with Tom Hiddleston (aka Loki). Seriously, if you want to choose a baddie, try Michael Fassbender (aka Magneto). Ian McKellen (aka the old Magneto) is not interested in Taylor Swift, unfortunately.

We are talking about the “admin fee” charged by Third Party Administrators (TPAs) or Managed Care (MC) companies. This came to public light during a symposium organised by The Care Cooperative which was reported by The Today Newspaper on 10 June 2016. Apparently, from the article, the percentage fee can go up to 25%!

It has also been made known that the Singapore Medical Association (SMA) has written to the SMC asking for “definitive advice”.

This Hobbit is not holding his short breadth for this one.

The usual advice we have been getting from SMC is something that goes like “SMC expects all registered practitioners to adhere to the ethical standards as prescribed by their SMC Ethical Code and Ethical Guidelines and to put their patient’s interests first when they discharge their professional responsibilities”.

Of course the actual words may differ somewhat, but the gist is something like the above.

In essence, in Hokkien, it is like “Gong Liao Boh Gong”. (Loosely translated into Singlish – say already like never say).

What doctors at the frontlines dealing with these TPA and MC companies really need is “definitive advice”. Motherhood statements like the above do not constitute “definitive advice”.

Definitive advice in this context comes in the form of “yes” or “no” answers.

Can I give the TPA and MC companies an admin fee based on a percentage of what I charge their patients? There are only two possible answers to this question that can be considered as “definitive advice” – “yes” or “no”.

If the answer is “yes” – then the profession has been definitively advised – which is a useful thing.

If the answer is “no”, can I give an admin fee at all, not based on percentage? Again, the possible answers which constitute “definitive advice” can only be “yes” or “no”.

In fact, not only are doctors hoping for definitive advice, this hobbit thinks the TPAs and MC companies are also wishing for the same thing.

So why isn’t the definitive advice forthcoming?

The problem I suspect is that there are some folks who are tying themselves in legalistic knots that have nothing to do with ethics.

This Hobbit again speculates that the (stupid) logic may go something like this:-

• The MRA determines that SMC should exist and defines the terms of its existence
• The terms of existence are such that SMC can only deal with doctors (and their professional practices) and nobody else.
• Hence, SMC has no say over how TPA and MC companies operate.
• And if SMC strays outside of regulating doctor’s professional practice by directly (or even indirectly) commenting on TPA and MC matters, SMC may be considered to be out of line and may even get sued or get criticised by the Courts in some test case.

The speculated answers to this speculated stupidity are:

• In Singapore’s context, no TPA and MC companies will EVER dare to sue SMC, a statutory body. The chance of this happening is even less than Leicester winning the next EPL season. (OK, I submit I may have to eat my hat on this next year)
• The Courts also need to know what SMC thinks about this.
• The patients, i.e. the people of Singapore need to know what is SMC’s position on this.
• SMC may not be empowered to regulate TPA and MC companies, but ALL doctors are regulated by SMC and these doctors DEFINITELY need to know what SMC thinks about this, whether they can pay a commission or admin fee based on a percentage of a doctor’s professional fees. Put it this way, SMC does not allow doctors to have sexual relations with their patients – this does not mean SMC is regulating the patient’s sexual behavior or love life.

Life is really very simple. If you are put into or elected to a position of power and responsibility – then stick your neck out on important issues that pertain to that position. If you are not prepared to stick your neck out and want to hide behind motherhood statements or some legalistic mumbo-jumbo, and all you want is to wear a nice, long gown during ceremonies and bask in the pomp and pageantry, then please do everyone a favour, step down.

And just to be intellectually honest and clear, definitive advice can come in the form of a “yes” answer – it is OK to give the commission or “admin fee”. Then everyone can also breathe easier rather than live with all this uncertainty. Of course, this Hobbit prefers the “no” answer but “yes” is still better than motherhood statements. At least someone is sticking his neck out….

Which brings us to the upcoming SMC elections. People who want to consider running for SMC elections, please be prepared to stick your neck out and give definitive advice when the crunch comes.

Again, this is pure speculation. This hobbit is still hoping definitive advice is coming our way. But it will also not be completely unexpected that we won’t be getting any.

But anything can happen and we should retain some optimism. After all, if Tim Hiddleston (aka Loki) is rumoured to be the new James Bond (aka 007) and is dating Taylor Swift, anything can happen.

Anyway, enough speculation for now. Let us doctors now return to the realities of ethical ambiguities, professional frustration and economic imperatives…..

It finally happened.

As it surely must. What we had expected has come to pass.

I am not talking about the sequels to X-men, Captain America or even Chen Shao Mao challenging Low Thia Khiang to be the leader of the Worker’s Party. I am not even talking about the arrival of the Zika virus in Singapore.

Speaking of the Zika virus, I must say that, like our taxation regime, it is a “progressive” virus, (i.e. affects the rich more than the poor). This can be seen by the fact that the virus came through a permanent resident living in the posh Watten Estate area, after he had spent some 6 weeks in Sao Paolo, Brazil. This permanent resident is probably rich to be living in Watten Estate, can afford to spend 6 weeks in faraway Brazil and also sought medical attention with a specialist working in a private hospital.

The bus captain living in a Punggol 4-room HDB flat cannot afford to go to Brazil for 6 weeks or see a private sector specialist.

But this hobbit digresses. What has come to pass is common sense prevailing. For some strange reason, this hobbit has suspected that some folks in Ministry of Health are waging a secret war that is even bigger than the War on Diabetes – the War on Treadmill. I think these folks may have a fetish to see treadmill testing eliminated in this country.

To me, treadmills are a relatively cheap and safe test to investigate a potentially and frequently fatal disease – Ischaemic Heart Disease. But some folks want to regulate it to death, as opposed to using it to prevent death. MOH issued a circular on 14 Dec 2015 saying hat it has finalised the “Guidelines on Provision of Electrocardiography Stress Testing (EST)”. It further said the Guidelines would take effect on 1 May 2016.

The circular and the appended Guidelines are very interesting in at least 3 aspects:

1. It said it had consulted respective professional bodies and has finalised the Guidelines. As far as this Hobbit knows, consultation indeed happened. But there probably wasn’t agreement. So while it gives a veneer of concurrence because it “consulted”, there probably wasn’t real agreement. This can be seen by the next two points –
2. Under Paragraph 3 or Section III of the Guidelines, “Patient Selection”, it is stated that should a patient who does not fall under the indicated criteria for a treadmill be offered one, he needs to be given “a cooling-off period of 7 days to consider whether to proceed”. I am not making this up. This hobbit will bet his last pint of beer that the requirement for a cooling-off period of 7 days for a treadmill cannot have come from a person who actually practises clinical medicine or any of the aforesaid unnamed professional bodies.
3. Lastly, while the circular is titled “Guidelines on Provision of Electrocardiography Stress Testing”, the next page shows the list of people who are purported to be responsible for these Guidelines and the page was headlined “Treadmill Services Workgroup”.

These are incredible times. An 18 year-old girl can get an abortion legally in a licensed clinic in Singapore on the same morning but a purported healthy guy needs a seven-day cooling period to get a treadmill. Where is the sense of proportionality here?

By the way, real doctors call a treadmill test, “A treadmill”, not electrocardiography stress testing, for crying out loud. And even if you do it call by that dreadfully long name, then do not call the workgroup “Treadmill Services Workgroup”. If you want to be annoying, please be consistently annoying.

This hobbit still doesn’t understand what is the fuss about ordering an un-indicated treadmill for a healthy person. What is the big downside? Did anyone get hurt? Yes, the doctor made an extra buck along the way. We may even discover the occasional asymptomatic IHD patient who claims to be very healthy and prevent a sudden death. So why this obsession to regulate a relatively cheap and safe investigation modality to oblivion? Don’t we have better things to do like examine why are people getting 8 to 10 stents inserted into their coronaries electively? Or look into why are people charging $10,000 or more for a colonoscopy? Or as this hobbit has said recently, regulate the Wild, Wild West that is managed care and all the kickbacks, fee-splitting and commission paying that is happening there rampantly?

But some folks just want to have their little private war and make the humble treadmill the Jose Mourinho of medicine. (The Special One). Can’t we just make it The Normal One (like Jurgen Klopp) instead?

Instead of doing real meaningful regulatory work, these geniuses want to stamp out unnecessary treadmills as if the treadmill posed a real great danger to our already battered healthcare system. It’s like trying to stamp out littering and jaywalking in war-torn Syria now. Seriously folks, if you have too much time, go to Watten Estate to swat mosquitoes.

So it is with great satisfaction that on 26 April 2016, an email was sent out to all licensees of clinics with an appended circular that the implementation of the Guidelines, originally slated for 1 May 2016, has been deferred till further notice. For the uninitiated, defer till further notice is the equivalent of  “a Prata” (Singlish).

But even here, the act of informing all licensees could be done far better. ALL the licensees’ email addresses are listed on the “cc:” section of the email in hyperlink mode. This is terrible email etiquette. The least the sender could have done is to put the licensees’ email addresses on the “bcc:” section so that the licensees’ email addresses are not exposed in a long list to everyone on the mailing list. I had to scroll down for what seemed an eternity just to get to the message proper and then open the appended files. Moreover, just because the government is not subject to the PDPA requirements does not give a civil servant the moral authority to share my email address with a few hundred other clinic licensees and vice-versa. What if the entire list of addresses was passed on to some pesky internet marketer or internet conman etc?

A wise wizard once told me that the most dangerous people to hang around are those that are diligently stupid. People who are lazily stupid actually do less harm. I guess this case qualifies….

Anyway, since this hobbit doesn’t offer treadmill services in his clinic, it’s really of little concern to me other than that his email address has been made known to a few hundred other clinic licensees. Time to go to Pek Kio hawker centre to get my prawn mee after the big clean-up so as to celebrate The End of The War on Treadmill (hopefully).

This is probably the hottest April Singapore has ever felt. And we are not talking about the weather. Although it’s certainly baking this April. We are also not talking about the parliamentary budget debates, which was about as exciting as watching the threads fray more and more on my clinic tourniquet.

We are not even talking about two major earthquakes on opposite sides of the Pacific. We are talking about accusations of dishonor and some very funny monkey business interspersed with relentless reporting of the actress Rui En asking “Do you know who I am?”

Like most hobbits living in shires, I don’t know.

Meanwhile, after years of writing absolute rubbish, this Hobbit is suddenly overcome with pangs of fear that he may have accidentally, unknowingly plagiarized somebody or something (including Wookie-like yawns, Ogre rants and R2D2 beeps).

Since the last column on managed care, many alert readers have asked this Hobbit about the issues of “fee-splitting”, “inducement” and “commission”. To short guys like me, life is simple. When it doesn’t smell right, it usually isn’t. Take dwarves for instance, they don’t smell right. Neither do orcs, they smell even worse.

That is not to say that this Hobbit is super-righteous and adopting a holier-than-thou attitude. Far from it. This Hobbit has its fair share of shadows and skeletons in Storm Giant-sized closets. But that should not prevent anyone from speaking out against something that is poisoning private practice doctors and the private healthcare sector. Especially when it’s early days still and what participating doctors really need is guidance and not condemnation or even criticism.

The issue is that we (and that includes me, This Hobbit) are so enamoured with the money and business of medicine and managed care that we euphemise the sin, make black become grey and increasingly paler and paler shades of grey until it looks a creamy light yellow. But it will NEVER be pure, pristine, 100% white.

We get de-sensitized and refractory to further such stimuli. The originally painful pricks to our conscience have become just what they now are – little pricks. And no more.

Let’s take the example of the 15% fee that managed care and third party administrators demand from participating doctors and clinics. In the normal course of business, a company bills another party for work the company has done. The bill is derived from the work and costs incurred by the company and topped up with a profit margin. There is NOTHING wrong with making a profit. But the point is that the bill is derived from the work and resources employed by the billing company (where work was done and costs incurred).

In this case, the billed amount is derived from the work done NOT by the billing company  BUT by the clinic and the doctor. In business terminology, that is usually called “a commission”. Calling this an “administrative fee” is just a euphemism or circumvention for “commission”. It is a commission dressed up as an administrative fee. When you dress an orang-utan in human clothes, it is still an orang-utan. The Uniqlo, Marks and Spencer or even Christian Dior apparel doesn’t make the orang-utan human.

When you buy or sell or house and use a property agent, you pay him a commission derived from the value of the property transaction, not from the effort the property agent has put in. That’s the way the property sector works. But this is not how the medical profession works (or at least worked in the past and is supposed to work).

Why is this so? Because the medical profession has its own set of ethics and professionalism. The fundamental basis for a patient referral is that we refer a patient to the doctor we think is best for the patient. In other words, a referral must be made based on the patient’s best interests. It cannot be based on whether the doctor gets the referral because he is willing to part with 15% of his fee or not. This giving of a percentage of his fee to the referring party is called “fee-splitting”. A long time ago SMC actually suspended a doctor for fee-splitting (in the eighties) with another doctor. And if you ask this hobbit, it doesn’t matter if the referring party is a doctor or otherwise. The referred doctor is guilty of fee-splitting as long as he gives a percentage of his professional fee to generate a referral (i.e. business). This is inducement to another party to either refer when there may be no reason to, or to refer to the inducer when another doctor is better suited to handle the patient’s medical problems – either scenario is not in the patient’s best interests.

Why is this so difficult to understand? It amazes this Hobbit that very senior members of the profession are finding it so difficult to grapple with such simple ethical principles. Either they have been clouded by money or they are just not getting back to the basics of ethics when they think.

Or let this hobbit put it another way. How will the public react when they find out that doctors give up 15% of their professional fee to another party just to get referrals? Do you think patients will consider it an “administrative fee” or a “commission” or worse, a “kickback”?

I guess to the layman, it depends on the amount. If it is 15% of say, a $60 bill from a GP- that comes up to $9. We can explain that the managed care company needs to deploy resources to administer the managed care or third party administration program and to make a reasonable profit. Most members of the public will say, “Yeah, it’s OK to pay them $9 a case”.

But let’s say it now involves major surgery and the surgeon’s fees is $12,000, the anaesthetist fee is $3000 so total professional fees come up to $15,000. 15% of $15,000 is $2,250. That’s a lot of money to pay a managed care company for one referral and subsequent administrative work. How can you justify that? To the public, this is most likely a “commission” to induce a referral. That’s because $2,250 bears no semblance to what resources that managed care company has used up to link up the patient with the doctors concerned and the consequent administrative work e.g. billing and payment etc. It is a cut (i.e. a percentage) of the professional fees given out as commission to the managed care company. Pure and simple.

It doesn’t matter what fantastic mental calisthenics we doctors play in our minds to try and justify this commission fee and salve our conscience (i.e. dress the orang-utan). It is a commission fee dressed up as an administrative fee, but at its heart, it is still a commission paid by the doctor to the managed care. That’s how the public will in all likelihood see it. Because everyone understands that without this 15% commission paid out, the managed care will not give this referral to Doctor X.

Or put it another way, Doctor Y who refuses to give the 15% but will really pay an administrative fee (which let’s say, can even be as high as twice the amount of the true cost, i.e. 50% profit margin- good by any standards) will NOT get the referral from the managed care company.

Like I said, if it doesn’t smell right, it usually isn’t.

Maybe this Hobbit is just bloody old-fashioned and out of touch with reality. Some folks have told me, doctors need to eat too. What’s wrong with giving up 15% to see more patients and earn more money?

I certainly hope SMC can do something about this. Because if they don’t stop these practices involving doctors, then what is the point of self-regulation? The SMC cannot regulate the practices of managed care companies, but certainly it can decide whether doctors can participate in such practices? Doctors need clear direction and unequivocal instruction from SMC before the collective conscience of the profession ebbs quietly into the night.

SMC and even MOH just need to ask themselves – will public confidence in the medical profession and the private sector healthcare system be diminished, unchanged or improve if the public finds out that this 15% is paid to the managed care companies? If they think public confidence will be unchanged or even improve, then by all means do nothing. If not, they have to do something and fast.

This is because if SMC or MOH doesn’t exercise leadership and give clear direction, then self-regulation will give way to trial and judgment by public opinion. And it won’t be pretty then.

To be absolutely honest, this old coot of a hobbit is gripped by doubt too lately. I am beginning to think that I am that lone voice in the wilderness, like a crazy and paranoid old man raising unfounded fears and unnecessarily scaring little children…..

Maybe the public will think it’s OK to give thousands of dollars to managed care companies which they understood originally were meant to be professional fees for doctors. I don’t know. Maybe…..

Something is baking this April. And it certainly doesn’t smell right.

Afternote:

Since this posting, an alert reader has said that given the low rates of reimbursement by some managed care companies, a surgeon’s professional fee of $12,000 is not possible and hence the grand total of $15,000 is not possible either. Maybe.

This Hobbit has snooped around a bit. Different companies offer different rates. Even within the same company, different doctors get different deals. Some favoured ones get better deals.

Also, this posting is about ethics, not poor rates of reimbursement. You do NOT have to accept poor rates of reimbursement. You can leave the scheme.

In any case, the 15% applies to ALL fees, including ward attendance and outpatient fees.

Most complicated cases will also require input from multiple specialists other than the surgeon and anaesthetist. Assuming you charge a very low $100 per visit and you make two visits a day for 7 days, that’s still $1400 of inpatient fees for the surgeon. And probably another combined total of $700 to 1400 for the other specialists if they visit once a day (Anaesthetist + one or two other specialists) . So it is not inconceivable that for a patient undergoing major surgery with let’s day 2 days of ICU stay, the total professional fees for one inpatient episode will come up to $15,000. (Surgery fees $9000. Surgeon inpatient attendance fees $1400 (2 visits a day). Anaesthetist fees: $2250. Anaesthetist attendance fees: $600. Cardiologist attendance fees: $900. Endocrinologist attendance fees: $900.

Assumptions: Surgeon visits twice a day. For the 2 days of ICU stay, all doctors visit twice a day. Otherwise its one visit a day for other doctors

Total 9000+1400+2250+600+900+900= $15,050

This figure excludes outpatient charges related to this inpatient episode

Yes, there are some companies that demand you only charge $70 for initial consultation and $45 for each follow-up consultation. That’s lower than restructured hospital charges. But as the previous posting said – no one is forcing you to join this plan. Again, it is worth repeating – this posting is about ethics, not poor rates of reimbursement. You do NOT have to accept poor rates of reimbursement. You can leave the scheme. Schemes that give good rates with poor ethics is far worse than poor rates with good ethics.

The government budget for 2016 has just been announced by the new Finance Minister. The first thing you notice is that the new Finance Minister has a lot more hair than the last one. And I mean a lot. In fact, the old and new Finance Ministers lie at the two extremes of the Cabinet in the trichology spectrum. This is the most important and exciting thing about this year’s budget, the new Finance Minister’s super-thick, jet-black hair. Post-politics, he has a great future as a model in the hair industry.

The second most exciting thing in the budget is the MOH budget. The budget for MOH got bigger (as usual). In the space of three financial years, the MOH budget has grown from slightly more than $7B (FY 2014) to almost $11B (FY2016). And that’s on top of the Pioneer Generation Package which is mainly used for health needs too. The MOH budget is growing faster than the hair on this Hobbit’s feet. This is a good thing for us doctors. But one must wonder – is this sustainable? What happened to cheap and good? This hobbit thinks we are getting less cheap and hopefully still good. But more money is always better than less money. So this Hobbit shouldn’t be complaining. Problems will surface in the future. But for now, let’s enjoy the gold rush.

Growing even faster than MOH’s budget is the appetite of managed care and third party administrator (TPA) companies. Apparently the “administrative charge” levied by some of these companies now reach 15% of the total bill. And apparently, the effective rate can be as high as 20% once the managed care companies “moderate” your claims. (I always wonder what they are moderating when the savings are not passed to the patient or their clients but kept by them).

Problems with managed care and TPA companies are not new. After all, managed care companies have been in existence since at least the late eighties and early nineties. TPAs are just a new and more virulent incarnation of managed care, like electronic cigarettes vs good old 555 State Express (OK, now you know I am ancient. For those younglings out there, 555 State Express was THE cigarette brand in Singapore before the Marlboro Man had armpit hair). The point is, they all kill, even though some tobacco is more expensive than others. (As a responsible doctor, this Hobbit has to put out a public health warning whenever tobacco and cigarette brands are mentioned).

But I digress. Let’s return to managed care and its problems. Doctors have many issues with managed care and TPA. I hope the survey conducted by SMA and CFPS recently will shed more light on this. But before the results are published, this Hobbit will give you an overview. Broadly speaking, problems can be divided into two main categories: They either pay. Or they don’t. (Gee, I am a genius, aren’t I?). If they don’t pay after you have done work, you have several choices. You can consult your lawyers or maybe you can write to SMA or CFPS to alert them. If enough of you write to SMA or CFPS, maybe these professional associations can help.

And if they do pay, problems are also subdivided into two categories. They either pay enough or they don’t pay enough. If they pay enough, you can stop reading this stupid column and go back to watching/puking over Descendants of the Sun as you wonder why on earth are women fussing over Song Joong-ki while you drool over Song Hye-kyo. Or vice versa. I mean, if there was a female surgeon as drop-dead gorgeous as the female lead, there will be lots of blood splashed on the OT ceiling, what with all the bleeding from the ethmoid and palatine arteries. And we are not talking about the patient here.

But if they do not pay enough, you can, like all Singaporeans do – complain. You can whine and complain all you like about the 15 or 20% that they are skinning off you. At these rates they are probably taking more than the skin, especially if you are a GP and working on thin margins. You can even approach SMA or CFPS or whatever to complain. But really, you can do better. You can quit the managed care or TPA company as soon as possible.

You see, no one is putting a gun to a doctor’s head to join any managed care or TPA company. You have a choice. But while you remain in a scheme that is manifestly unfair and grovel at the referrals that are thrown your way, or that you hope will be thrown in your way, nothing will change. They offer, you accept. This is the basis for contract law in this country. They only change if enough of you call it quits.

I heard there is a TPA scheme that is offering a $3 consultation rate. Actually I haven’t heard. I have seen a copy of the letter addressed to doctors in the scheme. If you can live with a $3 consultation, go on – take it. And don’t complain. Or you can drop out. Or perhaps you can complain to MOH. The professional bodies like SMA cannot do anything about a $3 consultation because the Competition Commission of Singapore (CCS) may consider this as price fixing. Actually maybe all CCS staff should go under this $3 scheme too to understand what they get for $3 when all they care about is getting the lowest price for the consumer and letting market forces reign. We store up serious problems when dogma reigns without reality checks.

Prices aside, one has to also consider the ethical perspective. Is giving a 15 to 20% cut even ethical? Is this not an inducement to the managed care and TPA companies to refer patient to certain doctors and not others? Is this in the best interests of the patient?

Maybe MOH can do something about a $3 consultation rate and 15% administration charges. But even if they can, it’s obvious they haven’t. Maybe they will just continue to ignore the problems that managed care and TPAs are creating and are left to fester. One day all this will probably blow up in MOH’s faces. But hopefully not on somebody’s watch. Meanwhile, don’t hold your breath for this. Managed care and TPAs remain unregulated as healthcare entities while they retain great powers to influence and direct healthcare provision in this country.

Next we move on to our residents. Residency has been in place for a number of years and its products are now finally leaving the system as qualified specialists in big numbers. Anecdotal evidence suggests that many newly-minted specialists may have problems securing long-term jobs in the restructured hospitals.

The problem is something akin to the Ministry of Transport/LTA and SMRT/SBS Transit problem that we have. LTA funds and builds the MRT lines. Then SMRT (and SBS Transit) operates and maintains the MRT system. The two sets of organisations have different resources, priorities and needs. This disjunction in roles, deliverables and funding had led to many of the problems we now experience.

Similarly in our specialist training system, MOH funds the training of residents, so the hospitals can put up many residency positions and recruit them to be filled. But once training is finished, funding for the employment of new specialists falls on the operating budget of the restructured hospitals. Restructured hospitals have different priorities, less resources and have to look at the bottom line. So they tend to want to hire far less than they train.

But these new specialists have to go somewhere. If they cannot get a job in the restructured hospitals, they either go overseas or they go into private practice. And if you consider the shortened training period that residency provides versus the old system, you really have to think, are they ready for private practice? But they already are fully qualified and registered specialists in every legal sense of the word. It only takes four years to produce a general surgeon post-housemanship now, versus seven in the old speciality traineeship system (one year MO, three years BST, three years AST). In truth, these newly qualified specialists trained under the residency system need more experience and some supervision by heads of departments and professors before they can truly work independently as specialists.

Again, when we rush headlong into something without thinking deeply, we are creating massive problems for ourselves in the future. In the case of the residency, the future is almost here. The chickens are coming home to roost. The day of reckoning is almost here. And the people responsible for this mess have left the room.

The Year of the Monkey is upon us. And it is not looking good. For one, the first casualty in the Year of the Monkey is not bananas but fish. The ubiquitous raw ikan parang or salmon found in “yusheng” during Lunar New Year has been replaced by all kinds of stuff such as abalone, jelly fish, and even truffles. “Yusheng” which means raw fish is now replaced by “Yusi” (dead fish) or “Yujia” (fake fish).

What is the connection between raw fish and jelly fish is really beyond me, let alone truffles. Maybe they will serve starfish next. What the fish.

But the real question we medically-trained people need to ask is why is the usual raw fish unsafe to eat now? We have eaten the stuff for decades and until recently, no one has lost an arm or a leg, let alone his life. Why now? An important point to note is that the spate of tragic cases cannot be traced to any food outlet. They occur randomly across the country after eating Chinese-style raw Toman and Song fish (fresh water) from many different food outlets. The infection can be traced to Group B strep infection but no one food outlet has been linked to a multitude of these infections. They are literally “all over the place”. In other words, the problem does not lie with food handling at any particular food outlet such as a hawker stall or restaurant etc. Which is why till now, the authorities haven’t charged any hawker or restaurant etc.

AVA and NEA have said that contamination could have occurred in the food supply chain. This Hobbit agrees with this observation. But these fish are mainly farmed fish. In fact, most of the fish we eat today, cooked or otherwise, freshwater or seawater, are farmed. The imagery of your friendly fisherman at the kelong or rowing his fishing boat into the sea and fishing with a net or casting a line against the splendor of the morning sun is really a thing of the past. Move over, Ernest Hemingway. Fish, like cows, lambs, chickens, pigs, orcs and frogs – are farmed. Has anything gone wrong with the farming process? Is anyone studying the farming processes since these fish are farmed around and near us?

The other thing about this issue is that of food regulation. In some countries, food regulation comes under one department or ministry; example: USA: Food and Drug Administration (FDA). A single agency approach also applies to Korea, Japan and Hong Kong, to name a few. In Singapore, food regulation comes under at least three agencies spanning three ministries. AVA (under Ministry of National Development) which supervises the importation and sale of raw food; NEA (under Ministry of Environment) which regulate food outlets such as restaurants, hawker centres and coffeeshops; MOH which looks at control of communicable disease outbreaks linked to food. And this excludes other agencies such as HPB which looks at promotion of healthy eating habits and HSA which oversees regulation of food supplements.

As anyone can see, this is rather complex. Unnecessary complexity is never a good thing. Which is why it took a rather long time before the conditional ban on selling of raw fish came into effect. And till now, there has been no further news on food chain contamination.

Shouldn’t we put everything under one roof, much like how the regulation of media and telecommunication industries now come one statutory board? Food for thought indeed….

We move onto SGH. The mother and cradle of medicine in Singapore (Although TTSH may disagree). This is where it all began. No, I am not talking about the first dialysis or renal transplant or separation of conjoint twins in Singapore. I am talking about faculty practice and 200% professional fee surcharges. (TTSH will NOT disagree)

Just kidding.

It was exciting to see our Prime Minister unveiling the SGH Masterplan. In all likelihood, when the Masterplan is completely executed in 20 years’ time, only the elves will be around. Nonetheless, it looks like a good plan. But this Hobbit would like to offer one teeny-weeny bit of feedback to the master-planers now if they don’t mind – please WIDEN the pathetic SINGLE-lane two-way roads and build MORE carparks!!!!!

I know there is this national agenda to make Singapore car-light and promote public transport but we are talking about sick people and their caregivers. If these sick people can take public transport or walk or cycle, they don’t need to be in SGH. I know of people who borrow cars from relatives and friends so that they can bring their loved ones to public hospitals on the day of the patient’s appointment. Please EXEMPT public hospitals from any well-meaning but erroneous car-light and walking-heavy transport plan.

And then there is staff parking too. For example, there is no parking space in a huge building such as The Academia. It must be the largest building in Singapore without parking. Seriously folks, what is the use of studying so hard to get into medical school so as to be able to afford a car if you can’t get parking in SGH? What is worse, you know the kind of stress that many of our medical students go through nowadays? Many of them have rich parents who buy them Porsches and BMWs to drive to public hospitals and these public hospitals do not provide parking. Spare a thought for these poor/rich medical students – they need parking lots too. They cannot handle such stress any more than they can handle 30-hour houseman shifts when they graduate (which is why we have 12 hour shifts now).

So if you see a Porsche in a public hospital circling around looking for parking, it is probably not owned by patients, visitor or senior consultants, the Porsche belongs to the medical student. The senior consultant can only afford a Volvo at best. If the senior consultant owns a BMW or Merc, he is probably moonlighting as a Uber limousine driver at night. Or he is from SGH, is on the faculty practice scheme or can slap on a 200% surcharge. (I can hear TTSH groaning)

So in a nutshell – more carparks in the Masterplan please. In any case, carparks make money, unlike proton therapy, cyclotrons and other swanky stuff. Car parks pay for themselves. And definitely not another huge building like The Academia where floors of offices remain largely empty during office hours. They should be converted into office hour parking lots accessible by car lifts. The genius who decided that the Academia didn’t need carparks should be brought onto the helicopter field behind MOH and hung at sunrise. Of course not, we must be more humane; he should do community service by being a valet in SGH campus for 30 days without the use of valet-designated lots. Or we can make him run back and forth from the multi-storey carpark behind MOH (i.e. further than Siberia) to Blocks 1,2 and 3 of SGH ten times a day. His cardiovascular health will improve even as he comes to the realisation that The Academia needs parking lots.

Finally, we move on to Managed Care. There has been a lot of discomfort and grumblings on the ground about Managed Care. They are certainly getting more aggressive. And they remain unregulated, unlike the humble hawker trying to eke out an honest living by selling raw Song Fish salad. Recently, they have even become third-party administrators (TPA) for established insurance companies offering Integrated Shield Plans (ISPs). Be careful when you sign up as a doctor with these Managed Care companies. You may think the relationship is confined to one aspect of this practice but you may be blindsided. You may suddenly find that your ISP patient who signed up for an “as-charged” ISP will not pay you “as-charged”. What has happened is that the ISP insurance company has also signed up with the Managed Care company as a TPA. The Managed Care company now will impose on you their schedule of prices for the services you rendered to your ISP patient who is supposed to pay you “as-charged”. On top of that, the Managed Care company will levy a 10 to 20% surcharge on you as “admin fees” – this amount is automatically deducted “at source” when the insurance company pays you.

In other words, you think you have two independent relations – one with the Managed Care company which is independent from the second relationship with the ISP insurance provider. Well, the Managed Care has conflated the two and imposed the terms of the Managed Care contract onto the ISP insurance company relationship because they have been appointed as TPA by the insurance company. And what is more, if you look closely, in the terms and conditions of the Managed Care contract, they have a clause that states they can change and alter the terms of the relationship anytime and unilaterally. So things can only conceivably get worse.

While these practices are linked to just one or two Managed Care companies now, if these companies succeed, others will probably follow suit.

After all, it is monkey see, monkey do…..

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.