Juicy July

Just when you thought it was safe to go back to your insignificant and quiet existence as a doctor after the magnificent launch of the Pioneer Generation Package, July saw the majestic herald of something even grander and awesome in healthcare.

No I am not talking about the Medishield Life. I am talking about Dr Susan Lim husband’s lawsuit against the lawyers of the Singapore Medical Council for alleged overcharging. The irony is so thick you can cut it with Darth Vader’s crimson lightsabre. Interestingly, the Senior Counsel who was involved in this case was judged to be not guilty of overcharging by a review committee of the Law Society because the law firm claimed he “was not involved in the preparation of the bills” (2 July, Business Times) . This hobbit wonders if we can apply the same standard to doctors. If the clinic manager bills a patient a million bucks for a liver transplant, the surgeon can be considered to be not guilty of overcharging as long as it can be shown he wasn’t involved in the preparation of the bills and the clinic manager did it on his/her own accord. I think I will set up a separation of operations and decision-making between my clinic’s billing department and the professional service department (Which incidentally is really a partition board separating me from my clinic manager who does the billing in my 20 year old HDB shophouse). Incidentally, my clinic manager also happens to be my wife and as any male doctor will tell you, once your wife is involved in the administrative matters and operations of the clinic, you really, truly have zero influence over how the clinic is run. You have less rights than the clinic residential lizard.

Will the Singapore Medical Council learn from the very wise review committee of the Law Society and accept such an arrangement as defense against accusations of overcharging?

Let’s move on to the other BIG news on the healthcare scene – the launch of the Medishield Life Scheme (MSL). This Hobbit actually welcomes many of the new features of the MSL scheme. For one, it won’t penalize me for living too long. I always wondered one day when the effects of The Ring wore out and I needed some serious medical care, what medical insurance will cover me? I mean, I am 165 and Medishield cover for me expired 85 years ago even though my only pre-existing disease is Taenia Goblinus in my hairy feet, which I contracted while fighting all those hideous goblins at Misty Mountains. Otherwise I am quite healthy.

My only complaint is that MSL’s payouts are pegged to B2 and C class bills, which are really quite little since the BS and C classes are already heavily subsidized.

With my newfound wealth from starring in a trilogy of movies, I really was hoping to stay in a better class bed when I get sick. There’s where the Integrated Plans (IPs) come in, I suppose. But these IPs are run by commercial insurers and you know how these commercial guys work. Once you claim for something, your premiums may either shoot up or you are then excluded from cover. These guys can be more commercially driven than those Lonely Mountain dwarves.

It’s the hot and humid season again and dengue is peaking and the threat of haze is looming. This hobbit doesn’t know which is worse, the dengue or the haze.

Anyway, let’s hope there is no mad rush for the N95 masks again. Just to recap how incredible/frightening the push for N95 use was – the relevant authorities stated briefly on their website last year –  “ The N95 mask is necessary for individuals who are susceptible to the impact of haze, including persons with chronic medical conditions especially lung or heart disease, elderly and pregnant women. These individuals should wear N95 masks if they plan to undertake prolonged outdoor activity when the air quality is poor”.

I am not making this up. This hobbit took a screenshot of this on 21 June 2013 and it is on record. Fortunately common sense prevailed and the advisory for N95 masks was changed to something that was more clinically sensible. If not, we may have had a lot of people dying from respiratory distress and heart failure from N95 masks than from the effects of haze itself. I am told by unreliable sources that the consummate professional who was purported to have approved this jaw-dropping advisory has gone back to the world of academia, where everything is academic.

Meanwhile, the World Cup has come and gone. There are a few things you can learn from this World Cup that is quite instructive:

• Flu is not an excuse for an MC. Seven of Germany’s players were supposed to have contacted flu before they played France in the quarter finals

• The guys at National Council for Problem Gambling need to get some counseling after being the butt of all those jokes

• Creating a vertebral fracture is a weapon of mass destruction

• Suarez’s incisors can be used as bone graft for Neymar’s fracture

• Growth hormone injections can really make a guy duller – just look at Lionel Messi’s facial expression when he received his Golden Ball award

Meanwhile, this Hobbit wants to put on record that he disagrees with the commonly held perception that our Ministry of Health is staffed by heartless bean counters who are so miserly that if they can help it, they will make doctors re-use drug pens and patients to bring their own toilet paper. This is totally untrue. Only patients that have been issued incontinent pads need to bring their own toilet paper.

Seriously, we should disabuse Singaporeans of the idea that MOH is miserly and heartless. Just over the last weekend, it was reported that the Auditor General’s Office had discovered that between Jan 2011 and Oct 2013, MOH had disbursed $64,000 to 99 people who had already died.  Maybe the dead need to pay for ERP charges on the highway to the after-life. Or maybe it’s an enhancement to the Medishield Life package – Medishield Life-after Super Integrated Plan. And we are not talking about seventh month hell notes here, dude. Legal tender Singapore dollars. This is to also underscore that we are truly an inclusive society and even the dead are not forgotten.

Well, that’s all for July, folks. See you in August when the Hobbit celebrates National Day. For now, if you see a short guy with hairy feet hanging around the Children’s section of public libraries reading books, you know who that is…….

Path of Moderation

Recently, a Member of Parliament who is also a doctor said that politicisation is bad for healthcare. Once politicians get heavily involved and health policy gets heavily politicised, healthcare delivery generally suffers.

That is the commonly held view. This hobbit also agrees with this observation to a large extent. BUT real life is not so simple or absolute. Or as Obiwan Kenobi said to Anakin Skywalker “Only a Sith speaks in absolutes”.

The idea of Singapore as an Administrative State (as opposed to a political or politicised one) was first made popular as far back as 1975 when Prof Chan Heng Chee wrote a paper titled “Politics in an Administration State: Where has the Politics Gone?”

Singapore was largely an administrative state until 2011.  But even as an administrative state, (the period before 2011), things got a bit edgy and rough for healthcare.

There are fundamental differences between administrators and politicians. And these differences lead to problems. For one, politicians in a democracy have to face the ballot box and the polity. Civil service administrators don’t have to.

So let’s look back at some of the experiences that a largely de-politicised and an administrative state have brought us.

Problem #1: Play It Safe

The first thing about being administrative is that it doesn’t engender innovation and risk-taking. Have you heard of a term such as “administrative innovation” or an “innovative administrator”? It’s almost oxymoron. We have heard of stuff like technological innovation, educational innovation, clinical innovation and even financial innovation, but administrative innovation? It is as rare as hen’s teeth.

Because we had an overwhelmingly administrative climate, people decided to copy lock-stock and barrel the ACGME system and hence now we have the ACGME-I system that is neither recognized even in JB nor Batam. There is safety in copying. Administrators are not praised or rewarded for innovation.

Problem #2: Dogma beats Real Experience

Remember the now-defunct SMA Guideline of Fees (GOF)? If you polled doctors in private practice and the man-in-the-street today, this Hobbit will bet that at least 90% of those polled will disagree that withdrawal of the GOF led to lower bills or a slower rise in bill size for patients. This was exactly what SMA said when it was reluctantly forced to withdraw the GOF. But we are still stuck in the dogma that guidelines of fees are bad for the consumer/patient and that there must be market competition. Some things just don’t conform to the dogma of market fundamentalism and competition. Healthcare is one. Other examples? Just look at our public transport and the big money we are paying to watch football on cable in Singapore.

All this was achieved when we were an administrative state with little politicisation. Dogma wins over our real life experience in healthcare, public transport and even the simple pleasure of watching football.

That’s not to say that competition is always bad. In most cases, it’s good. But it cannot become a dogma or even a religion and applied without question in all instances. Holding on to a dogma blinds us from achieving intellectual honesty.

Problem #3: The Secret Mojo of Complexity

Administrators want to be known as the clever people. There’s nothing wrong in that per se. Who doesn’t want to be known as smart? That’s how the term “policy wonk” came about. It underscores the importance and desirability of creating policies that reflect the intelligence and knowledge of the administrators. That’s where the problem starts because complexity often becomes a proxy for smartness.

Have you noticed for example the complexities of public healthcare funding and hospital charging? One experienced hospital administrator told this Hobbit half-seriously that no one really knows all the funding rules and mechanisms that have been implemented in our public institutions. There is service funding, capital expenditure funding, research funding, block funding, training funding, productivity funding, innovation funding, transition funding, research grants, emergency preparedness funding along with stuff like Medisave, Medishield, Medifund, Eldershield, disability grants and subsidies, funding for non-standard drugs and implants, blue and orange CHAS… the list goes on….And of course now we have the newer stuff like Pioneer Generation Package and Medishield Life as well.

This Hobbit speculates that if real politicians or political minds got into the act of designing the funding and paying system for healthcare, things would have been a lot simpler. Because politicians see the need to communicate and effective communication is often simple communication. Civil Servants, especially the elite and brainier ones – the policy wonks – love complexity. Policy complexity is the secret mojo of the administrative state…. But please pity the hospital and polyclinic counter staff who has to deal with all this complexity and an increasingly demanding and impatient customer/patient.

Enough about politicisation. This Hobbit agrees that we should guard against over-politicisation of healthcare. But a little politicisation of healthcare need not be a bad thing. Certainly, it can guard against some of the problems we have experienced as an almost purely administrative state.

But there are two other “-tions” we have to also guard against in healthcare.

Legalisation

One area we need to really guard against is over-legalisation. Again, the SMC disciplinary has been increasingly legalised to the point it is now been described as a “pseudo-criminal” process. There can be three groups of lawyers or legally trained people in a SMC Disciplinary Tribunal (DT) proceeding. (one group for the defending doctor, one group for prosecution and one group advising the SMC DT as legal assessor or one SMC DT member may be legally trained in which case there is no legal assessor)

This over-legalisation of medicine has led to much higher practice insurance premiums and more and more defensive medicine that must largely be borne in the end by the patient and creates a lot more angst and anxiety suffered by doctors. Only the lawyers almost always benefit (provided they get paid, which of course, they would be).

Some legalisation is necessary, because we live in a country with a strong rule of law and we benefit from this. Having said that, must a SMC trial run like a full legal trial and in an adversarial manner? Some other professions actually have far less legalised and adversarial processes.

Commercialisation

The third “-tion” is commercialisation. Again, some commercialisation is necessary for the simple reason that healthcare workers need to eat, feed their kids and pay an arm and a leg to watch the 2014 World Cup. But the problem here is over-commercialisation.

One clear example is again that of the withdrawal of GOF. The market trumps ethics and professionalism. Another is that of the liberalisation of medical advertising. If you ask the leaders of the independent medical professional bodies (i.e. those who led AMS, CFPS or SMA) in Singapore 15 to 20 years ago, they did not support liberalising medical advertising. But the powers that were decided this was a good thing and look what we have now – rampant medical advertising and pseudo-advertising. Some of the stuff are downright embarrassing.

Confucius advocated a “Path of Moderation”. When we have too much or too little of something, it usually is a bad thing. Zero-politicisation of healthcare may not be a good thing, just as over-politicisation is usually a bad thing. But along with over-politicisation, we also have to guard against and fight over-commercialisation and over-legalisation of healthcare.

Politicisation, Commercialisation and Legalisation – We can’t live without them in healthcare, but let’s not have too much of them either. We need moderation.

Pioneer Generation Package

May 8, 2014 at 11:27am

The Pioneer Generation Package (PGP) was announced to much fanfare last month. There are several notable features to this package.

1.    First of all, it applies to anyone born in Singapore before 1950. Which means Chee Yam Cheng (~MBBS 73, ~65 years old) just makes the cut but Sonny Wang may not (~MBBS 74, ~64). Life is tough.

2.    Secondly, it’s BIG. $8,000,000,000. There are NINE zeroes in there. And guess what, it is funded from 50% of the nett investment income from our reserves of just ONE year. This is very significant. It shows that our reserves are so BIG that just half of the investment income of only ONE year can fund the healthcare needs of 450,000 elderly people for many, many years. Next year and every year, we will have another 7 to 8 billion dollars of investment income that we can use to fund other things, such as my concert ticket to watch the Fleetwood Mac concert and a MRT line that won’t break down every other week.

3.    Thirdly, there is no means test and everyone as defined to be in the age-group of the Pioneer Generation automatically qualifies without filling a form. This is so counter-intuitive to the government and the civil service that this Hobbit suspects some guys in there are getting seizures just from seeing this get implemented. Trust me, there are civil servants who have sworn an oath on the souls of their grandchildren that they will NOT give a cent to anyone unless a form is filled that demand details that even your priest does not want to know during confession.

4.    Fourthly, the 8 billion bucks is supposed to pay for all the people (~450,000) for the rest of their lives until they pass on. I hope the money will last that long.

There are a few things happening on the horizon that suggest that well, $8,000,000,000 may not be enough.

The first thing is life expectancy. People are living longer even as we speak. Life expectancy is a moving target. As we live longer, we need more care.

This is compounded by doctors (yes, we are the main culprits) practising expensive medicine. Some say that the most expensive medical instrument ever invented is the doctor’s pen. Doctors are the main culprits and also the main victims. Doctors are forced to practise expensive medicine from two forces. The first force is the medical litigation climate. There is a climate of fear developed over the last few years. No one wants to be caught out so more and more doctors practise defensive medicine. No one wants to appear before SMC. Even when the complaints committee and disciplinary tribunal proclaim you innocent, the patient can still appeal to the Minister for Health for a second bite of the cherry. The Minister can, presumably on the advice of some enlightened people, ask SMC to reopen the case, with no reason or rationale given. This hobbit knows of several doctors who have been royally punished in this way. The entire process of why a case is reopened in SMC is opaque and traumatic to the doctor concerned, even if the doctor is not found to be guilty in the end. So as the saying goes:- “Only the paranoid survive”. We cannot blame doctors for practicing defensive medicine if regulators commit actions and decisions that promote this behavior, inadvertently or otherwise.And of course, costs go up. And this hobbit thinks that medical litigation will get more and more common if our legal system allows contingency fees (being discussed now, i.e. paying the lawyers only when he wins). This may encourage patients who think they are aggrieved to more easily sue doctors. There is nothing the medical profession can do if this comes about except to spend more on medical indemnity. As the experience of other countries has shown, this will be largely borne by the patients or their payers.

The second force is how we train our doctors. I.e. the American ACGME-I way. We are fragmenting our system more and more. Do you know that under the current Singapore ACGME-I system, general surgery residents do NOT need to know how to perform gastroscopies and colonoscopies?!?!?! Yes, don’t fall off your chair. In future, general surgeons may not know how to do scopes as they are not required to know them before they are signed off as trained and qualified surgeons. Some sponsoring institutions do mandate that general surgery residents learn how to do scopes, but not all do and its up to the institution to decide. This is because in America, general surgeons usually don’t do scopes, the gastroenterologists do. That means another specialist is involved (more cost) when in the past, only one was needed. This is but one such example.

Another training issue is the workloads our younger doctors are getting used to as they are being trained. A recent conversation with a Head of Department in a restructured hospital is telling: “When I was young, I saw 30 to 40 patients in four hours or a half day’s work. Now that I am older, I cannot keep up this pace. Also, I see more complicated cases referred by my colleagues, so I slow down to 20 to 25 patients for a half-day shift. Now my residents see a maximum of 12 patients per half-day, as dictated by the higher authorities based on ACGME-I guidelines. Then these same residents exit as specialists one day and suddenly they find themselves flooded with 30 patients in a half-day and they cannot increase their work output. They won’t know how to cope. And it will get worse when they get older and cannot work at the same pace as they were young. So what happens then? More will quit for the private sector”.

For the geniuses who rammed this residency system through a few years ago, there is metaphorical blood on their hands as our healthcare system gets more expensive and inefficient.

So going from the above, Singapore Medicine is going to get more and more expensive, even in the subsidized wards of our public hospitals.And the waiting times will remain long too. It is not just due to increased complexity of medical conditions in an ageing population or inflation. A big part of this is due to policies and systems that are inappropriate to our needs.

The next thrust about PGP and caring for the elderly is the emphasis on primary and community care.

The idea is eminently sound. Primary and community care are the places where most people should receive care. There is no need to choke up the acute general hospitals. But this Hobbit has observed several troubling trends in the last few years:

a)   There aren’t that many new GP clinics opening and these new “GP” clinics often offer aesthetic medicine as a major part of the services. In other words, the actual increase in capacity in the private GP sector offering “traditional” GP services may have been quite limited over the years, probably not keeping in line with the ageing population or the increase in population in Singapore.

b)   The A&E Departments of all restructured hospitals offer very good remuneration working as locum A&E MOs, with hourly rates of between $100 to 120/hour. Being an A&E MO is actually a safer bet than being a locum GP, because in the A&E there is always someone senior that you can get advice from on the spot. There is also a triage system that will assign the most difficult cases to the A&E specialists and residents. As a locum GP, you work alone and really, you try not to bug the GP who is on leave unless absolutely necessary.

c)   Career paths have also sprung up in restructured and community hospitals in the form of Family Medicine inpatient departments. This is not necessarily a bad thing, but it does take away a few GPs from the community.

So really, this Hobbit is really worried about who is going to do the heavy lifting in the GP and community care sector. Who is going to start GP clinics, run the FMCs and the polyclinics? That brings us to the rather touchy subject of foreign doctors.

We have relied and will continue to rely on foreign manpower to man our public healthcare services, doctors included. There is no escaping this fact. But there will come a time when a limit is reached. There will be serious issues when more than half of the profession consists of foreigners who are not locally trained. So one can safely say from a manpower planning perspective that for a sustainable environment, locally trained or Singaporean doctors must still make up the majority. Let’s put this at a reasonable figure of two-thirds. Guess what – if you look at the SMC Annual Report, we are there already for the public sector. In the latest available SMC Annual Report 2012, the public sector employed 6716 doctors. Of these, 2222 doctors were neither Singapore citizens (i.e. PRs or foreigners) nor locally trained. That comes up to 33.08%. The corresponding figure is far lower in the private sector. As the saying goes, Houston, we have a problem.

Given a choice, this Hobbit thinks our Pioneer Generation will prefer either Singaporean or foreign doctors who are locally trained. But as the numbers show, they have a one-third chance of not meeting one in the public sector. This figure is probably higher in certain departments and in the long-term care sector. Anecdotal evidence suggests that the public system has problems retaining even foreign doctors. Quite a few of them, especially specialists, actually leave for the private sector once they gain full registration with SMC. So will we have enough doctors, and by even a longer shot, enough local doctors to treat our Pioneer Generation?

All in all, the PGP is a great idea. But the PGP cannot be implemented outside the context of the other components of the healthcare milieu. And until we fix the other issues of our healthcare system, such as a climate that favours defensive medicine, staff retention, doctors’ training, etc, the PGP will face serious obstacles when it is implemented. $8,000,000,000 is a good start. But it won’t finish the job and it may not be enough.

For a start, we need to re-look at the whole system and ask –what are the policies and programmes trying to achieve in terms of the Golden Triangle of Affordability, Accessibility and Quality? It is said that no health system can achieve all three at the same time, maybe two at the best. One out of the three has to be sacrificed.

For the residency system – it is clear that quality is the main target. One may question if quality of training is actually raised by this system or if the system actually produces better specialists, but the intent is clear. By limiting residents’ workloads, mandating that core faculty trainers take off 40% of their time to supervise residents – they are trying to achieve quality. But this must be at the expense of affordability and accessibility since efficiency and hence productivity are severely curbed.

The Pioneer Generation Package is trying to achieve affordability, by declaring right upfront that our elderly do not have to worry about healthcare bills; hence the infusion of $8B over time. And since it is not means-tested, accessibility also improves. Hence by inference, quality is not a priority.

The various primary care and long-term community care programmes we have or that are being implemented is aimed primarily at improving accessibility. Affordability is a secondary objective since primary care is already quite affordable with the polyclinic system and the use of Medisave and CHAS etc. Quality takes a back seat especially in the long-term care sector.

The influx of foreign doctors in the public sector is obviously an attempt to improve accessibility.

Looking at the above, this Hobbit thinks the entire health system is being pulled in different directions by myriad policies and programmes; like torturing or killing a prisoner by quartering (Pulled apart by horses tied to the four limbs of the prisoner). That is why there is so much angst and frustration among public sector healthcare workers, doctors included,today. We need some clarity. Whatever the case, the status quo of this strategic ambiguity or strategic schizophrenia cannot go on. 20 years ago, the government was very clear – it was about achieving affordability – hence the title of the White Paper then “Affordable Healthcare”. What is it now? Is it still “Affordable Health Care”, or it now “Quality Health Care” or “Accessible Health Care”?

At the very least, we can choose two out of the three – such as “Affordable and Accessible Health Care” or “Accessible and Quality Health Care”. Please don’t kid ourselves that we can achieve all three –Affordability, Accessibility and Quality all at the same time. We need to prioritise and reflect this intent clearly across the board in a concerted way and not have programmes and policies that send out wrong signals and conflict with what is the overarching objective of our public healthcare system.

Hobbit’s Guide to Exams

April 14, 2014 at 11:32am

Ah, it’s that time of the year again.

Sweaty palms, palpitations, a flash of exhilaration when you see his face, or maybe crushing despair.

No, I’m not talking about Choi Siwon, Justin Bieber or even Pornsark Sukhumvit… I’m taking about Examinations. The favourite thing to love/hate by all Singaporeans. We can’t live with it, we can’t live without it. We are well trained since primary school to take examinations, in fact, we love it so much that we now have multiple smaller exams to train and prepare us for the big one. As part of a self-selection process, those who excel in the academics (i.e. Chao muggers who get pristine As) end up in Medicine, where even more exams take place to delight the heart of any kiasu parent.

From M1 to M5, there are end-of-posting tests, MBBS part I, part II, part III. Then whichever sub-speciality you choose, more exams to take, part I, part IIa, IIb, IIIx, Vz etc. In fact, because of the higher fail rates, some doctors have to retake these exams several times. Isn’t it a strange observation that these exams are rather expensive, and can be held overseas; and some doctors are so dead-set on passing them that they would fly all over to re-take the exams anywhere? So maybe there must be a set percentage of failures per year so that there’ll be returning customers? After all, the overseas colleges charge a fee, the organising committee charge a fee, and our own Singapore JCST charge a fee, even if the exam is not held here! But, this is a groundless comment, just my own flight of fancy. Of course, there are some strange doctors out there who have too much time and money on their hands, and are known to have sat for all the available sub-specialty exams available. These are the Professional Examinees. One famous example is Prof Chee Yam Cheng who passed Part 1 of MRCP, FRCS and MRCOG just for kicks. Then he became a hospital administrator, which does not require even a MBBS. Talk about irony. (Prof, in case you are wondering, I am the short squirt who is walking around your hospital with hairy feet and without a tie, and I am NOT one of the housekeeping staff)

The Hobbit is a simple doctor – I don’t have those fancy letters after my name. But I do know many people, oh the great and powerful, who have achieved greatness and success in their chosen fields. Let me put together some pearls of wisdom, and share this guide to passing the examination with you (without having to pay S$23.99 or subscribe to my blog; as many enterprising American residents have done to guarantee plus double-confirm “Success in ABSITE”.)

In studying:

1. Use short simple textbooks (preferably with lots of colourful pictures- for example, do you remember the full text of Lord of the Rings? No right? You only remember the spiffy quotes like, “You shall not pass!” (sorry. Bad example.). One such textbook is “The Black Book of Clinical Examination” by Tey Hong Liang and Erle Lim, two of the most pre-eminent examination sadists of our times.

2. Avoid using seniors’ notes (nice for revision purposes, but a bit silly to use this as your main textbook. Especially if said senior is now a part-time GP with interest in cosmesis- do you really, really want to use his notes from 2000?)

3. Start early – this is no problem for most of you medical students, because mugging is in your blood. Unlike the Wizarding World, we are very proud of our Mugger blood. But there are a few brilliant, talented ones- eh, whose talents probably lie NOT in studying- who continue to be very active in sports and the Arts. Trust me, MBBS or MRCS or MRCP – hard to wing it last minute and squeeze years of learning into 1 week of hard core revision. Can be done, but rather stressful. I do not recommend it.). For postgraduate exams, it is important that you can start early with examination sadists/gurus to get into the scheme of things from the onset. Long ago, the ultimate exam guru were folks like Prof Ng Han Seong and Prof Rajasoorya. Now there are still folks like Erle Lim who can destroy your ego and confidence in 47 seconds. Better now than in the exam later.

Exam technique:

1. Spot questions (seniors have traditionally handed down a TYS- ten year series- where examination questions are committed to their formidable memories all throughout that 3h of essay, and then transcribed and circulated for future batches. Worthwhile to look through and know what are the common perennial topics- “What are the structures in the T1 plane? Course of facial nerve? Classical signs in SLE and scleroderma? Signs of chronic liver disease?”)

2. Train for the right arena – If essay- bring in nice pens with smooth action and ink that doesn’t smudge. If MCQs- if the past 15 answers were D, something is wrong. If oral exam- practise to talk well. More on this later.

3. Know thy enemy, know thyself (There are a few feared examiners locally, and the myth and legend surrounding them has grown over the years, as they become more senior and their own seniors and peers who know them personally have either gone into private practice or passed on. I have heard that medical students nowadays practice presentation to a life-size poster of Prof W, so that they can get used to the sense of panic and fear in case they encounter him in real exam. Bollocks. Everyone started out as medical students, and everyone has made novice mistakes sometime in their career. Yes we should respect these bastions and giants of our field, but to fear them like some tyrannical dictator is not necessary.

The clinical examination:

This merits a separate section because most of the failures are from this component, rather than the written. At the speciality examination, most sub-specs have a viva component as well, and it takes a different kind of skill set. No point knowing all the textbooks and journals in the world but cannot articulate your thoughts.

1. Dress well – For the men, that means shirt +/- tie; cufflinks may be excessive. Ladies- while looking sexy and helpless works in some fields- probably not in ours, but there have been cases. There was this one girl with- her skirt, her erm, chest- never mind- stories for another time. Conservative is always good. Leave the fashion statements of purple hair, shaven heads, multiple piercings and rings for personal time please. I have nothing against that- I dye my feet hair blue sometimes. I just like the colour. And I’ve got piercings in places you probably don’t want to know about. For both: An ironed, spotless white coat (splotches of curry or other more personal fluids are a definite no-no.

2. Speak well – If English is not your first language there is a natural disadvantage. For those with Singlish as a first language/mother tongue – Singlish is not such a great idea in the exams, “This 60 year-old auntie say that she got stomach pain, and then hor, she like, went to see her doctor, and then like, took something and then she was ok lor.” But please don’t put up an accent; it is a touch incongruous for Student 127 Tan Ah Hock to have perfect Queen’s English. It would also be pretentious for student 128 Aloysius Amadeus Tan A.K. to have perfect Queen’s English. *names above are fictitious. Any resemblance to real persons, living or dead, are purely coincidental* For those with serious stutters or confidence issues, can get lessons from speech therapists, toastmasters, etc.

3. Carry yourself well – You know how in a Beauty Competition, every contestant looks gorgeous – dressing sometimes irrelevant as they are skimpily dressed, those who speak well score better than those who messed up the Q&A (“Australia? You spell wrong, it is A-U-S-T-R-I-A!”). But the winner is some graceful creature who has this lovely, indefinable air about them- great composure, great stage presence, great charisma. Now that, my dear boys and girls, is what will make you shine in the clinical exam. Trust me, your seasoned examiners, and your seasoned patients (don’t forget, some of them are veteran patients returning year after year, you know, the ones that hold a glass of water in hand and know how to hold water in their mouth, THEN swallow; or the ones who know to breathe in-out-hold their breaths and lean forward JUST SO for you to hear that elusive murmur) – they know when you know what you are doing; or not.

My final tip for you, our minds work best by remembering no more than three things. You do notice that I have classified my advice accordingly. The long-standing success of trilogies stand as evidence to this observation ☺

What NOT to Spend 7.1 Billions Dollars On…..

What NOT to Spend 7.1 Billion Dollars On……

March 3, 2014 at 11:01am

This latest budget for Ministry of Health has been announced and it is a whopping $7.1B. That is $7,100,000,000. And it is 22% more than last year. This is just great. MOH budget is growing faster than this Hobbit’s waistline, the COE and the price of beer at Kopitiam combined. It shows that the government is really serious about devoting more resources to healthcare.

At the same time, we should also ensure all this money is well-spent. So this Hobbit will now give some unsolicited and as usual useless advice to the bigwigs and bean counters in the Ministry of Finance on how to monitor and ensure how the $7.1B is spent. Given the limited intellect of this Hobbit (who had no A* in PSLE, did not score straight As at A levels, was never on the Dean’s list and most humbling of all, did not qualify to receive tuition from the most august Singaporean education institution of all: Learning Lab), this Hobbit actually doesn’t know what the money should be spent on. But this Hobbit does know what the money should NOT be spent on.

 

1          Another Cluster/Declustering/Reclustering Exercise

Speaking of clusters – please do not muck around with clustering, de-clustering and re-clustering exercises. It started in 2000 with the formation of Singhealth and NHG. Since then we had reclustering with NNI joining Singhealth and declustering of NUH and KTPH (Alexandra Health) from NHG and CGH from Singhealth. Many millions have been spent on these clustering exercises that to borrow a crude American term – it’s one big clusterfXXX.

According to the authoritative Wiktionary:

clusterfXXX (plural: clusterfXXXs)

1.    (slang, chiefly military, vulgar) A chaotic situation where everything seems to go wrong. It is often caused by incompetence, communication failure, or a complex environment.

Blame the dwarves for teaching this Hobbit such a vulgar word. But it’s really apt here.

2          Another Branding Exercise

Even if we do not spend money on clustering exercises, we must also avoid spending money on branding exercises. Branding exercises inevitably involve change of logos, letterheads, signages and uniforms and all these costs buckets of dough. It also creates a lot of confusion because just when you thought you figured out who is the staff nurse, nursing manager and health attendant, they change the uniforms again!

Having said that, this Hobbit is inclined to make one exception – Alexandra Health. Why is it called Alexandra when it is no longer in Alexandra but in Yishun and it is also set to sink its teeth and take a big bite out of Woodlands? To top it off, Alexandra Hospital is now managed by Jurong Health. This is even more confusing than figuring out the MCE.

3          Do not spend on yet ANOTHER trip to the Geisinger Health System if we are NOT prepared to accept the truth

We have sent many, many delegations to this fabled hospital/health system operator in the United States. This Hobbit has nothing against Geisinger. It’s probably a great place for doctors because it is physician-led (or that’s what the website says). But the most important lesson from Geisinger is one that we are unprepared to learn – which is it is a “closed-enrollment” system. You only get into a Geisinger facility if you  are already a member. That is why they can introduce all the right-siting and quality improvement programmes. The same applies to another system that was the flavor of the month about five to ten years ago – Kaiser Permanente. But obviously there is no such thing in Singapore – you can walk into a NHG Polyclinic in the morning, go to CGH SOC in afternoon and get seen at NUH A&E in the night. All in the name of patient choice.

Well, you can’t have it both ways, chum. So stop wasting money making long trips across half the world learning about closed enrollment systems when we do not have the political or administrative will to make our clusters closed enrollment systems. There are other easier ways to log frequent flyer miles.

4          A Proton Therapy Accelerator that costs US$100 million dollars

It was announced some time back that the public sector will have its proton therapy accelerator. It is rumoured that such a piece of machine will occupy a lot of space and cost something to the tune of US100M. Maybe things will get cheaper with time. But a course of treatment now in the USA on this machine is supposed to cost tens of thousands of dollars. Will we be much cheaper? Who is going to pay for it? Medishield Life? What is more,current evidence shows proton therapy outcomes are superior to other therapies only for paediatric, base of skull and maybe prostate tumours. Of course it is the prerogative of a private hospital if it wants to spend money on this. But to spend public money on such expensive and limited-use machinery is another thing altogether.  Maybe it’s just for Bragging rights (pun intended, for those of you who know what proton therapy is all about.)

5          A GP IT System that costs a bomb to develop and an arm and a leg to maintain

The much vaunted GP system that received funding from MOHH and developed by a local IT company a few years ago that was rolled out to certain GPs on a trial basis is going to bite the dust soon. Apparently, no one really wants to pay for the full upkeep of this system and the IT vendor has decided to pull the plug. Affected GPs have been informed already and the transition is going to be a painfully expensive one.

Actually, there are already two or three off-the-shelf GP IT systems that dominate the local market. There is no need to develop another one that costs a lot of money. Someone just has to eat humble pie and go to these dominant vendors and ask them to develop a common interface or platform so that the private GP clinics can operate or be linked together on a common platform. That’s it. Simple. No need for complex proprietary systems that have all the bells and whistles that no GP is going to pay for. They don’t need all this stuff. So, even as we bury this current GP system, please do not spend more money on another complex one. The old acronym KISS still applies – Keep it simple, stupid.

6          Pay American organisations (or any foreign body) to teach us how to train doctors and conduct exams which are not even recognised in the United States

Many years ago, our colonial masters allowed a medical school to be built in Singapore. But in order to maintain colonial supremacy over local medical graduates, the school was allowed to only confer LMS diplomas (Licentiate in Medicine and Surgery). The LMS graduates were not eligible to sit for membership exams in the UK (i.e. MRCOG, MRCP, FRCS etc) that were recognised as specialist qualifications. In other words, LMS was a dead end with no potential for one to be a specialist. And so many local graduates were repressed. They were often assigned to be Assistant Medical Officers to work for European doctors who in no way were clinically superior to them. One Malayan-born Tamil doctor Dr Chelvam with LMS actually managed to fool the examiners and sneaked in and passed the FRCS in 1929 and broke this glass ceiling.

Obviously no one learned from our bitter history and now we have surrendered our rights to conduct training and examinations to the ACGME-I system. So nowadays, even if our residents passed the exams in ACGME-I, (the suffix “I” meaning international), they are also not recognised for practice in USA where the ACGME system originated from.

So we have gone more than full-circle – we have actually deteriorated from our colonial days to something even worse – our LMS graduates in the past cannot take membership exams but now, our residents, after passing the ACGME-I (which is at least 80% similar to ACGME) exams, are not recognised for practice in USA.

So please, do not spend money on training systems and exams that are not even recognised by the countries from which they originated.  We are no longer under the colonial yoke.

7          Building under-sized hospitals

Many new hospitals are being built. After Sengkang, we may only need another two general hospitals. But maybe more are being built. Which is kind of scary. It takes a lot of time, money and people to start a general hospital.

It is probably better to have bigger but fewer general hospitals for quite a few reasons. Firstly, there is more flexibility. In the event that there is over-capacity in the system (if that ever happens), it is easier to close wards and clinics than to close entire hospitals. Secondly, you save on manpower costs because you don’t need separate departments of IT,finance, HR etc. Thirdly, you don’t need another set of CEO, CMB, CFO and another set of mission, vision and core values which seriously, no one remembers.  And most importantly, you also save on land because one big hospital takes up less land than 2 hospitals. The extra land can be used for park connectors and cycling tracks so that foreign-looking cyclists who don’t pay COE don’t have to rant at our motorists on our already congested roads.

Therefore, would it not have been better if KTPH had 1200 beds instead of having both KTPH (only 550 beds) and another hospital in Woodlands? We should learn from the mistake of building an under-sized general hospital as in the case of KTPH.

8          Do not spend on building someone’s legacy

Finally, humans are fallible, proud and mortal beings. Most of us want to be remembered well after we are gone. We want to leave behind legacies. Legacies can be free or frightfully expensive. People who control financial resources should guard against approving expenditure that may look reasonable and necessary but if you look closer, it is nothing more than something that materialised from the mind of a senior chap who wants to leave behind a legacy after his retirement. You may never prove with hard evidence that someone wants to leave a legacy behind. But like a pungent fart, you can smell it…..just look around us…..

No Horse Run……

February 5, 2014 at 10:42am

Welcome to the Year of the Horse. The Year of the Horse sees a new Director of Medical Services in the saddle. This Hobbit recommends that he wears a horseshoe ornament for luck. He will need it since there is so much horse dung lying around that is waiting for him to clean up. In fact, this Hobbit can predict with some accuracy that after the Year of the Horse, he will still be cleaning Goat-poo next year and uncovering heck of a lot of Monkey business in the year after that. And we are not even going to talk about the big pile of Chicken shit…..

Anyway, expectations are high about this year’s Budget and what goodies the government is going to roll out for the much talked-about and revered Pioneer Generation.

The first thing about Pioneer Generation is to define who qualifies for Pioneer Generation club membership. This Hobbit thinks anyone who

·     Has actually dialed a phone number (not press buttons) and remembers having a 5-digit phone number

·     Has ever worked with Sir Arthur Ransome

·     Has brought an egg to the char kway teow/chye tow kway hawker

·     Has bought a new HDB flat near SGH for less than $20,000

·     Had hot dates in Sky, Odeon and Capitol cinemas and then made out in the old Houseman quarters (i.e. now occupied by the Academia in SGH)

·     Remembers that hypodermic needles used for injections could be re-used after sterilization and it was the nurse’s job to sharpen them

·     Still owes money to Ah Ling from old KEVII Hall.

-Should automatically qualify as a member of the Pioneer Generation.

Having qualified as an esteemed member of this club, what benefits should be bestowed on them? Here are a few suggestions:

·     They are given priority to be hired in critical positions; e.g. hawker centre cleaners, hospital attendants and part-time helpers in Seventh Month banquets.

·     They can jump queues at polyclinics and be served first by foreign doctors who will communicate with them by any method from sign language to telepathy, as long as it is NOT in their language or dialect of choice.

·     Should they require specialist care, they will be given quick access to the general hospitals’ specialist outpatient clinics. By way of “quick access”, we actually mean a first appointment before the next lunar eclipse or when consultants who are “core faculty” have time to do some real work, whichever comes first. On the day of the appointment, these Pioneer Generation will spend about half the day finding their way around our mammoth hospitals which are equipped with signage mainly in the English language. These Pioneer Generation are also supposed to understand what terms like“otorhinolaryngology department” and “non-invasive cardiac investigations”mean. Assuming they are able to find their way there, they will again be treated by some foreign doctor or resident and be given two minutes of real attention while the remaining 8 minutes are reserved for doctor-EMR interface time.

·     Should they fall very ill and need long-term care, they will automatically qualify for a 50% discount in our new state-subsidised nursing homes where they will spend their final days lying in open halls of eight beds with seven other persons with practically zero privacy and near-zero dignity. To top it off, these nursing home beds will actually cost more than a C-Class bed in an acute hospital.

With these potential awesome membership benefits, is it any wonder the Pioneer Generation feels they are very important in the large scheme of things?

We move on to yet another hot topic of the day – the hospital bed crunch. Actually there is nothing new to the bed crunch. This is not the first bed crunch and it certainly is not going to be the last. What we need is to create more capacity quickly while also trying to manage demand. Building a new general hospital from scratch takes too much time. We need quick fixes instead. Here are a few completely politically unacceptable but workable solutions:

  • Fill up the huge lake in KTPH and build a new block there. Limiting KTPH to only 550 acute beds was obviously a mistake. It needs to be bigger really quick.
  • Don’t just lease wards – Merge Mount Elizabeth Novena Hospital with TTSH and we have the Mount Elizabeth Tan Tock Seng Hospital. Demand for beds will automatically drop as people will now think TTSH is an expensive hospital. However, with an acronym like METTSH, we should avoid setting up a very big oncology department there. Just a small one would do.
  • There is a lot of empty shelf space in the huge new block called Academia in SGH. Convert the space into sub-acute beds. All this research and training space is academic if you cannot even have enough beds to house the acutely sick.
  • The new shopping mall near the NUH MRT Station is largely still unoccupied. NUS/NUH is rumoured to own it. Move all the outpatient clinics from NUH there instead and convert existing clinic space into wards. Trust this Hobbit, we have enough shopping malls and retail space now for even the upper population planning limit of 6.9M people
  • Kick Land Transport Authority (LTA) out of the old KKH buildings and re-convert them back into wards. After all, at the rate things are going with the LTA, they should be housed next to the famous Central Boulevard so that they can see for themselves what a bad idea this MCE is.

The other big issue that is on people’s minds is what will the new Medishield Life cost and cover? The Minister has already let a whole litter of cats out of the bag when he said there would be a new subsidy framework for the Pioneer Generation and those who turn 90 will still be covered pending the findings of the Medishield Review Committee. Speaking of this Review Committee, it is very interesting to note that the MOH announced the formation of Medishield Review Life Committee on 9 Nov 2013. Since then, we have been informed of who the members are, what the Terms of Reference are and as of a few days ago in its first public update, this Review Committee is already into the second phase of work and focusing on three key areas, namely: benefits,coverage and integrated shield plans. Obviously, these guys mean business and they appear to at least know what they are doing. We may not agree with all of the Committee’s recommendations in the end, but one cannot accuse it of not working quickly and transparently.

Now compare this to the Singapore Medical Council (SMC) Review Committee. Its formation was first announced in October 2012. In February last year, it was announced in Parliament no less, that it was expected that the SMC Review Committee’s work would be completed in 6 months’ time (i.e. ~August 2013). To-date, after 16 months, we still do not know who is on the Committee, its terms of reference, and much less its findings and recommendations. And those guys heading SMC who scolded SMA last year repeatedly for questioning the running of the SMC expect the medical profession at-large to believe everything is OK? Do they take us for fools? By the way, does this SMC Review Committee even still exist?

Is the SMC more complicated than Medishield Life? How many people are affected by Medishield Life compared to SMC? This really makes a fascinating tale of two review committees.

Hmm, come to think of it, maybe the new boss needs many, many horseshoe ornaments….

OK, enough horsing around this month. Bye for now.

The Scotchtape Letters (With apologies to CS Lewis)

January 2, 2014 at 11:42am

To my dearest nephew, The Brainy One

I offer you my joyous felicitations in welcoming you as my more than worthy successor as the Chief Priest of the Conclave of Orc-Clerics and Ministry of Healing. I can think of no brainier successor than you, my dear. It’s been a long ten Middle-Earth cycles and I am finally moving on. I must say I am leaving you the Office of the Chief Priest in far better shape than I found it. I am sure you will, just as I have, continue to raise the Office of the Chief Priest to ever greater heights of grandiosity and power.

Nonetheless, I hope you do not mind if I proffer you some unsolicited advice so as to help you ease into the job.

The first principle you must observe is that you must have no moral principles. Please leave your conscience at the door before you wear the Chief Priest’s robes. On the other hand immoral or at least amoral principles are necessary and often welcome.

The second principle you should adopt is that you have no friends. None of the orc-clerics are your friends. Even if some of them were your friends, once you become the Chief Priest, they are now your enemies. If need be, you will oppress, subjugate or even destroy them. It is not for no reason that the last three digits of your communicator extension is “007”. You are licensed to kill. Wantonly and for effect, if necessary.

You want a friend? Get a dog.

Once you have mastered the above, you will probably, like me, have a long and successful spell as Chief Priest. But of course, these are still some tactical advice that I would like to give you to ensure that your reign will be a safe and glorious one.

Tactical Advice #1

Make BIG mistakes; not small ones. We all make mistakes. But it is important that when we do so, the mistake must be BIG. It must be so big that it cannot be seen to fail or for the decision to be reversed. This is similar to how the American banks were too big to fail in the last global financial crisis.

Do not ever make small mistakes. They will slowly cripple you and your reputation, especially if they are known to the Temple Masters that hired us.

Take the example of how I revamped entirely the orc-cleric specialty training system. The entire system is now too big to fail, even if it is not working out. It cannot be reversed because there will be too much of a loss of face to the Temple and too much resources have been committed.

Tactical Advice #2

Absolute Control is to be ensured at all costs. If necessary, sacrifice any number of orc-clerics to achieve this. Important decisions are to be only made by one person and one person only – the ChiefPriest. There is no need to consult anyone, not at least those bloody obnoxious professional guilds and bodies. However, in this day and age, there is this tiresome public expectation that there should be consultation and consensus.This can be addressed by forming committees stuffed with your cronies. Or if necessary, when there is some controversy, form a reveal committee that is designed to reveal nothing. Speaking of which, I did form such a reveal committee some time back. It has revealed nothing so far on my watch. I trust you will continue with this opacity.

You will also find upon your arrival that only yes-orc clerics remain in the White Tower. Practically all naysayers have been removed or have left on their own accord in my time.

Tactical Advice #3

Speak in Absolutes. As Obiwan Kenobi said in Episode 3 of Star Wars – “Only the Sith speaks in absolutes”.

Of course, the devil is in the details and some of the things I had proposed either do not work or demand too much resources to work. When those pesky critics come charging with their reasons as to why my idea is a bad one – I will hit back with absolutes such as

“Why are you against setting up a system of structured and rigourous training?”

“We must assess our trainees more to ensure quality and safety!”

“Log books will help to ensure currency and competency”

It is very hard to argue against statements of absolutes.After all, “absolute” values such as quality improvement, patient safety,competency, structured training are held sacrosanct by the public. Absolutism is especially handy when you need to cover up mistakes and weaknesses. If you look at America now, practically all of Congress is stuck in absolutism. There is no compromise and no thought of working your way through issues between both major political parties. I love The American Way – nothing gets done….

Tactical Advice #4

Outsource the problem. You do not have to solve everything. In fact, you shouldn’t. Bring in respected foreign systems and expertise to solve the problems so that even if the solution doesn’t work, theChief Priest doesn’t get the blame. It is similar to how some sneaky administrators keep hiring management consultants to do their dirty work for them. Take no risk.

When I had a problem with accused orc-clerics at the Inquisition Panels, I got the law changed to allow legal procurators to chair the Panels. In other words, I outsourced the problem to them. When I needed to revamp and speed up specialty training, I spent tens of millions of middle-earth credits to adopt Uncle Samuel’s methods and to get Uncle Samuel’s team down to impose their implement their framework.

Tactical Advice #5

Minutes of Meetings are important. The Temple Masters pay us our salary and we should be seen to serve them. We should tell them the truth as we honestly see it. This is mainly effected by writing appropriate Minutes of Meeting. If some idiot opposed my idea vehemently, I will get it recorded as “Idiot A expressed some concerns” in the Minutes. If another idiot threatened to immolate himself in protest, it will be recorded as “Idiot B expressed reservations”. If everyone kept rather silent at a meeting, that would be deemed as “broad consensus”.

Minutes of Meetings are important tools in the management of our Temple Masters.

Tactical Advice #6

Crush the Guilds. This is perhaps the most important advice I can give you and I will accordingly deal with this subject at some length.

Professional Guilds are the pestilences that must be destroyed. They are like festering chronic abscesses. I should know – I was very active in one of them. I have an entire armamentarium to deal with these obnoxious vermin. I must confess that early in my term in office, I did go to one of them for some minor assistance when I messed up some public relations event, but since then, I have not looked back. Unfortunately they still exist, albeit now in a very impoverished state. I leave it to your good hands to utterly exterminate them in your good time.

The first method is to belittle them. Each guild is no more important numerically than a single doctor. For example when we ask for feedback on using legal procurators on our panels, any feedback from an individual orc-healer is counted as one feedback. The feedback from a guild council representing a few thousand members is also counted as one, single,feedback; no different from that of a single doctor. Such statistical practices also help me to manage the perception of the Temple Masters and the public.

The next thing is when they clamour for more responsibilities and resources, I will deny them on the basis that we cannot have a long term relationship of trust because their leadership is unstable and may change with each general members meeting. And if they criticize my work,then I will do a 180-degree turn and accuse the guild that that certain undesirable individuals have entrenched themselves in the guild leadership rendering any mutually edifying relationship impossible. Heads I win, tails you lose.

Also, some of these guilds may set a trap for you by behaving like supplicants and asking you to meet the orc-clerics at some town hall session. Do not ever turn up, but evade at all costs. In fact, accuse them of engaging in collective action. We work behind the scenes and meeting stakeholders to get real feedback and discuss issues is not the kind of work Chief Priests do.

And finally, when a certain guild or association continues to criticize me, go nuclear. I will consider shooting off a letter scolding them, accusing them of all kinds of things, including serious leadership problems and conduct lapses. The letter should be copied to a lot of people, including the Temple Masters, so as to show them I am a mighty warrior of great skill, resolve and courage. The letter should also paradoxically be marked “confidential” such that the guild that has been chastised cannot tell anyone they have been so admonished or defend themselves in public. I will sign off as Chief Priest of the Conclave. This may unwittingly give the impression that I have consulted and all Members of the Conclave have agreed with me when in truth, I never did ask for all of their approval or concurrence before I send off my nuclear letter.  Trust me, going ballistic helps, especially when the Conclave cannot be sued for defamation but the guilds can be.

Final Words

It has been a wonderful time in office for me. I wish you the best. In case you need my input in anything, you know where to find me – at the Edifice of Cleric Testing, where I shall continue to tinkle with novel ideas of making the lives of orc-healers more miserable. Do drop in for a spot of tea when you are free.

I wish you many rewarding years as Chief Priest.

Yours Affectionately,

Uncle Scotchtape

Chief Priest Emeritus,

Conclave of Orc-Clerics and Ministry of Healing

The Desolation of Smug – Hobbit’s Guide to Being a Good Resident

December 18, 2013 at 9:17am

“Residents”.
When I first heard this term, I thought, “As in, Permanent Resident versus Citizen?” or as in the game and movie “Resident Evil”? I also thought itmeant that the resident RESIDES in house 24-7, otherwise why the term? That first one year of rolling out Residency Program, there was chaos. It used to be that call rosters are straightforward, and hierarchy is clear.

The houseman clerks the patient (ie. talks to the patient, fills in something calling a “clerking sheet”, sets a plug, draws blood, does an ECG, orders a CXR). The good houseman gets all these done, steps ahead of the rest of his team. The bad houseman asks his MO to help, because having 2 admissions at one time is too hard to manage.

The medical officer then reviews the patient (by checking that the clerking was done properly, orders more stuff to try to impress the registrar; maybe tell patient things like “kiv CT”, “kiv “PFO”). The good MO functions as a top-notch HO as well as effective registrar. The bad MO hides in the call room and claims all the credit for the HO’s work.

There are different grades of HO/MO. The best ones are hardworking and smart of course; of the rest, they may be classified into:

Grade 1: lazy but smart- “Slacker”
Grade 2: hardworking but stupid- “Blur cock”
Grade 3: lazy and stupid- “Space cadet”
Grade 4: lazy and stupid but think they are God’s gift to Medicine- “Consultoid”

Consultoids actually aspire to greatness when they do not have any of the required ingredients; similar to current Mediacorp serial: “The Journey: a Voyage”. For those of you who have not watched this (which I reckon is about 99% of the profession), the serial is about 3 ASTs kena jammed by the residency system and now have to complete their specialty training overseas in strange foreign lands.

Treatment:
Grade 1: no need to do anything, they will drift into their chosen subspeciality or locum-land
Grade 2: keep teaching and hope that eventually something sinks in
Grade 3: leave alone- hope that they drift off out of medicine and never be in a position to do harm
Grade 4: no cure- they grow up to be bad registrars and bad consultants

The registrar does the final review on call, and makes the tough decisions (eg. What shall I get the team for dinner? Bak Kut Teh or Zi-char or pizza? BTW, YLLSOM graduates do NOT eat pizzas when on-call. These are reserved for those with posh-nosh foreign degrees)

Seriously though, in most disciplines, the most senior person who stays in-house is a registrar. He must make the right balance; manage sick patients independently without compromising patient safety. If everything call consultant, will be seen as useless; if everything don’t call consultant, may be seen as reckless. The good registrar knows his work, escalates to the consultant appropriately (rather than a phone call to say, “eh, sorry boss, should have called you earlier before patient went into asystole…” and looks after the junior team well. The bad registrar is the consultant’s worse nightmare. The smart con soon learns to be friends with the roster planner to avoid having a bad registrar on call for him.

The consultant on call is the final bastion. His word is law, his will be done. Except when there is a VVIP patient in which the consultant (especially a young one) will be reduced to standing around in the corridor until the Head of Department, Division Chairman, CMB, CEO, GCEO appear to make a collective decision on anything from performing major surgery to whether the VVIP gets fish or chicken porridge for breakfast. Otherwise, the good consultant is a master of his craft, a teacher, a good administrator, a good researcher and a healer. The bad consultant doesn’t really know his work, does not know how his hospital systems work, has forgotten (or maybe never knew) basic medicine and surgery. He was probably a consultoid in his younger days. The good consultant is well loved and well respected by his juniors and peers. The bad consultant is hated, being the cause of a lot of unnecessary work. (Refer endocrine for hypocount 14, refer GS for Hb 12->9 after hip replacement, refer CVM to start medicine for hypertension or fitness for OGD when it is obvious the bleeding peptic ulcer patient is going to die if an OGD is not done…)

Nurses used to know clearly whom to call to do certain things- actually, everything call housemen first. Housemen are the magical elves who make things happen. But over the years, as more and more duties get taken away from housemen- eg, phlebotomists take blood; nurses do ECGs, check blood before transfusion, etc; consents are taken by at least an MO and above… housemanship seems to become more and more about clerical work.

Now, back to RESIDENTS. Different programs take in residents at different years post-grad. Residents are a varied bunch- some have just graduated medical school, some are medical officers of varying seniority, a few are foreign grads who might not have working experience in Singapore, and some are trainees in the old system who got played out and had no choice but to change to the new. You can recognize them because they walk around with a look on the face that screams “Screw me harder – I can take it!!”. [machiam Leonidas from “300”]

So, a team of 3 HOs and 3 MOs may have 1 HO-resident, and 2 MO-residents- and the roster reflects them as “residents” instead of the traditional HO/MO. What this means on the ground is that, nurses were not sure who call to do changes sometimes! It didn’t help that some departments appointed HO-residents to tag on MO calls, without actually doing MO work because of the P-number, but also not doing HO work. While this may seem superficially to be beneficial for the HO-resident, it actually is detrimental! This HO may not learn enough skills as a HO to be effective at a MO level; and when he turns into an actual MO, can he perform his tasks? Anyway, the key message is that the clarity we had in the HO/MO days is now a royal mess.
A good resident is expected to be a super high achiever. The student who applied would firstly, have to have good grades; secondly, the compassion of Mother Theresa; thirdly, a national sports champion and finally, Friend to all. Continuing this self-fulfilling pattern, he then goes on having to live up to expectations of being in the 100th percentile for ABSITE, win President’s Charity Award, complete training in 4-6 years, get good feedback in the “360 feedback”, publish 10 papers a year and be the next DeBakey.

This Hobbit has noticed that more and more “junior” people are looking down on him. Not just because Hobbit is short. Residents seem to be uncertain how to behave- confidence comes across as cockiness; humility is a forgotten virtue. Yet, how many of them feel pressured to act confident because they fear showing any signs of weakness? Confiding in your peers may be the last mistake you make because you don’t know who will betray you to the PD (program director). No way is any resident going to confide in a senior. So how? Just hide behind a facade and try to juggle everything.

Please let this Hobbit reassure you, dear resident. Have faith (not just confidence, but faith)- you were chosen because you are good. Do not let anything distract you from being the best doctor you can be, and that comes back to the heart of what makes you a good doctor- your initial passion and empathy to want to help the sick.
You must have been a “hardworking and smart” HO/MO to get to where you are. Resist slipping and becoming lazy- being smart can only take you so far. Keep reading and studying and operating to stay “smart”- and not just book knowledge, but be an all-rounder- build up teaching, research and leadership skills. Don’t neglect interpersonal relationships- truly be friends with your peers, seniors, allied health; don’t be friends just to get them to do things for you. Be friends because you do want a good working environment and a second family. Remember to still invest time in your first family, whether it’s your spouse, your parents, your sibs, etc.

Find good role models, and aspire to be like them, or even better than them. Be a master in our craft- how did this consultant KNOW that patient had aortic dissection just by LOOKING? How did this consultant manage to “NEVER” have a perioperative morbidity? How did this consultant become so well loved by everyone? How can this consultant have >200 publications? Admittedly, role model consultants are getting rarer with each passing year as the old legends retire and the younger ones leave for private practice to escape the system that you are in now.

But then, what do I know? I just live in a hole in the ground.

Hobbit’s Guide to Being a Houseman: An Unexpected Admission

November 20, 2013 at 1:45pm

I have not been on call in years, so some of you may wonder- am I qualified to be writing a guide to housemanship. Uncle B had the misfortune to be admitted recently for severe abdominal pain- most likely from overeating or food poisoning from orcal-fecal contamination. You know how these disgusting orcs just poop everywhere. And what with our fondness for food and beer, good or otherwise – especially during Oktoberfest. Anyway, from where I was sitting at the emergency department where Uncle B was waiting for attention, I can observe many of the young doctors on the ground bustling around doing their changes, and what a heart-warming sight it is!

After hours of waiting in the P2 area in the emergency department, kept fasted because no one can exclude an acute abdomen, xrays done were unable to see free air or bowel gas because there was too much adipose tissue … anyway- we finally got a bed in the subsidized ward where we waited for a CT scan. Nowadays, a CT scan is ordered to diagnose anything from acute appendicitis to chronic ingrown toenail.

He had a precarious blue plug on his left hand- after many failed attempts… of course, our hairy feet precluded any chance of plug setting there. The drip was finishing- the trace of blood back-flowing up was mildly disturbing to him as a layperson.

A fresh-faced young lass came up to him and started clerking. Interestingly, she has already filled in much of the clerking sheet. The questioning went something like this,” So, Mr B? You know what you have? Pain right? Ok. Don’t eat until my senior comes and sees you. Thanks, bye.” Apparently, she has already obtained the history and physical examination from what was already available from online. The rest of the night was uneventful, except for my Uncle B making a fuss about to eat, and me secretly sneaking in a vending machine sandwich for him. He was discharged well the next day.

Being the good nephew that I am, I kept him company the whole night, and it was an interesting experience being the patient’s family, rather than being the managing doctor! From what I can see, housemanship has changed a lot since my time. For one thing, there’s a lot more of them! It used to be one houseman looking after 30-40 patients, now it seems like there are more doctors on a ward round then patients sometimes! Of course- in my time, policemen wore shorts, the television network was called SBC and most importantly, Britney Spears was still a virgin on the Mickey Mouse Club (OK I exaggerate on the last point. I actually meant Madonna).

Housemen nowadays are a mixed group, maybe one-third are “out-of-phase” doctors from foreign universities; some are post-grad doctors- most of them are “residents”, already pre-selected into a specialty training program, and some display this in a few ways:

1. Bochap-ness when it’s a condition outside of their chosen specialty

2. Confidence, bordering on arrogance when it comes to a topic that comes under their specialty (never mind that they are 2 weeks fresh out of medical school; all full of book knowledge but no clinical experience.)

3. Talking back to their registrars or consultants (it used to be, when my boss said jump, I asked how high? And just do it. Even if I can’t really jump, what with my bad knees. Now, residents will argue that there is no need to jump, if you want, go ahead and jump yourself.). Some even call their registrars and consultants by name (which in my time, along with buying McDonalds for supper, was a crime punishable by death or exile into the Phantom Zone).

However, this doesn’t mean it is all bad. We are still getting the best and brightest into medical school, so they must be the best and brightest young doctors. In fact, now that they have structured, protected training, they are even better than the current registrars and consultants. I bet, if the current Regs and Cons have to do the ABSITE, the scores will be dismal. So maybe they are entitled to their hubris. After all, residents’ and students’ complaints and feedback are taken so seriously that Registrars and Consultants get penalized; while it is near to impossible to fail a HO/MO, no matter what a lousy doctor he/she is.

Skills and job requisites for housemen have changed a lot as well. I think the key skills needed now are:

1. Proficiency with computers- with the rollout of electronic platforms for EVERYTHING, a good doctor must be one with the computer. Tracking patient’s location, ordering investigations, getting consent, tracing notes from other institutions, looking at imaging, changing settings, reviewing medications, etc. Naming these programs Sunrise and Aurora may be misnomers. More appropriate names are “Hangman”, “Crashes” and “Error loading”.

2. Fluent in Acronyms- SOOB, BIBA, TOC, ERx, CPSS, C-DOC, OTRS, OOTS, CPACS, AIC, CMIS, ROSC. OMG, LOL.

3. Diploma in printer repair- a good doctor must know how to unjam paper, replace toner, replace ink; change printer settings from single to double page; must know how to print things from a remote location because the printer in your ward just won’t work, especially when there’s an emergency OT chit to be printed out before the porter & nurse can bring patient down to the OT.

4. Certificate of competency in Whatsapp-ing (SMS is so ‘90s)- the convenience of chat groups for a generation raised in this media age is a welcome escape from actually having to talk to a colleague to hand over cases. If clinic reviews may be done via Facebook or Snapchat, it’ll be embraced. An example:

Postcall HO: “Hey Team 3 HO, pls note ytd adm 1 perf PDU, for EOT, chit n consent up. Tq. ☺”

Team 3 HO: “g8t, thx!”

Despite the years between us, some things never change. The good houseman must still be like an octopus- multitasking and getting things done, because they are the invaluable ground team and mini-miracle workers who get things done. Many have used the minions from Despicable Me as their FB photo. I can still relate to that!

The good houseman/resident must still be able to:

1. Create a patient list (no matter what computer program is used)

2. Engage in bovine-worship (In ancient Biblical times, there was the golden calf, now there is bowing at least 4 hours a day before the ubiquitous COWs – computer on wheels)

3. Lie through the teeth to get an urgent review or scan done

4. Convince a social over-stayer to go home/ convince MSW to hasten application to nursing home

5. Trace changes, order meds (done in the comfort of the aircon lounge because it’s all online!)

6. Look after patients when their seniors have disappeared to clinics/OTs/snake temple

7. Take a good history (with more foreign patients nowadays, good thing we have more foreign nurses and doctors to help with translation. Unless it just so happens that the combination is not ideal- eg. PRC patient, clerked by a Singaporean overseas grad who speaks only Queen’s English, with a Fillipino staff nurse, and a Tamil speaking assistant nurse.)

In fact, while housemen nowadays seem to my old, jaded eyes to be less well-trained; is it the fault of the system which has made them so? I won’t be able to function as a houseman nowadays; I type with both index fingers. I can take bloods, set plugs, do hypocounts, insert NGTs, do ECGs, put up drip; but I can’t type fast. The modern houseman has more help from nurses and allied healthcare to help with the physical changes; to the point that some perhaps, have not quite learnt how to do them. More importantly, there is this surreal expectation from policy makers practicing zero-risk medical administration that once you pass housemanship, you can miraculously take on new and additional responsibilities like sign a death cert and take consent for simple procedures.

Moving forward, how can we improve the training system for doctors, and specialists so that we won’t face a shortage of generalists in 10 years’ time? That is a topic for another day; The Hobbit II “The Isolation of Smug”. I need to go have lunch with my Uncle B

Interview with Candidate Jiro-Jiro

October 28, 2013 at 7:30pm

Tiffany Halifax-Cumberland (THC):

Hello, welcome to this installment of the interview series of the Syonan Medical Association Newsletter. I am Dr Tiffany Halifax-Cumberland or THC for short and I am the Editor of this august publication. This month, we are very honoured to be given the opportunity to interview Dr Jiro-Jiro, the candidate who has consistently polled the highest number of votes in the last few Conclave Elections.

Konnichi wa, Jiro-jiro-San. Once again, you have performed superbly in this latest Conclave Elections, polling some 38% of the votes cast, more than double the next highest candidate amid a tight field of 5 candidates, excluding your goodself. Congratulations.

Jiro-Jiro:

Thank you, Tiffany-san.

I must say with all modesty I am quite pleased and surprised at this result, considering I did not agree to run, hence I did not even sign the nomination form. And of course, there were no proposers or seconders. I must take this opportunity to thank the Conclave for offering Jiro-Jiro as an option, without which I would not be here.

THC:

If I may say, this is no flash in the pan. You have been outpolling other candidates for quite some time now. Can you tell us what is your secret to success at these elections?

Jiro-Jiro:

Well, the secret is that there is no secret. Take a low profile, don’t do stupid things like twerk in public or queue overnight for a donut and one should be fine. Let the Conclave do the rest.

THC (choking on his donut):

(Cough, cough) Let the Conclave do the rest? Can you elaborate?

Jiro-Jiro:

The Conclave’s record speaks for itself. I do not wish to elaborate, lest I give the wrong impression in any or several ways, or do not seem to be fair to any of the members of the Conclave. But it would be no exaggeration to say that the Conclave is the main factor behind my electoral successes.

Again, in all humility (stands up and takes a deep 90-degree bow), the large number of votes I have received would not have been possible if I had not received strong support from all sectors of the profession: private sector, public sector, specialists, GPs, local graduates, foreign graduates, RI Alumni, ACS Alumni, SCGS Alumni and the NTU-LKC Alumni-to be etc.

I wish to take this opportunity to thank especially the Chief Priest, the President of the Conclave, my parents, my wife as well as all the folks who are waiting for Bus Service 190, which must number in the millions.

THC:

Indeed, the widespread support is quite astonishing. What do you think a vote for you, Dr Jiro-Jiro represents? What were the doctors thinking of when they cast their votes for you?

Jiro-Jiro:

Their votes can represent many things. But I think the common thread is that the status quo is untenable. People do not want more of the same sh*t. People want more transparency on the disciplinary, appeals and administrative processes of the Conclave. People want accountability. This is especially important when the profession bear the cost of running the Conclave. I must say that I am very happy with the Conclave and have no doubt things are humming along under the great leadership of the Chief Priest and his buddies. But it is just that there are lots of fellows are out who want more transparency and accountability. What they want may be right but not possible.

THC:

(Trying to appear disapprovingly of Jiro-Jiro’s comments and failing miserably so) Are you saying the Chief Priest and his buddies are running the Conclave badly? Why, the Chief Priest has been there for eons and he has done an excellent job! He has said he has no part in the disciplinary process and has even set up a Reveal Committee to make sure things are right.

Jiro-Jiro:

And indeed he has. Well, it has been many moons since the Reveal Committee was set up and the Committee has revealed nothing as yet. And I speculate that when all is revealed by the Reveal Committee, it will be status quo. Life goes on, business as usual. (lips pursed, eyes narrow).

THC:

Going forward, how would you try to improve things within the Conclave? You do have a mandate, given the size of the support at the elections.

Jiro-Jiro:

That’s an interesting point. But one must know that a vote for Jiro-Jiro is a special vote. Because no matter how many votes I get, I will NOT sit in on the Conclave meetings or participate in any of the disciplinary proceedings. I think it is precisely of my non-participation that doctors have voted for me: I will never be part of the Conclave even if the Conclave allows me to exist. In a passive-aggressive way, a vote for Jiro-Jiro can be construed to be a vote for apathy, cynicism, and even hopelessness. Even though I must stress again, Jiro-Jiro thinks the Chief Priest and his buddies are doing a great job; its just that many folks do not agree with this view. (Eyes narrow further, chokes on his own saliva)

THC:

That’s a very strange picture you paint there, Dr Jiro-Jiro. Could there be other possibilities, for example – that people out there do not know the candidates that are running and hence cast a vote for you instead?

Jiro-Jiro:

That is a possibility, but a remote one. How big is the Syonan medical profession? Look at the candidates in the last few elections. There are quite a few good and well-known people out there. Surely at least 95% of the doctors will know at least one candidate in each election? One must have been living in a cave to not know any candidate in the last few elections. It’s like saying someone out there does not know any of the members of Big Bang, Super Korea or Girls Generation? Is that possible? Someone check this guy’s vital signs stat!

Another way to look at it is that people will vote when they know they can make a difference. But when they do not believe so, they vote for Jiro-Jiro, which is essentially a non-vote. But I once again say I am a great fan of the status quo (eyes stayed narrowed, breaks into a wide grin). But I cannot change or convince those that think otherwise.

THC:

What of the future?

Jiro-Jiro:

Well, at the rate things are going, I think more people will cast their votes for me. When the situation becomes embarrassing, they will kill off Jiro-Jiro.

THC:

(Looking slightly pale) Kill off Jiro-Jiro?!?! That is terrible! They can’t do that!

Jiro-Jiro:

They can do anything. Remember, we do not control the game and the rules. You know they can and will do anything. Look at how they claimed that everything was just fine when more than 98% of the people voted. Under the threat of a fine of suspension, of course almost everyone voted! Some people say that answer was an insult to their intelligence. But I say hold on. These are edgy times. People are very insecure. After Vettel wins the F1 four times, people now also want to change the rules, yes?

And so the truth is dangerous. And so is intelligence. Veritas mortis parit. That is why in these times, we must always profess our love and loyalty for the Conclave and the Chief Priest and his buddies.

THC:

(looking paler by the minute). Indeed. Hinc lucem et pocula sacra.

Thank you for your time, Jiro-Jiro-san. I wish you well and many years of election success ahead.

Jiro-Jiro:

Thank you, Tiffany-san. Donuts are bad for your health. Shitsurei Shimashita.

(Dedicated to my dear friend Dr Tiffany Halifax-Cumberland, interviewer extraordinaire)