Another White Paper

September 25, 2013 at 11:04am

There are white papers and then there are white papers. The recent Population White Paper will forever be unfortunately associated with the infamous figure of 6.9M. But not all white papers are as controversial as this one. Twenty years ago, the Government also published another White Paper. It was titled “Affordable Health Care” which served as a blueprint of sorts for Singapore for about ten years until a generation of folks running healthcare sort of ignored or forgot about this landmark WhitePaper and its recommendations.

This Hobbit thinks the Affordable Health Care White Paper was quite coherent and focused in its approach. Far more than what is happening in recent years, unfortunately.

So for those people out there who think that because a population upper limit of 6.9M was mentioned in the population White Paper, it will surely come to pass, fear not. The following will show that even if they are mentioned in a white paper, people can still forget about it or even do the exact opposite. This Hobbit gives a few such examples that were found in the Affordable Health Care White Paper which have not come to pass even now, twenty years later.

Philosophy

“Any health care policy has to trade off among four competing goals:

 

  • Equitable access;
  • Freedom of choice forpatients
  • Affordability; and
  • Freedom to organise production and to price

 

…”Given Singapore’s environment, we have to compromise the last goal: freedom to organise production and to price. (Page 13)

Except for the egregious example of the Susan Lim case, the private sector now has total freedom to price. In fact, freedom to price has been enshrined by the Competition Commission of Singapore when it outlawed the SMA’s Guidelines of Fees.

Basic Medical Services

“The Government has promised Singaporeans access to affordable basic medical services. This basic package will reflect good up-to-date medical practice, but it will not provide the latest and best of everything” (Page 17 to 18). “MOH will define the basic medical package which all Singaporeans will have access to, as it has always done”.(Page 21)

Actually, no one really knows what is the basic medical package (BMP), a construct as nebulous as the this year’s epic haze. We only know a few examples of what is NOT in the BMP.

The closest we have to a BMP is really what is claimable under Medisave and Medishield. But then again, there is a lot of funny stuff happening in Medisave too. For example, up till now, ultrasound-guided excision biopsy of breast lump, which is curative, is not claimable under Medisave, even though the scientific literature provides solid evidence supporting this therapeutic modality. People have been told to claim under (non-therapeutic) diagnostic breast lump biopsy. Either the folks in Medisave are living in the Stone Age or they do not know they are actually asking breast surgeons to deliberately code wrongly for what they are doing.

Private Sector Share of Hospital Sector

“The private sector presently provides 20% of acute hospital beds, mainly at the higher end of the hospital market. There is room to increase their share to 30% by 2010”. (Page 31) (According to Table on Page 37, this figure excludes A class beds in subvented hospitals and there will be a total of 9,690 beds in acute hospitals in 2010)

According to the Health Facts Singapore 2012 published by MOH, in 2010, there were a total of only 8064 acute hospitals beds, of which 6686 were to be found in the public sector and only 1,378 beds (17.1%) were to be found in the private sector.

There are another 2,195 beds in the public sector that were classified under “specialty centres” and not under “acute hospitals”.  Presumably this large number of “specialty centres” beds can be accounted for by IMH?

In other words, we are a long way off from the 9,690 acute hospitals beds that was forecasted in the 1993 White Paper, even if we take into account the opening of Jurong General Hospital in 2014.

Bed Class Distribution in Subvented Hospitals

“Fewer patients are choosing Class C, and more are opting for Class B2 or better. This trend will continue”; “Presently they (Class C beds) form 33% of beds in subvented hospitals. MOH expects this proportion to fall to 25% by the year 2000” (Page 36 and 37)

Again, this is way-off as experience tells us that there is great demand for Class C beds. SGH originally did not offer any C beds when the hospital was rebuilt in the seventies and eighties. That was described to be “a mistake” in 1989 and C class beds were built in a very limited way. Then in 2001, SGH had to offer C class beds in all disciplines.

We also know in other hospitals, waiting times for C Class beds are always the longest and the most frequently “up-lodged”. If you consider all the up-lodging that is happening everyday, then the actual demand and utilization of C Class beds could well still be around 33% today.

Private Wing?

“A subvented hospital may want to develop additional Class A wards or clinic suites, in order to offer new unsubsidized services. It may do this on its own, like any private hospital, provided the project is commercially viable and can be funded on a commercial basis without Government support. The project should preferably be run as a separate company with a different corporate name and image. Physically the additional facilities should be as distinct as possible from a subvented operation, e.g. in a separate bloc, which for practical reasons can adjoin the public hospital” (Pages 37 to 38)

This is an interesting one. If you read the words carefully,the term “private wing” is never mentioned. But the passage certainly describes a private wing in every sense of the word. However, no subvented hospital has a private wing today. Is it because there is no demand and there were no requests for a private wing to be built? Or is it because MOH has never approved the building of private wing? We may never find out….

Medical Research

“Improvements to the healthcare system do not depend on indigenous breakthroughs in medical research. While medical research increases the pool of human knowledge and can improve the quality of health care, it generally does not yield any financial returns, even over the long term”. (page 51)

This is a strong statement that bears reading over and over again. Yet, we are now building not one but two academic medical centre campuses (SGH/Outram and NUH/Kent Ridge) that will soak up billions of dollars of resources.

Medical Research

“The third category of research should be undertaken only with strong justifications. Even then we must be careful to avoid raising unrealistic public expectations that the new procedures and drugs will become universally available, and will successfully treat conditions which were previously untreatable”

 

Third Category:

“Research that has practical applications which are expensive, e.g. organ or bone marrow transplantation. Such work is often developmental, involving experimenting with new procedures or drugs that have been developed elsewhere. It can thus raise health care costs without commensurate returns. (Page 52)

Again, this has been turned on its head. One just needs to read the papers and find reports of groundbreaking research on rare diseases,expensive drugs, robotic surgery etc. One may argue whether such research is good or undesirable but this Hobbit thinks no one can deny that the frequent reports of such work have certainly raised unrealistic public expectations about what treatment modalities can become universally desirable.

Postgraduate Medical Training

“MOH is responsible for coordinating postgraduate and advanced medical training at subvented hospitals. Because of the expense involved, and the need to deploy talent optimally, the training of specialists should be based on service needs. It must be centrally coordinated and periodically reviewed”.

This example is one of a flip-flop in thinking. Long ago, everything was centrally controlled. Then, everything was decentralized. First, restructured hospitals can recruits as many trainees as they could, to the point that trainees who have passed their postgraduate degrees like MRCS cannot find advanced specialty trainee or registrar jobs. With the introduction of the ACGME-I system, residency decisions were passed to the residency advisory committees (RACs) sponsoring institutions, program directors etc. Well, these guys took their jobs seriously and decided to promote some residents they thought were good to senior residents. Then in one fell swoop,some wise guy decides to unilaterally overturn this and override the governance structure that had been set in place, even reverse some promotions (promotion letters already sent out) of some residents.

So it has been centrally coordinated, then divested to the sponsoring institutions and RACs, and then now abruptly centralised again.Couldn’t everyone have been spared all this anguish and angst by just sticking to the doctrine of centralisation in the first place?

Should we have another White Paper on healthcare?

Lately, white papers may have gotten a tarnished name. But lest anyone misunderstands, this Hobbit thinks that having a healthcare white paper once in a while is a good thing. The above examples are just a few examples of what did not happen. Some recommendations were quite off the mark, but many did not happen not because these original recommendations were wrong, but probably because conditions have changed or some folks have decided to ignore the prudence that the White Paper was trying to inculcate. And to be clear, many good things did come out of the 1993 White Paper.

A White Paper forces policymakers to think long term and commits them publicly to a course of action that has been carefully thought through previously. Such commitment requires gumption, clarity of thought and allocation of resources. Not everyone may agree with what is written in a White Paper, but it also puts everyone on the same page. There is no ambivalence and vacillation in a well thought-out White Paper. That sure beats making plans in secret with minimal consultation, making things up as you go along or unleashing nasty surprises on stakeholders. The residency is one such bad example. There was no light on how the decision of using the ACGME-I residency framework was arrived at; in retrospect, clearly no in-depth understanding of the resources that were required to operate the ACGME-I framework; and no roadmap for career progression of residents (hence the sudden decree to overturn certain promotions). And hence, it is now still mired in darkness and people down in the trenches have to try to make the system work by instituting ‘patches’ haphazardly like engineers and technicians trying to fix some nightmare software programme. And this Hobbit reckons we will still be mucking around for a long time to come.

We actually need another white paper on healthcare. The last one in 1993 was a good piece of work. We can have another one that is just as good, if not better.

Charging Ahead

August 13, 2013 at 3:36pm

It is finally over. The titanic struggle between two parties that made Jaegar vs Kaiju battles in the movie, Pacific Rim look like two pygmies wrestling in a plastic infant bathtub, is over. We are of course talking about the Susan Lim overcharging saga that has finally come to an end.

And certainly it must. This Hobbit has actually gone through the SMC judgment (83 pages) and the Grounds of Judgment for the appeal to the Court of Three Judges (153 pages). This Hobbit encourages all of you to do so. Going through these two documents entails certain health benefits:

·     The hair on my feet has grown by an inch in thesame period.

·     It cures all forms of diarrhea.

·     It gives you inner peace as you better understand why you are still poor and languishing in your HDB clinic.

·     Your mind can “drift” just like the Jaegar pilots without any co-pilot. In fact, you can drift right into stupor after about 5 pages.

These are quite a few lessons one can learn from the whole saga and from reading these two documents.

Firstly, its OK to charge poor patients less or to even waive charges completely. But it’s not OK to charge richer patients more just because they are rich. So no “Robin Hood”. In other words, please raise your “standard” charges for everyone else (other than the poor) just to take into account the possibility that you do not want to always subsidise the poor out of your own pocket. Of course, the middle-class will suffer the most from this, since they neither deserve charity as the poor nor are they as wealthy as the rich. Take home message – the wealthy cannot be disadvantaged because they are wealthy. To borrow and adapt from tax terminology, there can be no “progressive professional fee charging” even though there is progressive taxation. Too bad if you do not buy this logic, but this what the powers have pronounced. Next take-home message – if you are middle class and not poor, you have to pay as much as the rich for doctors’ fees.

Secondly, it is generally a bad idea to charge a third party payer a lot if your chief lobbyist, i.e. the patient, is dead. If possible, try and charge more when the patient is alive so as to avoid complications like in this case.

Thirdly, charging an average of $15,000 a day appears to be OK, but $200,000 is out. But how about an average of $20,000 a day? (BTW, that’s about what an anaesthetist appears to have charged in the Susan Lim case, over a period of about 110 days). That appears to be OK too.

Long ago, it was opined by an oncologist that taking away the Guideline of Fees was like taking away the speed limit on our highways: the driver used to driving at 60km/h when the speed limit was 90km/h would still continue to do so, with or without the speed limit. But the person who had been driving at the 90km/h speed limit would be uninhibited and have no qualms driving as fast as he could. Now we are told there is an ethical limit to charging. To borrow the same metaphor, that means we now have an ethical speed limit. Only problem is we do not know what is this ethical limit in definite numerical terms. How does ethical limit translates into numbers? Charging is about numbers as much as it is about ethics. Imagine telling motorists on the German autobahn that there is an ethical speed limit when there is no numerical speed limit. Now you know why “angst” was originally a German word.

More importantly and encouragingly, the Courts and SMC have decided that ethics should trump contracts (or market forces) for the individual doctor. The Hobbit agrees with this 100%. But it appears the converse is true for a professional organisation: the CCS said that fee guidelines issued by a professional association like the SMA is anti-competitive. In other words, market trumps ethics for SMA but ethics trump market and contracts for the individual doctor. So it appears that that are different philosophies, principles, standards for the individual doctor versus the professional association/body. Can the Courts, SMC and the CCS rationalise this? Because this Hobbit certainly can’t.

Here is the crux of the matter. No one argues that pure water can exist as a liquid and as a solid. Ice is 100% water. So is liquid water. Likewise, there are also two dimensions to charging by doctors – an ethical dimension as well as a numerical dimension. By imposing an ethical limit but denying the medical profession any definite numerical guidelines on the matter of charging is to try to have your cake and eat it too and denying this duality exists. But this is exactly what the regulatory authorities (SMC and CCS) are collectively doing. The medical profession has been inadvertently put into a most unpleasant position by these two bodies. This is not only grossly illogical, it disadvantages the patient and places the medical professional in an untenable position in the long run.

Contrast this with what’s is being discussed now in the legal profession: champerty: which is allowing lawyers to take on cases for a cut of whatever the client may recover in a legal action, otherwise known as “contingent fee arrangement”. Straits Times journalist Andy Ho said on 2 August 2013 “Let David take on Goliath in court” said that a contingency fees system is consistent with the market ethos of our culture” and that such an arrangement was first started in capitalist USA.

Legal aid already exists in Singapore for the poor but it appears that this may not be good enough and there are some folks who think that champerty should be allowed for the poorer segments of society as well so that they have improved access to lawyers. The first point to be made is how do we define who is poor and entitled to champerty?

If in the future, if champerty is allowed for the legal profession in Singapore, then seriously folks, we should really allow doctors to take a cut of the patient’s wealth for keeping the patient alive and healthy? After all, one’s wealth is meaningless to oneself if dear oneself is feeding daffodils seven feet underground or gathering dust in an urn somewhere in Kranji.

And to make champerty more “progressive” in nature along the lines of improving distributive justice, perhaps we can put in requirements that doctors who get a share of the patient’s wealth be required to donate apart of these champerty earnings (say 25%) to a healthcare charity or to Medifund to help the poor have better access to healthcare.

Finally, it was reported in the Business Time recently that the starting pay for lawyers is now 6000 bucks a month. Also, one can safely say that some of the people who benefited most from this Susan Lim saga are the lawyers who have collected probably lots of fees for their work. So, if champerty is allowed in Singapore, one can expect a lot more work for litigators, and that includes cases that involve malpractice suits against doctors and hospitals, both in in the public and private sectors. Medical malpractice and hospital insurance premiums are likely to go up in such a climate and if so,will be passed on to patients eventually unless you really believe doctors live only on fresh air and Newater and hospitals are here to make losses. But if a British actor can play Superman and promote the values of truth, justice and the American way, then anything can happen in this crazy world now.

As another (green) short guy remarked long, long ago in agalaxy far, far away, “I sense a grave disturbance in the Force”.

Meanwhile, sources working in the private hospitals tell this Hobbit that the referral agents are now working with greater ferocity –they are now asking for up to 25% kickback of professional fees as “referral charges”for the patients they refer to agreeable specialists. Agents and participating specialists both stand to gain from the ever upward spiral of fees on these unsuspecting patients who think that the agents only charge a small administrative fee for these referrals. Fee-splitting is not allowed by the SMC but everyone knows this is going on. These agents are the real weapons of mass overcharging that pervade more and more of our private specialist care delivery system. They remain in the shadows. And these agents and the participating specialists are also smart enough to leave no paper trail and all transactions are done in cold, hard cash. Perhaps only a forensic audit will uncover the truth. But no one wants to deal with the problem for now.

So, perhaps the last and only useful take-home lesson from this Susan Lim saga is – be a lawyer. As for the medical profession, we are certainly going boldly to where no man has gone before – we are charging (over,under or otherwise,) ahead into darkness….

Crazy Hazy Days

June 28, 2013 at 3:30pm

The days of haze are upon us. Which means that according to a certain pathetic minister from the big brother country of this part of the planet, we should stop behaving like children.

This Hobbit agrees completely. As responsible adults, we should do the following:

a)   Thank Indonesia for sending us the haze in 2013 along with their marines that bombed MacDonald House on Orchard Road in 1965

b)  Tell Chelsea, Arsenal and Liverpool to cancel their trips to Jakarta in July 2013 because you never know if the haze will suddenly appear there then.

c)   Hope General Zod looks for Superman in Bali

d)  Stop all our dirty old men from spending all their CPF money in Batam on you-know-what.

e)   Tell Indonesia we are a resilient nation and we will survive this. You know Singaporeans are really tough when our Hello Kitty toy queues are longer than our N95 queues.

But seriously, judging from the number of adults queuing up for Hello Kitty toys, one can safely conclude that there are a considerable number of Singaporeans who indeed behave like children. And actually, those that queue up for these toys in the middle of a haze are actually dumber than most children. Most children are smarter. These are idiots. Idiots are by definition adults who have mental age of a three-year-old or with an IQ of less than 25. And the folks who contributed to the situation whereby the police had to be called in probably have an IQ of a mudskipper. Just think of it: don’t the police have lots of better things to do than manage an argument resulting from a queue for Hello Kitty? These folks should be banished together with the aforesaid minister who said we were behaving like children to the Phantom Zone of Riau.

Now, a word about these “haze clinics” which the young, the old and the poor can go to for treatment for haze related problems and pay only ten bucks. This Hobbit thinks it’s a great idea. But we should recognize that these patients often require rather expensive medication like inhalers and nasal sprays.  i.e. the true costs of treating these patients would probably exceed $40.

I think GPs that participate in haze clinics should really be recognized as doing valuable national service. It’s a national crisis and there is nothing wrong with asking GPs to do so for a short time for these haze-afflicted patients, but the authorities should at least recognize the GP’s contribution in all this. You do the math yourselves – one nasal spray plus one eye drop and some simple oral medications would cost $20 to $25. Rental, utilities and clinic assistants’ pay would cost another $15 per consultation easily.  In other words, the doctor is working for free seeing these patients. The bottom line is: $40 is not a good deal at all.  So let’s give credit to these GPs for accepting a short-term bad deal in the interests of the public and the country. If MOH can’t do something concrete like waive my clinic-license fees this round, at least maybe send me a “Thank You” card when all this is over?

When the haze first started, there was really weird advice coming from supposedly very reliable sources. These jaw-dropping advice include:

·     “The N95 mask is necessary for individuals susceptible to the impact of haze, including persons who have 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”.

·     “For those that are healthy and would just like to wear a surgical mask, they can do so, but if you are pregnant, a child, an elderly, or have respiratory conditions, please use a N95 mask instead”.

No, I am not making this up. Obviously, terms like de-compensation, cardiac failure, oxygen de-saturation, increased dead space and breathing against resistance didn’t quite come into the picture when such advice was dished out. Common sense has since prevailed and the earlier advice has been thankfully heavily modulated and amended. The N95 can be a dangerous piece of equipment and the public needs to be reminded of this during this haze. In the meantime, please feel free to reduce your dislocated temporal-mandibular joints.

Now, some real and practical advice on living through thishaze:

·     Try not to go to Lorong Chuan anytime soon. It’s “chuan” enough already.

·     Do not give a N95 mask to your 85 year-old mother when she goes outdoors. Give it to your mother-in-law instead.

·     Keep yourself occupied amid all this gloom: Dig your nose frequently. You can go from OM to TDS easily if you are not wearing a N95 mask all the time. (Yes, another very negative side effect of wearing N95 is that it retards the formation of snot drastically)

·     Buy Toto based on the last two digits of the PSI readings at 4 hourly intervals

·     Fart quietly at will outdoors in this foul-smelling haze. No one will know.

While we are still on the subject of N95 mask, it is the subject of some of the most inspiring/moronic scenes (depending how you look atit) I have seen. These include

·     A worker wearing his N95 on his forehead

·     One guy wearing his N95 upside-down

·     People wearing N95 while driving in their air-conditioned cars (rather common)

·     A guy holding a N95 to his mouth and nose with his hand intermittently; the rubber straps on this N95 mask have been removed

·     Some dumb jock wearing his N95 mask and jogging.

·     One genius taking off his N95 to smoke his cigarette outdoors heroically when the PSI was 400. You cannot fault his dedication to his smoking habit.

Amid all this haze, it is heartening to see MOH giving out mobile aircon sets to the nursing homes and the un-air-conditioned wards in general hospitals. But we all know that the real solution is to air-condition permanently all these places in the first place. We have always taken pride in saying that while creature comforts may vary between different classes of wards, the safety/quality is the same. I.e. the chances for morbidity and mortality for a particular person with a particular condition is the same, regardless of the ward class he is staying in. This is no longer true with the haze (or even with SARS for that matter, because your chance of contracting SARS in a single-room is probably lower than if you had stayed in a B2 and C class ward). If we really mean what we say about safety and quality, then all wards should be air-conditioned. The cost increase is probably not that great and with means-testing, the abuse of subsidies is already largely minimized. If the Ministry of Social and Family Development can give subsidies to childcare centres and kindergartens for air-conditioning, surely we can do something permanent for the old and poor in our subsidized wards?

And just when you thought it was safe to go outdoors when the haze situation improved, we were struck by a hailstorm. Raining hail is the meteorological version of shitting bricks. This also takes the concept of Newater to a completely new level.  I have just dug up my old SAF helmet in preparation for the next hailstorm. For those of you who have not been issued a helmet, just use the jockey cap. Singaporeans are not known to be a hardheaded people for nothing. And for those guys waiting out there for your Hello Kitty toys in this haze and hail, you don’t even need to wear a jockey cap. There is probably nothing to protect there anyway.

Have to run. It’s time for a happy meal…..

Reading and Writing Chee Yam Cheng – 12 and 26 Years Later

June 19, 2013 at 11:50pm

Long, long ago, in a galaxy far, far away, before George Lucas cashed out and sold his empire to Disney, there was the Last Jedi Master, CheeYam Cheng (that was way before he decided to dress up as Elvis and crooned Love Me Tender recently. Shows you what staying in the public sector can do to you after 40 years).

In 1987, Prof Chee (aka known as “Elvis” wrote in the SMA News)about his hopes for the future. The article was known as Vision 1999. He had arather view of the future. 13 years later in 2000, then Editor of the SMA News,Dr (Now Prof) Cheong Pak Yean asked this hobbit to write a response to Vision 1999 circa1987. I know this sounds of confusing. It happens when you realise the British science fiction series in the seventies, “Space 1999” was completely wrong –the Moon was not cast away from Earth and Moon-base Alpha is only a planning target when our population reaches the hypothetical figure of 6.9M.

Anyway, it’s now 13 years since this hobbit wrote a response to Prof Chee’s Vision 1999 and 26 years since Vision 1999 was published in 1987.Dr Cheong has recently reminded this Hobbit that maybe it’s time to revisit there-visitation in 2000, something akin to a cross between the movies “memento”and “inception”

In 2000, this hobbit simply took 10 quotes from Prof Chee’s Vision1999 and commented on them. The article as published in 2000 and it was titled“Reading and Writing Chee Yam Cheng” The quotes and comments are re-produced below. For 2013, this hobbit has added in another response to the original 10 quotes and 10 responses. This hobbit unreservedly apologise if anyone finds this article rather misty-eyed in tone. When the PSI is 321, even hobbits get misty-eyed….

Quote 1
Master 1987: “The acute hospitals are bearing the burden of housing these poor folks in their last days and it is, to my mind, not cost effective at all”.
Hobbit 2000: Nothing much has changed. Except for a lone hospice that had to be relocated due to the antagonism of a bunch of insensitive residents, acute hospitals are still the place of choice for dying, with theexception of our Malay brothers, who still know the value of a home to thedying.

Hobbit 2013: There has been increased awareness of the need for palliative care, and overall there are more doctors, more hospices, and a good home hospice system. However, the idea of dying at home is still not a comfortable one with most patients, or rather, their loving families, who frequently panici n the last few hours and send the patient back to an acute hospital to die.

Things may have actually worsened on the long-termcare front. Residents and communities have often voiced unhappiness and objection whenever it is announcedthat a nursing home will be built around their place. If people cannot accept the elderly near them, how can they accept the dying?

Quote 2 
Master 1987: “Some residual animosity on the part of the outgoing doctor on the doctors left behind in service makes trust and cooperation very difficult”. 
Hobbit 2000: I don’t know about the animosity. But certainly, the chasm between the private and public sectors remain just as wide for some specialties.

Hobbit 2013: After learning just how much doctors can learn in private sector, this hobbit can only say that the chasm has only gotten widerthan the mouth of the Sarlacc[1].It has also increased the number of doctors leaving public for private; medical officers breaking bond, specialists leaving for the private hospital so conveniently located just next to their old hospital. But there is no shortage of doctors in public, not at all, as there is active recruitment of NTS doctors to help fill the gaps, thanks to the foresight by MOH. But foreign doctors now make up about 30% of the medical workforce and one wonders how much higher can this figure go up by? Up to 40 to 50%? And if these doctors are mainly to be found in the public sector, then it would not be unreasonable to speculate that foreign doctors make up significantly more than 30% of the medical workforce in the public sector.

Quote 3 
Master 1987: “The specialist register would be a reality and so too would continuing medical education be part of every doctor’s life”. 
Hobbit 2000: The specialist register is indeed a reality, but to what extent do doctors participate regularly and adequately in CME? Some estimates put this figure as low as 5% or as high as 20% for those obtainingthe 25 points to be given a CME certificate. There are many reasons for these statistics. Certainly more work needs to be done on CME.

Hobbit 2013: The CME requirements continue to be refined, and this hobbit gets a bit confused by the pro-rating, and the different categories of points required. The only sessions this hobbit attend are those with free food. Doeswine tasting count as CME? For example, does anyone really understand if weare required to fulfill our CME point requirements this year while the CME IT systemis being upgraded?

Quote 4
Master 1987: “Those specialists within government institutions should strive to attain a level of knowledge and skill that is the best available world-wide before embarking into private practice. There should be no obstacle to going into private practice. The only self-made obstacle is for the intending doctor to question and examine himself– is he of an acceptable standard, can he last the 10 – 15 years in private practice doing good work before he calls it a day…..remember then that the public cannot be fooled anymore, not that they were fooled before. But they will be better educated and more aware of improperly trained doctors…” 
Hobbit 2000: 2 pluses and a minus here. Certainly, there is no obstacle about going into private practice now. The public are also certainly more aware and less tolerant of medical errors, as given by the recent publicity over this. The minus is the number of 10 – 15 years of private practice. Specialists are finding it less rewarding than ever to stay in the public sector. A 10 – 15 year period implies that specialists go into private practice when they are between 45 – 50 years old. Nowadays, most specialists go into private practice in their late thirties or early forties.They will remain in private practice for about 20 years. In fact, talk to a young registrar or senior registrar and you will find that none of these colleagues of ours have any plans about retiring in the public sector. Could public service be made more attractive and a lifelong service in public sector a desirable career option?

Hobbit 2013: Things have worsened in this area since 2000. The natural life cycle of a specialist seems to be BST-AST-public consultant- private consultant. Of couse, the natural habitat matters. It is noted that in some environments, the BST phase takes very long before an AST phase, while in others, doctors remain stuck in AST before turning into a public consultant. In some places, the transformation of public to private is a matter of years, while some places manage to nurture public consultants for life. It will take a wiser person than this hobbit to understand why. It can’tbe all about the money, can it? It is also interesting to note that as we migrate to a Residency program, most trainees in various programs are not quite certain how they “exit” training and achieve specialist accreditation. This may nicely solve the problem of them ever going private as there is just no way to do so. Nor will they ever be able to migrate overseas and practice there, asACGME-I is “Uniquely Singapore”. This is compounded by the fact that with the shortened period of residency training,folks become specialists at an even younger age than what was previously possible. Are they truly ready for private practice after say, one year of housemanship and 4 years of general surgery residency?

Quote 5
Master 1987: “Our local graduates deserve more than what they are getting today: I believe we are not equipping them to face the harsh realities of life… Worse still if they feel that longhours, hard work and years of experience are unnecessary relics of the past”. 
Hobbit 2000: I was a houseman not so long ago. We had no call allowance, we gave IVs, did 120 second hypocounts and even injected potassium into saline bottles. Now I understand that housemen don’t do such menial tasks anymore. Good for them. Thanks to some of our colleagues in SMA and MOH, they even get a $70 call allowance! But has this translated into better care for patients? I hear of housemen quitting housemanship recently because they cannot take the hardship (no IVs and no hypocounts!). This was simply quite incredible to us ‘older’ folks. Maybe its because people are getting generally softer, or is it because $13,000 university fees attract a different breed of people than from my time (they can afford to pay up hefty bonds), I don’t know.

Hobbit 2013: I just found out recently that starting HO pay is $3200.Wow. It has been a long time since I was a houseman. More “houseman” work in my time has been further delegated to nurses- my HO now does not know how to startor titrate warfarin as the hospital “Anti-coagulation clinic” will do it; IV cannulations, blood cultures, inserting chesttubes, the list goes on. The current HO faces the problem of learning how to do online documentation, remembering passwords for the various systems needed to order a test, trace results from another cluster or polyclinic, making referrals to step-down care. Rather than learning medicine,or learning skills that is relevant to clinical practice, it feels like an internship for IT and technical support. I wouldn’t repeat housemanship now or ever, no matter what the pay, even though now houseman work less hours than ever before. Hardwork never killed anyone (exceptin Japan), but meaningless work kills the spirit.

Quote 6
Master 1987: “How can we remunerate doctors for humanistic qualities that are difficult to quantify?….Society cannot keep rewarding richly only services that can be quantified easily”. 
Hobbit 2000: Nothing has changed. We still reward those who contribute to the bottom line. I always wondered as a student how much of mytuition fees went to people who really taught me medicine, like Robert Pho, Ng Han Seong, William Chew, Tan Cheng Lim, Low Cheng Hock, my registrars like Wee Siew Bock, Agasthian, Teo Sek Khee, Low Chee Kwang and the like and how much of the fees went to paying some glory/money seeking academic who never gave me a tutorial or even returned my greeting in the corridors? For all the talk about elderly, we still do not have a geriatrics department in our tertiary hospitals and our only medical school does not even have a single geriatrician under itsemploy on a full-time basis. I understand that William Chew, Ng Han Seong and company only get a few hundred bucks a month to teach medical students andfrankly, they did more than they were paid for. We have long talked about recognising good teachers, acknowledging role models for our young doctors and developing geriatrics. But believe me, where decisions are made, the bottom-line of a balance sheet  seems paramount. And with DRG-based payment,Chee Yam Cheng’s fear of society rewarding only quantifiable services is morereal than ever. The talk is never walked. Talk is cheap and socially correct talk is cheaper.

Hobbit 2013: I like how the U2 song goes, I still have not found out where my undergrad tuition fees went. Post-grad training: no tuition fees per se, but yearly fees to JCST, and again I’m not quite sure what for. Do any of my teachers get the money? There is still no real monetary incentive for teaching; and true teachers will continue to teach regardless of the rewards, or lack thereof. Unfortunately, that means that they are approached by many students- undergrad, post-grad, and overseas clinical fellows! There are only so many hours he can devote to teaching; no good doctor will allow patient care to be compromised. Meanwhile, teachers who are not so “popular” may be smarter at clocking in teaching hours and getting recognized. There are many lessons that are not learnt by a sit-down classroom lesson, or even a stand-around bed hour-long tutorial. The way a surgeon operates, the way a palliative doctor breaks bad news, the way a renal physician convinces his patient to be compliant to medications- a good student learns these from mentorship, from observation; and there is no way to track that.

The real danger is that we are reaching a breaking point in the system that no “structured”system like the residency can address– the dearth of role models as the older legends of medicine retire and they are not replaced by younger ones, as practically most of the younger ones leave for private practice at an ever faster rate. Ideally, a clinical department should have two or three legends in their late fifties and sixties, quite a few “masters” in their forties and early fifties and many junior consultants in their thirties. What has happened often is that the “master” level is hollowed out, leaving one or two legends (also awaiting retirement) and a bunch of inexperienced junior specialists holding the fort. Some folks think that this was caused by the release of two new hospital sites which led toanother few rounds of specialists resigning. But that view is simplistic.The enemy is always within – if you cannot face internal problems squarely and fix them, people will always leave in droves, whether there are new hospitals or not. In Philippines,few private hospitals have been built in the last twenty years, but doctors still leave – they become nurses (no kidding) and go to America.

Remember – the really bad guy in the latest Star Trek movie is not the terrorist Khan, but the Starfleet General…..chew on that…..

Quote 7
Master 1987: “A GP is not a dropout of the system meant to train specialists… there should be… a proper register for general practitioners”; “If he opts to be a family physician, that should also be recognised as a specialist post”. 
Hobbit 2000: Again, a complete failure after 12 long years.GP/Family Medicine as a specialty is as distant as Siberia. We talk of putting the family doctor as the centre of healthcare, but let us look at the starkfacts: Hong Kong, Australia etc recognises Family Medicine as a specialty, wedon’t. After 5 – 6 years of having M.Med (Family Medicine) exams in Singapore, we still don’t have a Consultant-Grade Family Medicine doctor in the polyclinics.It must be the only MMed degree in Singapore without a consultant. There is still no department of Family Medicine, although half of each cohort of undergraduates ends up as GPs. In the meantime, we have bought a Gamma Knife,some Excimer lasers, expanded our Singapore National Eye Centre; we are in the midst of building a new National Heart Centre and last I heard, thinking of buying a PET scan. The MMed (Family Medicine) is possibly the most economically irrelevant NUS MMed degree today. It is irrelevant because the government wants Family Medicine to be “affordable”. But what can Family Medicine in Singapore afford today, I ask?

Hobbit 2013: The GDFM and MMed (Family Medicine) is having more recognition and pick-up among young doctors now. Many of them appreciate the structured training available, and of course, most healthcare groups offer abetter salary for those with these qualifications than a fresh MBBS, However,when the upcoming LKC school was perceived to be a school to rain GPs, there was a mini-stir with everyone quickly disclaiming that it trains doctors as usual,with a more integrated primary care. I firmly believe that a strong primary healthcare is essential to a healthy nation, and provides the foundation for a good healthcare system. Now if only everyone believes too, and make it happen.The jury is also still out on the new FMC model of practice introduced by MOH. It can either help Family Medicine/GP in a big way or drive another nail into the FM/GP coffin.The devil is in the details.

Quote 8
Master 1987: “Who should government subsidise and who should government not subsidise?” 
Hobbit 2000: The multi-million dollar question is still unanswered after 13 years. It is a question that no one with only a fleeting interest in healthcare would want to answer. And the sad point is, it will be so if health is in fact run by fleeting stakeholders. Why risk unpopularity during my brief watch in health, the street-wise may ask? And so, in the absence of a means test, or rather the absence of a will to have a means test, our frontline doctors and nurses in the public health care system continue toslog through armies of patients in the polyclinics, many who should not bethere, subsidised specialist outpatient clinics, and subsidised wards. Theflesh is unwilling, the will is also weak.

Hobbit 2013: There is still no good answer. No perfect healthcare system exists, anywhere in the world. Obamacare has its supporters and haters. Thereis a price for everything; “free” healthcare comes at the price of higher taxes. If more goes into healthcare, something else has to go. The nation as awhole, and maybe doctors specifically, need to be more informed, educated about national budgets; and maybe more importantly, the government has to listen. If doctors who care are asked to shut up, how can there be change ? Does ithelp to employ overseas foreign experts to analyse our problems, where those in the system are trying to identify what is wrong? ? Inputfrom local doctors should be respected and taken into account; after all, we are the ones on the ground.  Being short,I’m actually nearer the ground than Wizards and Orcs, but does anyone listen?? But this hobbit is never giving up in commentaries, because “even the smallest person can change the course of the future.”

The current total spending on healthcare at 4% GDP (with government spending accounting for 1/3 of healthcare expenditure)  is clearly unsustainable.The government’s announcement to up its share of total healthcare spending is certainly to be welcomed. The question is where should this money go to? Should we spend more on developing hospital IT systems that have many nice to have features or should we spend more onlong-term care? Our choices reflect our values.

Quote 9
Master 1987: “… come 1999, the Singapore doctor would have benefited from a planned, rational schedule of training and apprenticeship – from housemanship days till he becomes a specialist on the specialist register”.
Hobbit 2000: Certainly, we have more exams to take, but do we have a better training programme? How could it be, when we leave it to altruism to keep good senior staff? People make the difference. When the last of the great teachers retire, what good is a programme on a piece of paper? The last of the Mohicans, like the Master himself, is already in their fifties. In 10 years time, there will be no such icons left. Because we reward by the bottom-line, we will perish likewise, by the bottom-line. How can basic trainees have good training, when we continually expand our services but depend on the same number of 1200 bonded Housemen and Medical Officers? This number has not changed for the last 10 years or more. The population has grown. Newand bigger hospitals have been built and new subspecialties created. Surely the average trainee will now have less time for training and research, since the number of junior medical staff has not changed in the past 10 years and this same number must provide a greater volume of service. Maybe that is why the few Housemen quit in the last few years. You don’t need a Master in Public Administration to figure this out.

Hobbit 2013: 26 years later, we have a better training system- on paper, but only time will tell. In the AST system, registrars have a clear exit path,taking their own relevant papers/clinical exams in due course, etc. However, planning rotations may be haphazard, as each registrar has their preference inplace to train, and of course, the department must have the training post available. In addition, training-job applications may be department-based instead of national based. This means, that a suitable candidate may apply fora job at several institutions sequentially before getting one, resulting in a “delay” in training and subsequent promotions. In the Residency program, the strength of it is that the entire 4 to 6 years (depending on which subspeciality) is planned out from start, and each trainee will have a very structured and standard exposure to various sub-spec deemed relevant and necessary for his own speciality. The currently problems are the balancing of service needs versus training needs, and hospitals are filling in the gaps bygetting the AST registrars to take up the slack, and employing NTS (non-traditional source) MOs. Some disciplines allow M5s to enter into training, ie. Housemanship is counted as a training year. There are some who feel uneasy about it, both trainers and trainees, especially for the surgical fields. We shall know in another 2 years, if a resident is the equal of aAST-trained registrar. And by that time, it may be too late. The recent paper published in the Annals of Medicine about decrease in operative time of residentsversus trainees is certainly a cause for concern.[2]

Quote 10
The Master’s closing remarks in 1987 then were “That isthe challenge ahead. We have 12 years to achieve. I am optimistic we can”.
Hobbit 2000: Where are we and when are we going? Vision 99 was written when Chee Yam Cheng was in his late thirties. It is now 2000. I am afraid he was more wrong than right. I do not share the same optimism about the next 13 years that he had 13 years ago about the next 12. Perhaps I know too much. Perhaps I am a product of the cynical late nineties, when I saw before my eyes the unravelling of the medical profession in positions of influence and power. Vision 99 remains just a vision even in 2000.

Summary 2013 These past 2 years have been a demoralizing periodfor the medical profession, with public cases of overcharging, outrage of modesty, tax evasions;and of course, the recent very public clash of SMA and SMC. Like Frodo, this hobbit is getting very tired, the burden is getting very very heavy. I probably need my own Sam to help take up the burden for a while.

Maybe Vision 99 looks even more distant in 2013 than it was 2000.

However, there is still hope. We must remember those doctors who continue to do good work, the healers,the teachers, the leaders. This year, as we remember those who have fallen inthe line of duty battling Sars, let us all come together and remember what matters most in our profession- our patients.

[1]     A monster with a huge mouth that lived in the dessert of Tatoonie whichappeared in Episode 6 that just about swallowed everything.

Moody May Ramblings

May 7, 2013 at 6:47pm

May is usually a very complicated month in a doctor’s life.This is mainly due to the fact that in May, we have a bunch of houseman and medical officers starting work in our public hospitals. It is even more complicated now because unlike the days of yore, these young folks expect tohave a life, which as we old coots all know, is a completely unrealistic and unreasonable expectation in medicine. Medicine cannot co-exist with life.Junior doctors have no life, hence the Hippocratic aphorism of “ars longa, vitabrevis” which literally means in Latin if your butt is long, wear briefs.*

But even more disturbing that the issue of new housemen and medical officers is the twin plague of mid-year exams and Mother’s Day in May.The juxtaposition of these two events must be a cruel joke designed by the most diabolical mind of our times. First, we have Mother’s Day, where fathers and children are coerced by TV, radio, newspapers and Ironman to perform acts of kindness to mothers. These acts of kindness include queuing and paying an arm and a leg for bad food at restaurants offering rip-off set menus and buying gifts that contribute to global warming. That’s the easy part. While fathers are paying and children are trying to be kind – remember, the mid-year exams are just around the corner – that means Tiger mums are now at their worst trying to whip their kids into shape through all manner of torture and threats– which include denial of access to the really important things in life: –sleep, the toilet and access to any gadget with a name that is prefixed by the letter “i”. All this while, the father is caught in the middle of the wife/mother going berserk and kids taking cover in trenches and guess what, he still has to organise, plan and pay for an expensive and tasteless Mother’s Day meal – and also convince the kids that they still need to be nice to mum.

Honestly, on days like this, don’t you just wish instead of staying at home and hanging around your wife and kids, you were in the hospital looking at a patient’s large, smelly, festering wound? So May is a tough month by any measure. But by the looks of things, this year’s May will be even worse.

For one, we are in the middle of a Mother of All Dengue Outbreaks, which in all likelihood will peak around Mother’s Day. With more than 500 cases a week being reported (and many more probably unreported), this year’s dengue epidemic will be BIG. The control of dengue lies in prevention and not us doctors. But it does mean more business for doctors and hospitals. Recently, I came across a private hospital bill that stated the charges for transfusing a pint of platelet was about a thousand bucks! Not bad business for giving a product that is supposed to be free in this country, other than processing charges by HSA. I wonder how much HSA charges for processing a pint of platelet? It must be a fraction of a thousand dollars?

Recently, there was this bizarre newspaper report of a guy going around polyclinics sedating patients who were waiting to see their doctors and then stealing stuff from them. This Hobbit thinks all this is frankly unnecessary. Come on, there are some poor fellows waiting so long to see their doctors in the polyclinics they are already in rigor mortis! They don’t need any sedation – you can just walk up and take whatever you want from them.

In the first week of May, some of us may have received an important letter from MOH. The letter states that by the powers vested in themfrom Section 12 of the Private Hospitals and Medical Clinics (PHMC) Act, if you happen to perform treadmill tests in your clinic, you are to submit 6 months’worth of patients (of those who had undergone treadmill tests between 1 July to31 Dec 2012) data to them so that they can select patient records for audit.This data include not just simple biodata but stuff like reasons for ordering treadmill as well.

The first thing you should note is that when a section of any Act is quoted, you have to obey. This is the law and no one is in any mood for bargaining. If you happen to be a busy cardiologist and you order two to four treadmills a day, it may well mean that 500 to 1000 of your patients have undergone treadmills in the stated 6-month period. It also means that you, or your clinic assistants/nurses now have to comb through these records (assuming you even know who these patients are) and extract the required information from each and every relevant patient record. And if you think this sounds like a nightmare, para. 3 of the letter states “For a start, we would appreciate it ifthe following information could be forwarded to us by 31 May 2013”.  This is ONLY “for a start”, bro. It means they may well ask for more information which you, the doctor, HAS to comply under the provisions of Section 12 of the PHMC Act.

This Hobbit doesn’t offer treadmills in his clinic. Whew. For the rest of you who do, all this Hobbit can offer is to quote what his Orthopaedic Professor is found so oft to say – “Good luck, chum”.

But even as we have to comply with the law, one can still question aloud why treadmills are chosen for audits? One usually audits procedures and investigations that are expensive, open to abuse or high-risk. And the treadmill test does not fall under any of these considerations. And even if one orders the unnecessary treadmill once in a while, that could easily be accounted for by the fact that the doctor is erring on the side of caution. Generally speaking, a doctor or a patient (or anyone) would like to err on the side of caution when it comes to the subject of heart attacks.

There are better things to do than auditing treadmills. “For a start” (yes, this Hobbit is a fast learner), one can audit all elective PTCAs that involve putting in 4 or more stents (i.e. what cardiologist call “full metal jackets”). Now, wouldn’t that be more interesting than treadmills?

Finally, for moody May, there is a very interesting letter in the latest issue of the Annals of Medicine, published by the Academy of Medicine Singapore. This letter is titled “Will the Local ACGME-trained Surgeon be Adequately Prepared? An Estimate of the Impact of Duty Hour Restrictions on Operative Experience” (April 2013, Vol 42 No. 4, pages 203 to 206). This letter compared the number of operative hours a first year General Surgery registrar under the old AST system will get compared to that of a 4th year resident that would have met the ACGME (new American-style residency system) requirements. (Note: a first year registrar is roughly equivalent to that of aYear 4 resident in terms of experience and training).

The results were, to put it mildly, disturbing. The letter studied three registrars’ training records and concluded that had these three registrars been trained under the new ACGME system, they would have experienced 12% to 22% less operative time for that year. If you think this sounds OK, here comes the sucker punch – registrars under the old AST system go through FOUR years of being registrar and TWO years as MO/BST – a total of SIX years. The ACGME resident only goes through FOUR years of training in TOTAL: two years rotating through various disciplines like a BST, and TWO years “advanced training” (similar to a registrar) instead of FOUR.

According to this Hobbit’s very rough ball-park estimates, ACGME residents may only undergo 40% of what the old ASTs went through in terms of operative time before they are signed up as Specialist General Surgeons by our Special Accreditation Board (SAB).

The letter’s authors opined, “While we fully acknowledged that the numbers presented here are but rough and somewhat simplified estimations, the fact that there will be a significant and substantial change in the amount of operative experience obtained by the products of the ACGME system is indisputable”.

The authors concluded that “while the new ACGME-accredited residency programme is an attempt to innovate the national specialist training landscape, the results presented here show that there will be an inevitable decrease in clinical and operative exposure, brought upon by the inherent reduction in the duration of the training programme and further exacerbated by restrictions placed on duty hours…. and the question of whether or not “specialist” graduates of this system will be adequately prepared for the clinical responsibilities of a full-fledged practitioner……must receive serious consideration in order to ensure an adequately trained and adequately prepared healthcare force for the challenges ahead”. Well said.

This Hobbit takes his hat off to this letter’s authors fortheir courage in submitting the letter to the Annals and also to the people who decided to publish this for public record. Some people will get very defensive and upset about this, but that is to be expected.  Veritas odium parit.**

*Actually the phrase means the art is long, but life is short

** Truth begets hatred

10 Years Later*

April 22, 2013 at 1:53am

The heat of the gown that boiled off a portion of your spirit with every step,

That sickly smell of wet ash that reeked from the masks,

And the haunting cadence of laboured breathing interspersed with muffled speech,

As you teetered somewhere along fear and hypoxia,

And vacillated between sprints of survival and spent stupor,

Since seared into every sulcus and fissure of your brain permanently.

There were no blows to parry, no bullets to dodge,

Much less an enemy to capture or slay.

It was a war of attrition as we clung to our calling,

And also to our caps, goggles and masks,

In silent desperation; amid the sick and the fallen,

We who remained were just thankful to have lived yet another day.

There are wounds that heal and wounds that scar,

And then there are those demons that visit you on nights so dark,

There are no shadows and no screams.

Memories laid bare, still raw and wrenching,

They bleed every vessel and rape every nerve,

Just as they always do, year after year.

*in memory of Alex Chao, who died 10 years ago this day

10th Anniversary of SARS, 10 Years of Suffering Since

March 14, 2013 at 12:41pm

Ten years ago this month, SARS came to Singapore.  For those of us who lived through SARS as a frontline healthcare worker, SARS changed our lives forever, from the way we treated our patients, to the manner in which we saw ourselves. It was a defining moment; it cleaved the ornamental from the essential as many of us found ourselves locked in a daily and deadly gamble of life and death with the virus. Some of us lost.

 

Never before were healthcare professionals, and especially doctors and nurses brought so low. And never before did the professionalism and dedication of healthcare workers shine so bright.

 

The medical profession did not fail this nation. We stuck to our posts, from the SARS-struck tertiary hospitals such as TTSH and SGH to the GP clinic round the corner of the street, doctors did not leave their posts. As the battle of SARS was slowly won in the weeks after March 2003, doctors and other healthcare workers were lauded like never before.

 

If the arrival of SARS brought us to our knees, then the departure of SARS also raised us up like never before. Suddenly, doctors and nurses became community heroes. If there ever were a great time to be a doctor, it would be late 2003 and early 2004. We could do no wrong. Even my mother-in-law thought I was a great guy.

 

But what happened since then till now? I would say I think there are forces out there that want to make lives more and more difficult for doctors. They have forgotten that by far and large, doctors are decent  (forget heroic) folks who want to earn a living trying to help patients. I suspect some people think doctors are by default crooks and everyone is a crook until proven otherwise. They want to clamp down on us, regulate us and contain us like the SARS virus.

 

Let’s take a walk down memory lane on what has happened in the last 9 years or so since SARS and remember some of things that have been foisted on the medical profession. This hobbit is getting old and senile and he can only remember the ten items mentioned here. There are probably more.

 

Removal of GOF (2007)

They branded SMA a “trade association” and made the Guideline of Fees (GOF) illegal. The GOF had to be withdrawn and we lost our ability to advise doctors on how to charge. The result: all the overcharging issues we see now rearing its ugly head.

 

Administrative Guidelines on the Prescribing of Benzodiazepine and Other Hypnotics (2008)

Other than relevant specialists, every doctor can only prescribe a grand cumulative total of 8 weeks of benzodiazepines to patients, regardless of how long the patient has been seeing you. For a GP patient seeing you more than 10 to 20 years, this is almost impossible to follow and doing no one any favours (other than perhaps psychiatrists)

 

Big Brother Attempted To Get Our Psychiatric History (2011)

Remember the infamous “Application for Renewal of Practising Certificate” letter from SMC in Sep 2011? They asked us to declare if we had been treated or were undergoing psychiatric treatment? Unlike the Population White Paper, this is not a typo. The intent was clear. Luckily it was fixed just in time. But it was a very close call

 

Re-trial of SMC cases with no reasons given

And then in the last few years, there were several cases that went before SMC in which the doctors were found innocent. But the cases were re-opened and then the doctors were subsequently found guilty. No reasons were given as to why the cases were re-opened. The law provides for this re-opening and re-trial of cases but no one is the wiser why they happened.

 

Lawyers and Retired Judges on Disciplinary Tribunals (2009 and 2013)

Remember what was the main reason for having senior lawyers and retired judges when this move was introduced in 2009? A letter from DMS on 13 July 2009 stated that

 

“the  main reason for needing a chairman who is legally trained is for cases where “a prominent or senior medical practitioner, or someone known to the entire Council is the subject of the disciplinary proceeding”. DMS further clarified in his letter to us that having lawyers or judges chair the Disciplinary Tribunal adds value by “avoiding potential conflicts in the medical community in high profile cases”. Now fast forward to 9 Jan 2013 when SMC’s letter was published in The Straits Times Forum.

 

“SMC’s cases reported in the media recently were dealt with under the old Medical Registration Act (MRA) as the complaints were made before the amendments came into force on 1 December 2010. SMC is now no longer bound by law to appoint its Council members to the Disciplinary Tribunal. Experienced doctors and lawyers can now be appointed to the Disciplinary Tribunal as members or as the chair. As SMC continues to push for such changes, we hope that doctors will support this in the public interest.”

 

Interesting to see how the rationale has changed? Stay tuned for more and more lawyers in the work of the SMC. It’s like some people are very happy giving more and more work to lawyers….

 

SMC Investigators have more liberties than the police (2010)

In the last amendment to the Medical Registration Act effective 201, Section 60A was added. Please read it if you have the time, its on the internet.

 

SMC can appoint investigators. These investigators can enter your clinic during regular business hours, search your clinic and seize practically any thing from your clinic without a search warrant. Even the police needs a search warrant to search your house. Personally speaking, whoever thought of this is NOT my friend. It makes George Orwell’s 1984 look like Mickey Mouse Club.

 

Residency and Screwing BSTs and ASTs (2009)

The change from our traditional BST and AST system to the American-based Residency system sent our entire medical specialty training into convulsions. Enough said on this already.

 

Family Physician Register  (2012)

The setting up of the FP Register should have been a happy thing. But the requirement for an element of “currency of practice” meant that many well-trained GPs who did not work in GP clinics or polyclinics could not qualify to be on the FP Register. This made the whole FP register thing unnecessarily controversial. And the requirement to remove the word “family” from GP clinic signboards and clinic names if the clinic did not have a FP practicing there was downright high-handed.

 

Unsatisfactory Guidelines Regulating Aesthetic Practice (2008-2012)

The High Court in the ruling of Low Chai Ling vs SMC case already said as much in their judgment. No need to elaborate.

 

Doctors banned from practicing any form of acupuncture other than “needle” form, i.e. moxibustion, cupping etc. (2012)

This only affects a small group of doctors but it underscores the fact that SMC will intrude into those parts of lives that don’t really fall under SMC’s expertise. Maybe some day they will tell us what food to eat and whether we can go to casinos or not.

 

Akan Datang (2013-??)

Heard from the rumour mill – Licensing Exam? Revamping of CME framework to include log books and maintenance of competency? Revamping of SMC Ethical Code and Guidelines? Who knows what stuff they will think of next?

 

I thought doctors did some good during SARS. If that is so, why did we deserve all this in the ten years since? I don’t know about you, but I feel increasingly oppressed as a doctor since 2004.

2103 Hobbit Movie Awards

February 27, 2013 at 3:40pm

Well, it’s the season of movie awards again and the Oscars have just been given out. No surprises other than the fact that Michelle Obama made a virtual appearance to give out the Best Motion Picture award to Argo.

 

Well, it’s been quite a few years since this hobbit has given out any movie awards. And if a movie about a movie that is used as a decoy to rescue Ben Affleck’s career from J. Lo and Pearl Harbour can win a best movie award, then its certainly about time this hobbit have out a few awards of his own again.

 

Best Adult Movie:

Ted

This runaway hit is about a foul mouth teddy bear that called nursing “low-skilled”. Stars Mark Walberg as Ted’s owner who had to do heck of a lot of damage control. Also has a pricelessly funny song about screwing thunder, which admittedly in the local context, can mean a lot of things…

 

No Backbone Movie/Worst Medical Evidence Award:

Dark Knight Rises

The masked crusader shows how one can reduce a spondylolisthesis spontaneously without spinal surgery. The auto-reduction obviously affected his great powers of deduction adversely and as a result, the world’s greatest detective only figures out who is the villain in the last 10 minutes of this long movie, and only after he gets stabbed by her.….?

 

Surprise Hit of the Year:

007: Skyfall

Resulting from the glitch of a obsolete IT system (No, we are NOT talking about town council here), all orc-healers are given a one-year reprieve from continuing education requirements. Literally drop down from the sky-kind of reprieve. Licensed to “ziam”….

 

Best Action Choreography:

Cold War

This movie is about two professional boards engaged in a cold war. On one side is the Orc-healers Conclave pitched against the Evocation Druid Council on another side. The Conclave has banned orcs who are dual-accredited (i.e orcs who are also trained as druids) from casting fireballs. The chief priest has decreed that orc healers are only limited to use the “needle” kind of evocation spell-casting, even though strictly speaking, evocation spell casting comes under the regulation of Evocation Druid Council. All these lines of regulation are clearly demarcated under the various ordinances of Middle-Earth. After all, the Evocation Druid Council is not a subsidiary of the Conclave, do how can it tell one how to practice evocation? The movie ends in one big shootout.

 

Worst Sci-fi Movie

Total Recall

A movie set in the near future where due to the introduction of the Family Orc-Healers Register, all clinic signboards that have the word “family” have to be recalled if the clinic does not have a registered family orc-healer practicing there.

 

Blockbuster of the Year:

The Avengers

The top-grosser of the year. This is about a secret small group of orcs and eleves who have been tasked to review the Orc-healer Conclave after widespread complaints about and dissatisfaction with the Conclave. Unfortunately, these are masked avengers and despite repeated questioning, the public and the profession do not know who is on this committee. We wait with bated breath as to when this review committee will be revealed. What can be engrossing than a top-secret review committee?

 

Most Expensive Local Movie:

Ah Boys to Men

This is a movie about growing up. A bunch of graduate medical students go through a very expensive foreign-brand name graduate medical school based locally only to discover the degree is not recognized in the lands it came from. On top of that, it is rumoured that the Chief Priest wants to hantam them with a licensing exam….They boys loose their innocence and grow up real fast…

 

Sequel of the Year:

The Expendables 2

This is a sequel to Expendables 1, where regulation was rolled out on medical devices that were so stringent many product importers pulled the plug on many medical expendables. Expendables 2 is a happier movie with the authorities back-tracking and loosening up on these requirements for low risk expendables. Let’s face it, Middle-earth is such a small market that it is expendable to the MNCs….

 

Worst Martial Arts Movie:

Tai Chi Zero

This is about the regulatory branch of the Ministry of Healing that regularly referred cases to the Orc-Healers Conclave. Unfortunately, Conclave judgments on several of these referred cases were subsequently overturned. Want to tai-chi but in the end backfire. Sigh…

 

Best Actress:

A Simple Life (Tao Jie)

Stars Deannie Yip as an old retired ma-chieh (domestic maid from China) suffering from dementia. Their kind bosses want to put her in a nursing home but they cannot find one because everybody doesn’t want a nursing home in their neighbourhood. A movie about the ugly phenomenon of Nimby (Not in my neighbourhood) and the pains of ageing. A stellar performance by Ms Yip and Andy Lau as her employer.

 

Longest movie award:

The Lady (not to be mistaken for Iron Lady)

About a female surgeon charged with overcharging. It’s a very long movie and the ending is not known. This is not to be mistaken for another movie called “Iron Lady” is about a paediatrician running a large healthcare cluster with an iron fist.

 

Flop of the Year:

The Three Stooges

A black comedy about three orc-healers who sat on a disciplinary committee. Their work was considered to be a tragic and complete waste of time when their Elven legal procurators drafted charges that were deemed to be embarrassing.

 

Best Horror/Action Flick:

Underworld: Awakening

This action movie is about the underworld of werewolves and vampires that have awoken to the fact that they are being continuing screwed by the evil wizard holed up in an ivory building. They hit back by casting 10,000 votes cast for no-one in a recent election. The underworld has awoken.

 

Best Comedy:

The Dictator

This is about a dictator writing a five-page letter to his subjects. It’s quite a funny letter because it mentions quite a few things that are laughable. Unfortunately not many read it and even fewer understood the rambling letter. Sacha Baron Cohen rocks in this one.

 

Best Actor Award:

The Grandmaster

This stars Tony Leung as the Grandmaster/Chief Priest. Tony develops a new kind of management art (not martial arts) which ensures a long stay (practically immortality) in a high office. This management art includes screwing up so badly that no one wants to take over from you and hence you get to stay forever in the job. The Grandmaster will in all likelihood last far longer that what it takes to make a Wong Kar Wai movie.

 

Best Disaster Movie:

The Hunger Games

Movie about how an up-market restaurant in a five-star hotel caused food poisoning for many customers resulting in the restaurants’ closure for a period. A lot of hunger here from the BO and vomiting.

 

Worst Disaster Movie:

MIB3

MIB stands for Mistaken Infant Botch-up and 3 is the number of staff that were disciplined in this incident in which babies were mixed up and a newborn was given to the wrong parents in Middle-earth. This is not to be mistaken for another movie Taken 2, which is stars Liam Neeson as the surgeon who “chopes” the last clinic space put on sale in Mount Expensive Old Hospital.

 

Best Animation

Ice Age: Continental Drift

A nice cartoon movie about a bunch of health workers caught in the formation of regional health care cluster when their old regional hospital was cut adrift when they separated from the huge tertiary hospital cluster

 

 

Worst Screenplay Award.

The Perks of Being a Wallflower

A movie about how a nationwide system for the GPs of Middle-Earth took many years to develop. In the end, there were few users of the system because it was too expensive to maintain and too complex to use. The user-interface was impossible to use and it truly deserves this worst screenplay award

 

Most Violent Movie Award:

Dredd

This is about how  Judge Dredd chairs the Disciplinary Tribunal of the orc-healers conclave. He is judge, jury and executioner. Just about blows up everything in sight. Not for the faint hearted.

 

Movie of the Year:

The Hobbit

Long movie about a short guy in Middle-Earth that seemed to court trouble wherever his hairy feet went. It is rumoured that the Chief Priest wants him – dead or alive. L

Chief Priest’s Epistle to the Orc-Clerics (Abridged and with Nonsensical Explanatory Notes)

January 18, 2013 at 12:28pm

Dear Orc-clerics of Middle-Earth

 

I have heard your recent grumblings all over the realms of Middle-Earth about how the Conclave of the Orc-Clerics has supposedly mishandled the Inquisition processes.

 

First of all,  the Conclave is subject to the ordinances of Middle-Earth and they were put in place by the various Elven legal procurators of old. Changing ordinances takes a heck of a long time. I am trying to change them (explanatory note: by allowing in even more elven legal procurators so that you buggers can’t squirm you way out of any inquisition)

 

The various inquisition panels are run independently of the Conclave. I am but the Chief Priest. I do not sit on any of these panels. (explanatory note: see how impartial and detached I am?). In addition, the Temple that pays me also has no hand in the panels as well (explanatory note: hand does not include fangs, feet and forked tongue).

 

Over the past several years, I have been trying very hard to change the ordinances to allow for a speedier inquisition process. These exclude using external inquisitors that are not members of the Conclave and bringing in learned Elves to even chair the panels (explanatory note: Elves know more about royally screwing orcs than we orcs). I have also put in place changes that allow junior inquisition panels to impose major torture methods that were allowed previously only for the senior panels. But it will take time for these junior inquisitors to be trained for these tasks.

 

The bloody nuisance orc-cleric association opposed the move to have increased elven input, especially getting an elf to chair the panels (explanatory note: But I still prevailed. I am the Chief Priest!).

 

Some wise guy from the association actually said we should learn from other realms. The other realms also allow elves, gnomes and halflings to chair their inquisition panels. (explanatory note: So he’s actually contradicting his own association. Ha!)

 

Now I will come to these specific inquisitions. Basically we used the wrong rack to punish them and the Elven Elders have said these orc-clerics should be set free. This will not happen again once I get the elves to chair these panels. These are exceptions. Actually we have done well so far and I will bury you with statistics to prove so. The Conclave remains an effective Machinery of Terror and Oppression.

 

You should perish the thought about getting more or all (Sauron forbid!) Conclave Members to be voted members. Having all voted members may result in less terror and oppression, which is not good. But you must all still vote. (explanatory note: if you cast blank vote(s) again, I will be very upset). In fact, consider it a privilege that all Conclave Members are still orc-clerics. Elsewhere, it is not so (explanatory note: Am I not benevolent?)

 

Running the conclave is bloody expensive. We actually receive subsidies from the Masters of Middle-earth, you cheapskates.

 

I welcome your input which are made in good faith and for betterment (explanatory note: You must first love me as Chief Priest – the content of your feedback is secondary, and I only offer you this olive branch under duress, you bunch of ingrates!).

 

I have also appointed a reveal committee to sort things out. (explanatory note: I have stuffed this committee with the usual suspects. Nothing will be revealed. Hence I cannot reveal to you who sits on the reveal committee)

 

Yours truly,

 

Chief Priest

Orc-Cleric Conclave

Middle-Earth

Context and Finesse

January 15, 2013 at 11:51am

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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