These are exciting times in the local healthcare fraternity. We are not talking about groundbreaking research being performed by A*STAR whales or the renovations that are underway in the Most Expensive Old Hospital so that doctors can admit their patients to the Most Expensive New Hospital.

We are talking about the reproductive process. At the Singapore Gonad, sorry, I mean, General Hospital no less. We have ex-senior civil servants purported having sex in a carpark somewhere on the hospital campus. Now this is a true mystery to me. The Hospital is a 24-7 place where there are busy people working on shifts and family members and friends visiting patients round the clock. And the car-parks are reasonably well-lit, even for the multi-storey carpark located in the equivalent of Siberia within the campus. How do you have coitus discretus in a hospital carpark? Unless it’s the one in the mortuary…..or the one across the street behind the big white building. Some of those guys working in that building are so brain dead that they wouldn’t notice two humpback whales humping in the carpark if they walked past them. Your only worry is if a helicopter suddenly lands next to you.

And there is also this mention about a carpark near a women and children hospital. You may want to deliver your baby there, but seriously, you don’t need to “do the do” near it. Personally thinking, I think the carpark at IMH has the best ambience. But that’s the psychotic side of me speaking.

You would have noticed that the carparks at private hospital have been ignored by the SP and chip folks. That’s because at the rates the private hospitals are charging, you might as well check into a room in a six-star hotel.

So much for the mucus stuff. Now for the serious.The SMC elections are underway again. Please remember to vote.

Anyway, I know a chap who is so disillusioned with the whole thing he voted “00” three times. I am more optimistic. I voted for the person I didn’t know so that should I ever need to appear before SMC,  at least there is one SMC doctor who can chair the disciplinary tribunal instead of getting a senior lawyer or retired judge. Then they can’t all claim they know this Hobbit and stuff me with a lawyer chairperson.

Speaking of SMC, it’s has been in the news recently. And if I may say, for the wrong reasons. Some of its work has been described as “legally embarrassing”. As a doctor, this hobbit has absolutely no clue what is “legally embarrassing”. But I can give examples of what I think are “medically embarrassing” situations:

• You prescribe Propecia to a bald monk
• When a female patient complains of urinary urgency, you attempt a per rectal prostate examination on her
• You certify someone as dead and he/she comes back to life

In most medically embarrassing cases, I think the doctor will waive their fees or at least offer a big discount. I am not sure what applies in “legally embarrassing” situations. Maybe the lawyers can advise us.

Anyway, the SMC just issued a press release stating that the two cases that had been cited as controversial were processed under the old Medical Regsistration Act (MRA) and new cases will come under the new and better MRA that was amended recently. I have read through the press release and this Hobbit is still unsure how these new changes in the amended MRA will prevent similarly legally embarrassing situations from happening again. They said having a retired judge or senior lawyer on the Disciplinary Tribunal (DT) will improve things. Maybe they will. But how are these learned ladies and gentlemen going to prevent legally embarrassing charges from being drafted? Are they supposed to help in the drafting of charges and also to judge the case as well? I hope not.

I am no great fan of aesthetic medicine. Having said that, the SMC action to apply to the High Court to set aside the Disciplinary Committees’ previous decisions on two doctors practicing aesthetic medicine is to be welcomed. The next question that should be asked is who should pay for the legal costs of all parties of what are now legally embarrassing efforts? It would seem grossly unfair if the two doctors have to pay. If SMC pays, it means all registered medical practitioners end up paying and perhaps increase in subscriptions if SMC cannot balance its books. Guess who gains from these legally embarrassing cases?

Finally, the SMC press release stated a Review Committee will be formed. It will be chaired by a senior doctor and assisted by a senior legal practitioner and will comprise senior doctors and other legal practitioners. That’s good news. This hobbit has a few serious suggestions to make:

• The doctors, especially the Chairman on this Committee should be doctors in active practice, in touch with what is happening, especially in the private sector, since many SMC cases involve the private sector.
• The doctors in this Committee should not be current or recent SMC Presidents, Registrars, Secretaries, members or even SMC lawyers. You can’t review yourself objectively. They should be at best resource persons
• This Committee should present its findings and recommendations publicly
• The ultimate decision to accept or reject the Committee’s recommendations should rest with the Minister for Health and not anyone now in SMC.
• All new SMC members must undergo substantial training in ethical principles of medicine and legal processes. All our trainees and residents take a two day ethics course organised by the SMA before they can exit. How many days of training do these new SMC members get?
• Maybe we should get the Legal Service to permanently second a legal officer with DPP experience to help SMC draft charges and SMC can stop relying on law firms to do so. The legal officer is probably more experienced in drafting charges and cheaper.

As readers of this column will know, this Hobbit rarely if ever says anything serious. But things in SMC are really at the cross-roads now and even this super –idle hobbit feels compelled to make these serious suggestions.

Finally, a word on residency. All of you know how this Hobbit feels about the residency that we have adopted from the American system. To underscore how hugely complex the American residency is, the latest Nobel Laureate in Economics actually wrote a landmark 49-page paper on how residency applicants are matched with training positions in the USA: “The Redesign of the Matching Market for American Physicians: Some Engineering Aspects of Economic Design” by Alvin E. Roth (one of two of this year’s Nobel Laureate for Economics) and Elliott Peranson (American Economic Review, Vol 89 (1999) pp 748-780). It is a fascinating read on how complex things can be in America. I think I will just settle for the good old days when Chee Yam Cheng and his PA settled all HO and MO postings in a small corner of MOH. Maybe we should nominate him for Nobel Prize for Economics and Medicine next year. Simplicity and elegance:- We don’t see that often nowadays.

After the last two posts on Facebook which were kind of heavy going, it’s time to revert to something light and cheery again. This hobbit doesn’t have much of a choice. Peter Jackson has been reported to have chopped up the movie “The Hobbit” into only three parts. But the evil wizard has been rumoured to have asked the orcs working in the ivory building up the road to chop up this hobbit into 19 transverse sections. Gulp. The Hobbit is very scared.

The recent report about the several Korean plastic surgeons coming to town to “see” or “interview” prospective patients is kind of disturbing. It is disturbing for a variety of reasons:

• Very soon, all our girls will look exactly like each other or like one of four famous Korean starlets now acting simultaneously in 2,614 serials with essentially the same plot.
• The patients have probably done their sums – paying for a return airticket to Seoul and getting a nose job is still cheaper than going under the knife in Singapore.
• People actually don’t mind getting plastic surgery from a country that gave the world PSY and the “Gangnam Style”. Good luck

In deference to all those guys on Nexium, Dormicum and Prozac up the road, I promise this column will have no adverse mention about the residency. This hobbit does not wish any old chap to kick the bucket with the cause of death stated as “Reading SMA Hobbit posting on FB”. So all you guys up the road, please relax – You can again go back to your usual state of denial and brainstem existence as you try to hatch your next evil plan to make lives more miserable for doctors.

Talent is everything and aside from the quality of residents, the quality of the people we choose into medical schools is also equally important.  Once we again, we have reason to believe that the medical school has always gotten the cream of the crop, even better than law schools. This can be seen by the case of the law student purportedly having sex and lavishing expensive gifts on her lecturer in exchange for good grades. It’s a lot simpler in medical school in our time. On the night before the exam, as per the advice of our wise seniors, we sent two female students to a male lecturer residing in the hostel. Don’t get me wrong, it’s not that the lecturer was into threesomes or other kinky stuff. These two girls were just sent there to cry (they are professional grade criers) and inevitably, the soft hearted lecturer would give the two a cryptic tip or two. And these two girls, in the true public spirited and selfless nature that differentiates medicine from the rest, then shared the tip with the other 132 classmates who were mugging away outside the medical library at 11pm in the night.

That’s it, no gifts, no sex and no corruption. Of course, sometimes the tip isn’t accurate or the girls were hard of hearing. “Angle of Louis” became the “Circle of Willis” and a quarter of the class had to take the viva or the re-paper for the 1st Pro. Sigh. In case the CPIB is reading this, let me state clearly that this happened in the very mythical Middle-earth Medical School which has got nothing to do with what’s happening or had happened in Singapore.

I think the main issue with men is that men can’t really think when women are involved. If the world’s greatest detective, aka Batman can’t figure out that Marion Cotillard is the villain until the last 15 minutes of a two and a half hour movie (and only after he was stabbed by her), how can we fault the law lecturer for not doing the right thing under such affection from the female student?

The biggest healthcare news that broke recently is that Singapore is the richest and healthiest country in the world. This is great news for everybody and sort of explains why we just bought those Brompton bikes when our founding father ministers refused to pay hotel laundry charges and washed their own briefs. But this Hobbit thinks we still need to renew this spirit of frugality by telling all senior civil servants and politicians that they cannot claim laundry charges when travelling. They should be issued with disposable briefs – one for each day of travel and an additional one in case of emergencies. This practice should continue until we have firm evidence that:

• Patients in the private sector actually pay less for more without the Guideline of Fees when compared to the time the Guidelines existed (inflation-adjusted)
• Our GDP per capita rises to that of the richest country in the Milky Way, surpassing the planets of Krypton, Alderaan and Vulcan.
• All the management, training and exam design consultants the public sector have hired in the last 10 years actually contributed to better health outcomes for the population in a way that we could not have achieved by ourselves had those guys in the big offices only trusted us and actually gave us the money to do it.
• Our total fertility rate (TFR) for Singaporean humans or wild boars reaches 2.1 (whichever comes first),

That brings us to the issue of assumptions. Everyone works on assumptions because our knowledge is incomplete and imperfect. But we need to revisit them when new information becomes available.

So beware the false prophets that make policy pronouncements about this and that when there is obviously no evidence to substantiate the claims. The profession has experienced a gut-wrenching, blood-draining and spirit-bashing ride in the last few years in terms of professional regulation, licensing and training. And for what? Where is the evidence that all this was necessary and the best option available? For example, are patients better off without the Guideline of Fees? Now according to SMC, there is an “ethical limit” to what doctors can charge and that you can’t charge rich people more because they are rich. But wasn’t the SMA GOF pretty ethical for the 20 years it existed but it was killed out of a legality (otherwise known as the Competition Act)? Law trumps ethics. As far as this hobbit is concerned, the lemon law IS the Competition Act.

Speaking of charging the rich, logic dictates that if you can’t charge the rich more, you can’t charge the poor less either. So like the Sheriff of Nottingham, we may have accidentally outlawed Robin Hood here. This is not a good thing because I know many doctors in private sector practice who have behaved a bit like Robin Hood pretty often. So after killing GOF, Dr Robin Hood may have to die as well.

So here, we see the tragic irony of law versus conscience. The GOF was originally put in place by the SMA after much persuasion by MOH in the eighties. Those old doctors running MOH then knew what they were doing. They left the issue of charging to the conscience of the profession. The SMA’s GOF served the public well for 20 years because the unspoken message of GOF was to behoove doctors to be better beings in the matter of charging and that charging should be guided by a collective conscience as embodied in the SMA. When SMA’s GOF was outlawed, the issue of charging was forcibly removed from the collective conscience of the profession and now we see what we are seeing. It’s difficult to put Humpty Dumpty back together again.

Today I was listening to radio station 93.8’s program “Talkback” which featured doctor’s fees and the subject of overcharging. It is interesting that most lay folks who called up favoured guidelines of some sort. So while we are trying so hard and maybe going around in circles trying to curb overcharging now, can someone just eat humble pie and admit they screwed up and let SMA bring back the GOF? Is pride so important?

Anyway, let’s close off on a lighter note. The London Olympics just ended. One sport that struck me as particularly pertinent for those guys up the road is synchronised swimming. Synchronised swimming has much in common with bureaucracy –

• They don’t listen very much because they spend a lot of time submerged
• They can literally turn their whole beings upside down when submerged
• When they are visible, they all have this plastic smile, glazed look and do the same thing, just like how all bureaucrats give the same answer when they are questioned
• Once in a while, for effect they do a spectacular stunt like throwing someone up to do a somersault
• But seriously, seconds after they all leave the pool, the pool returns to its usual self and whatever the synchronized swimmers did had no lasting impact on the waters, other than dirtying it.

I think all the guys up the road will be very good at synchronized swimming. Other than table tennis, we may yet get another medal from synchronised swimming in the next Olympics.

4 Sep 2012

You know life is getting interesting around here when the new Permanent Secretary for Law doesn’t have a law degree but a MBBS (S’pore). Given the mindset on health regulation in recent times, maybe the next DMS should have a law degree and not a MBBS.

We have been grappling with the business of aesthetics for a long time. Much angst, vexation and even anger has come forth. But after years of mucking around, we are still no nearer a well thought-out solution to this problem than finding a cure for the common cold

But first, let’s remind ourselves of how we doctors got into the realm of aesthetics. Other old coot doctors like this hobbit will remember the days of yore when doctors do not practise aesthetics. This was when locums charged $45 per hour, the polyclinic only had beta-blockers and diuretics and medical officers were paid forty bucks a call. In other words, this was circa 3rd century BC when Hannibal and his barbarians wacked the daylights out of the Romans and middle-aged people had sex (if they had any at all) in a bedroom and not in a Big Splash car-park lot. Hannibal actually looks rather civilized in today’s context – I am told he had fun on a bed. Those were also the days when we had a drive-in cinema where people made out. We have of course progressed a lot since then, we now know the cinema bit is redundant and we only need a car park lot. Which brings us to the point as to why we don’t have enough babies on this island – we don’t have enough car-park lots.

Seriously, other than the odd skin peel that GPs performed on patients, aesthetic practice was rare beyond plastic surgeons and a few dermatologists back then – in the nineties. Generally speaking, the people who did this beauty stuff on homo sapiens were either morticians or beauticians, depending on the GCS score of the person concerned. What happened then? Some beauticians were performing procedures that were way over their heads. I remember there was a case reported in The Straits Times where a beautician injected silicone directly into a lady’s eyelids and nose and caused gross and permanent disfiguration. The beautician was charged under the Medical Registration Act (MRA) for illegal practice of medicine. The fines were rather low then and the MRA was amended sometime after that. This happened about 15 years ago and it was only in the last 10 to 12 years or so did aesthetic practice take off in a big way among doctors.

One can rationalize this trend to a few simple reasons

• Demand for aesthetic practice has always been there and is increasing. The question is who is performing the service? Most people feel that it’s a lot safer to get their fix from a medically trained person than a beautician.
• Other than safety, doctors can avail themselves to drugs that the beautician has no access to
• The high cost of practice, i.e. rent, salaries etc means GPs have to generate more revenue faster than before and it’s a lot easier to do with aesthetics than seeing common ailments

But then problems arise when we then try to fit aesthetic practice into our “normal” framework of medicine. Its like a bad donor-host rejection from a botched transplant job.

Let’s consider what the normal framework of medicine is: –

• There is a patient complaint and a consequent pathology or symptom to address and manage and in most cases, a therapeutic end-point.
• There is evidenced-based body of knowledge that the doctor should rely on whenever practically possible
• There is a social contract between the patient and doctors, such as that described by Parson’s sick role.
• There is the ethical framework for informed consent which is based on risk, benefits and alternatives to a certain treatment modality to manage a symptom or a disease.

Now in aesthetics, there is no real pathology or disease. Maybe at best, a “symptom” (if it can be called one at all) of a feeling of a lack of beauty. And since there is no real disease to treat, there is also no therapeutic end-point that can be objectively agreed upon. As such, how can there be good evidence to say that a modality works (maybe some evidence, but certainly not the good evidence you can get from say, a randomized control trial)? There is also no real sick role – nothing for the patient to be excused from and he doesn’t need to want to get better and hence,  the social contract that exists in clinical medicine doesn’t quite fit here either, and neither does consent as we know in the usual sense of  the word.

Let’s face it, other than in some instances involving reconstruction work, the majority of aesthetic work doesn’t quite fit into the realm of clinical medicine. In fact, one would argue that aesthetic practice is not clinical medicine. It is a service provided by a medically trained person for safety reasons. And maybe we will be better off by acknowledging as such. There will be much less angst for folks like us that do not offer any aesthetic services and for those that do so almost all the time, the full-time aesthetic practitioners.

So really, there should be another register of aesthetic practitioners who are medically trained. These guys can then be governed by a different set of professional registration laws and ethical codes while they retain the right to use drugs and perform invasive procedures so that consumer (not patient) safety is ensured. The PHMC Act can also have a different class of clinics called “aesthetic clinics” with its own set of requirements.

How about those doctors that want to retain their clinical work while still offering aesthetic services part-time? Well, we can learn from the example of a registered medical practitioner who is also a registered TCM practitioner. Here, the same person must practice in different premises. The TCM premise must have its own signboard and entrance which must be apparent to the patient or the aesthetic customer. Or if this not feasible, as a minimum, the clinic should state clearly and separate the operating hours for clinical medicine and that for aesthetic practice, so that the patient or consumer walking into this one clinic will know up-front if he or she is walking in as a patient or as a consumer of an aesthetic practice.

This hobbit is not trying to put down doctors who office aesthetic services, on the contrary, they try to fulfill a desire in many people to look better. But to continue to foist stuff like evidence based and clinical medicine and even clinical practice ethics on this group of people is not going to solve the problem. They will feel frustrated and over-regulated. The only aspect we should not compromise is consumer safety. But what is safe need not be evidence-based to be therapeutic. This is the principle of TCM regulation today as well. We don’t really have hard evidence that many TCM modalities work, but we still allow the practice of these modalities as long as they are reasonably safe.

What is the alternative? We crush the development of aesthetic services here through the weight of current laws and SMC ethical framework and people will still try to get their fix overseas or to the local beauticians who will try to fill up the gap. The current approach makes it easy to find doctors guilty but it will not address the consumer’s desire for beauty.

Many people will obviously not agree with the views expressed in this note. They are fully entitled to their opinions. But we could perhaps at least agree that the current approach is not working out well and a new mindset and a new approach is needed to deal with regulating doctors who offer aesthetic services.

In the meantime, we should also ensure that we have an environment that does not push more and more doctors into offering aesthetic practices so as to make ends meet. The joke going around these days is that with HDB heartland clinic rents exceeding $30,000 a month, the only way for these clinics to survive is to turn them into 24 hour aesthetic clinics.

But there may be a little light at the end of the tunnel – with all this obtaining sexual gratification stuff going around, it is rumoured that certain IT companies’ recruitment advertisements now come with the tagline “Beautiful people need not apply”.